We must ensure junior doctors can give one patient excellent care before asking them to balance caring for more than one patient.
Lifelong Learning in Clinical Excellence | February 12, 2019 | 6 min read
By Alim Pardhan, MD, McMaster University, Ken Van Dewark, MD, University of British Columbia, Teresa Chan, MD, McMaster University
The majority of medical training is based on the single patient encounter. Medical students are trained in a particular sequence of events when assessing patients. This sequence typically plays out as identifying a patient, finding out their chief complaint, taking their history of present illness, doing a review of systems to find out any other problems, examining the patient, and then creating the differential diagnosis and investigation/management plan based on the information gathered. As more information from investigations becomes available, refining the differential diagnosis and management plan.
This approach makes a great deal of sense when initially learning the diagnostic process as it highlights managing one patient well, which is (hopefully) the end goal of medical training and likely stems from a clinic-based linear environment. It unfortunately does not well prepare trainees for the chaotic acute care hospital environment where there are multiple patients, in multiple places, that all need to be seen, assessed, and managed with varying degrees of urgency.
The modern acute care hospital is increasingly complex. Units are routinely at or over capacity with patients in non-traditional spaces. Emergency departments often have patients in hallways, and internists are rounding on multiple sick patients at once.
We have taken an interest in exploring the education of trainees in multipatient environments. We aim to figure out how trainees perceive these environments, learn within these environments, and whether or not we are adequately teaching trainees to survive within the current system with the associated pressures.
A skill that requires a non-linear progression
A few years ago, Teresa Chan, MD, began investigating how trainees teach and learn in busy, multi-patient environments. In the first paper within this programme of research (Failure to Flow), she led a team in examining how we rarely teach trainees how to handle multiple patients at once.
One of the key findings from this paper was that teachers were reluctant to entrust trainees to handle multiple patients if they did not demonstrate that they could handle single patients one at a time. Similarly, the needs of learners as they progressed evolved in terms of how they manage multiple patients simultaneously. Of course, this makes sense. Just as you should probably understand how each chess piece moves before playing chess, so too should we ensure junior doctors can care for each patient they encounter well before asking them to balance more than one patient at once.
The Failure to Flow paper identified a gradient for developing such a skill in learners. The identified organic concept, formerly undefined from a competency standpoint, shifts our attention from single patient focus to multi-patient focus as training progresses. Others remarked that as we set forth to redesign our learning systems around competencies, that this may need to become a core skill within the emergency medicine – and that we must find a way to make clear the milestones that result in this type of competency.
But how DO physicians think about multipatient environments?
Our team then went on to explore how experienced emergency physicians and junior trainees experienced these multipatient environments differently. In our second paper (Managing Multiplicity), we highlighted a new conceptual framework to help people understand how physicians pick and choose priorities when faced with multiple patients that need their attention simultaneously.
We found that clinicians, both novice and experienced, often considered all available patients and then compared and contrasted the various aspects of the information available (vital signs, chief complaint, history of present illness, past medical history) to generate a functional patient story that they then used to “chunk” the information into a packet that they could more easily consider in their brains. Such “chunking” consists of building a library of frequently occurring clinical patterns (archetypes) that lead to management decisions.
The finding in this study was akin to DeGroot’s study of chessmasters. DeGroot’s landmark study demonstrated that experts, for example chessmasters, can make good decisions efficiently in complex situations by “chunking” information and identifying key patterns that result in a “best move.”
For instance, it was demonstrated that an expert physician could effectively “chunk” clinical information from multiple patients as a cognitive load minimizing strategy. For example, an expert physician quickly recalls that an unstable female patient may represent an ectopic pregnancy and that this requires specific actions. This contrasts forward searching techniques, used by novices, that are responsive to the current environment rather than expectant of future circumstances. As a consequence, experienced physicians developed more nuanced and rich “chunks” which presumably enhanced both success and efficiency in caring for multiple patients.
Bringing it back to the bedside
Understanding how physicians think is all well and good, but sometimes practical experience can still be crucial for acquiring a skill. With increasing pressures on an already overtapped healthcare system, it is not getting easier to handle our increasingly high acuity and challenging environments. And yet, despite these clear changes in our healthcare systems, there is very little faculty development on teaching within busy, multipatient environments. An increased understanding of these processes with relevant faculty development stands to improve physician cognitive load. Such an improvement may enhance care and safety in such increasingly demanding multipatient environments.
In the third paper within our programme of research (Coaching for Chaos), we examined how modern teachers actually teach in these busy multipatient environments. This paper examines the new methods for handling multiple patients, highlighting that many of the techniques used in these busy clinical environments harness a cognitive apprenticeship model to help train and empower trainees with the skills necessary to function as physicians within modern systems. This paper also highlights the opportunity to develop new methods and platforms for teaching about multipatient environments, since very few strategies that we currently employ are classroom-based experiences.
While multipatient simulations may hold the key to teaching some of these skills, such experiences can be costly. For instance, a local mass casualty incident (MCI) simulation that we run on a biannual basis (e.g. every 2 years) takes about six months to plan and costs a fair bit of money (over $1,000). Since such events will not be a good alternative to experiential models in the clinical environment, we thought about how we might leverage some other techniques to educate about multipatient care environments.
Serious games (i.e. games that are meant to help people learn, rather than just for fun) are a genre of games that have existed for quite some time. Somewhere between a simulation and a game, serious games can be used as a technique to engage learners in concepts through gaming. Since 2016, our group has pivoted towards designing an alternative to live multipatient simulations, known as the GridlockED board game (www.gridlockedgame.com; see our Academic Medicine blog and paper too).
Collectively, this body of work demonstrates that teaching the management of multiple patients in acute care environments holds unique challenges. This research has revealed an improved understanding of how expert physicians think and cognitively meet such challenges in these environments. This new body of literature could improve how we train the next generation of emergency physicians, and might spur similar programs of research in other specialties. In considering these factors, new tools such as serious games can help tomorrow’s emergency physicians better meet the challenges of providing care in departments with ever-higher volumes and acuity.