Untold Stories from the ER: Emergency Medicine Residents’ Experiences Caring for Diverse Patient Populations: Development of Professional Values & Interpersonal Communication Competencies by Adrianne Haggins
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Presentation delivered at the second annual William G. Barsan Emergency Medicine Research Forum, Ann Arbor, April 12, 2017.
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Untold Stories from the ER: Emergency Medicine Residents’ Experiences Caring for Diverse Patient Populations: Development of Professional Values & Interpersonal Communication Competencies by Adrianne Haggins
- 1. UNTOLD STORIES FROMTHE ER: EMERGENCY MEDICINE RESIDENTS’ EXPERIENCES CARING FOR DIVERSE PATIENT POPULATIONS: DEVELOPMENT OF PROFESSIONALVALUES & INTERPERSONAL COMMUNICATION COMPETENCIES Adrianne Haggins, MD, MS Barsan Research Forum April 12, 2017
- 2. Acknowledgements ■ Collaborators: – University of Michigan: Laura Hopson, MD, Michael Clery, MD, Emily Hogikyan (MS2), Josiah Smiley (MS2), Tim Guetterman PhD – EmoryUniversity: Sheryl Heron, MD, Renee Johnson, MD, Patrick Meloy, MD, Monica Khan, MD – University of Chicago: James Ahn, MD, Christine Babcock, MD
- 3. Background ■ Emergency medicine patient population – Uninsured – Immigrant – Minority – Medicaid – Transgender https://upload.wikimedia.org/wikipedia/en/4/4a/Poster_for_The_Waiting_Room_Documentary.jpg
- 4. Background ■ Exposure to medically underserved populations ■ Accreditation Council for Graduate Medical Education Milestones – ProfessionalValues – Interpersonal Communication ■ Lack of practical guidance to on ”how” best to teach residents to achieve milestones https://www.acgme.org/Portals/0/PDFs/Milestones/EmergencyMedicineMilestones.pdf
- 5. Objective ■ To explore EM resident experiences caring for patients in diverse clinical settings
- 6. Methods ■ Participants 3 Multi-Site EM ResidencyTraining Programs: Vary by Patient Population, SES, Medical complexity, and Medical Resources University of Michigan University of Chicago Emory University Clinical Training EXPOSURE: Underserved Academic Medical Center Community Academic Medical Center Community Underserved Underserved Community Academic Medical Center
- 7. Methods ■ Data Collection – Direct patient care/observed interaction ■ Interviews – Cultural Identity – Frustrating Patient Care Experiences – Vulnerable Populations – Ability to Adapt
- 8. Methods ■ Data Analysis AH EH LH MC 1st 2nd
- 9. Characteristics Residents n=24 (%) Residency Program University of Michigan N=10 (41.7%) Emory University N=8 (33.3%) University of Chicago N=6 (25.0%) PGY-Level PGY-1 N= 10 (41.7%) PGY-2 N=6 (25.0%) PGY-3 N=4 (16.7%) PGY-4 N=4 (16.7%) Gender Female N=10 (41.7%) Male N=14 (58.3%) URIM status◊ Non-URIM N=20 (83.3%) URIM N=4 (16.7%)
- 10. Themes Subthemes Patient-Provider Cultural Identity Conflicts •Gender •Race/Culture •SES
- 11. “…everyone was just so nice to him. Getting him everything he wanted right away….Then admitting him into the hospital pretty quickly. I don’t know if it was because… he was white,…, or if it was because he had money or because he followed up with his appointments,… …. An African American guy who had failed to follow up at a few of his appointments, and he was like, “Hey,.. I’m sorry, but I went out and ate some fried chicken and a hotdog.”…people labeled him as non-compliant right away. …The quality of care that [the second patient] received, the disparity between it was astounding…. [the first patient] asked the nurse for a water and got it within 30 seconds, whereas the other guy, [was] sitting there yelling from his bed for someone to get him something, and no one responds….The second guy maybe waited in the emergency department for over four or five hours. waiting on a bed….That was just something that I saw, and it irked me a little bit in the ED.” -10021
- 12. Themes Subthemes Underlying Reasons for Challenging Patient Encounters • Socio-Behavioral • Value Differences • Mistrust • Health Literacy or Language Barriers
- 13. “I have had the most challenging encounters with the more low income, African American population, because it's so different than the culture in which I was raised. I'm from a somewhat wealthy, white background. My medical school was actually an urban safety net hospital, so I've been exposed to this population for several years now, and I'm definitely learning how to relate with them better,…but I would say overall, they give the impression that when you're dealing with them, it seems less respectful and a lot of time they seem less engaged in their healthcare.“ -10013
- 14. Themes Subthemes Effect of Cultural Differences on Care • Time with Patient • More tests ordered
- 15. “…a few different occasions where using an interpreter phone, …— I can only get so much of a history from the phone, so we have to, unfortunately, work somebody up a lot more than we would otherwise,…despite having professional interpreter services, how you differentiate chest pain is a lot of the time based on history. Does it sound like GERD? Does it sound like angina? Does it sound exertional? …What's the cardiac history? Patients just don't know that, and you're not going to get it talking through an interpreter, so unfortunately, a patient is getting a very extensive workup that they may or may not have needed,...That can be quite frustrating.” --10017
- 16. Themes Subthemes Influence of Residency Program • Exposure Enhanced Perspective • Culture and Curriculum Improved Communication
- 17. Influence of Residency Program ■ Diverse Clinical Settings: Exposure Enhanced Residents’ Perspective – Unfamiliar Cultures – Improve Confidence – Post-residency asset
- 18. “… I think it was a difficult situation because—more because the [underserved hospital] that I'm at is so incredibly busy, it's busting at the seams with patients…The actual attendings who take care of the patients never have time to talk to the families. Because they see so many patients….seeing the patients takes eight to ten hours.There's no time left to talk to a group of 20 family members. The families feel like they're not being informed of what's going on. Understandably so, because they're not. Because the attending is not calling them. Is not reaching out to them, because they don't have time to. I mean, they spend eight hours on war grounds just trying to see the patients.…I don't see that in the other hospitals. 10023
- 19. “…we have people with different sexual orientation, people with different ethnicities, black, white, a good amount of females versus males…We [have] people who are Muslim….that increases the odds of delivering good care because you just have a better understanding of what the patient may want to work with. As a physician you want to hear from other people, what their perspective is, just in case you’re faced with a patient that may have a similarity with one of your physicians.They may [say], “They won’t do this because of X,Y, and Z.”…Sometimes if you don’t have that supply or diverse experience you can be missing out on the efficacy of your care as well as the opportunity to send people from your program to serve a certain community. “ -10024
- 20. “…patient became more alert, and we had an opportunity to have a discussion about how they viewed gender and identity and what was their genetic sex and what was their gender identity which are two distinctly different things.We were better able to care for the patient …We allowed them to essentially advocate for themselves and be more involved in their care…I feel like we recently had a lecture about how to navigate these scenarios. I felt prepared for this….you learn something in theory and then you actually have to use it,… I feel like that scenario stands out in my head because I had to apply something that I had just recently learned.” -10027
- 21. Limitations ■ Social desirability ■ 3 sites may not be generalizable ■ Sample selection bias ■ Coder bias
- 22. Conclusions ■ Emergency Medicine ResidencyTraining – Patient-Provider Conflicts – Residents’ confidence improves with exposure and familiarity with diverse populations – Educational approaches could enhance residents communication and interpersonal skillset
- 24. Themes Subthemes Achieving and Evaluating Milestones • Feedback • Targeted instruction
- 25. Themes Subthemes Adapting Care • Asking more clarifying questions • Using ancillary resources
- 26. Background ■ Accreditation Council forGraduate Medical Education Milestones – ProfessionalValues ■ Demonstrates compassion, integrity, and respect for others as well as adherence to the ethical principles relevant to the practice of medicine. – Interpersonal Communication ■ Demonstrates interpersonal and communication skills that result in the effective exchange of information and collaboration with patients and their families. https://www.acgme.org/Portals/0/PDFs/Milestones/EmergencyMedicineMilestones.pdf
Editor's Notes
- This project was funded by the Center for Research on Learning and Teaching.
- Emergency settings presents a complex challenge for providers to learn to adapt to diverse patient populations and provide culturally sensitive care. We don’t choose our patients, and are required to provide a screening exam to all-comers. In our waiting rooms we come across diverse populations which may include the uninsured, immigrant, minority, Medicaid, and transgender populations, among others. Evidence from decades ago found that the INability to be sensitive to the needs of diverse populations has been attributed to adverse effects on patient adherence and health outcomes.
- Prior research supports that exposure to underserved patient populations positively influence cultural competency skills. Accreditation Council for Graduate Medical Education (ACGME) milestone competencies set standards related to the development of Professional values and Interpersonal communication to ensure residents demonstrate compassion, effective communication, and respect towards their patients. However, little practical guidance has emerged to instruct medical educators on ways to achieve these milestones and shape residents’ communication skills.
- The objective of our project was to explore EM resident experiences caring for patients in diverse clinical settings
- Eligible participants were emergency medicine residents in multi-site training programs at University of Michigan, Emory University, and University of Chicago. These programs have at least 3 clinical training environments(underserved, an academic medical center, and a community hospital) which provide a diverse clinical exposure based on differences in patient populations, socioeconomic factors, medical complexity, and medical resources. Residents across all post-graduate training years were eligible.
- We explored resident experiences related to working at the different clinical sites which include direct patient care or observed interactions. We developed a semi-structured interview guide to explore topics related to: cultural identity, frustrating patient care experiences, strategies for identifying and caring for vulnerable populations, and the residents’ ability to communicate with and adapt to the needs of their diverse population. Residents were interviewed via phone. Each interview was audio taped, transcribed, anonymized. Participants received a $20 gift card.
- Two authors independently reviewed the transcripts (AH and EH) to identify statements. Using phenomenological lens, we then categorized these statements into broader categories that seemingly represented meaningful experiences and themes across individuals. The codes and themes were compared (AH and EH) for discrepancies and revised accordingly to achieve consensus. A third (LH) and fourth author (MC) independently reviewed all the transcripts to confirm the identified themes. All data was reviewed iteratively to generate initial codes. The codes were compared and discussed among the authors to ensure the trustworthiness of the analysis. Recurring codes were organized into categories of similar content. These categories were then further compared, scrutinized and organized into broader themes.
- We completed 24 interviews, and here are the Table 1. demographics.
- Residents described experiences were they observed patient-provider cultural identity conflicts that lead to challenging clinical encounters, which were commonly in 3 categories: Gender, Race/Culture, and socioeconomic status.
- Here is an example of a resident describing their experience at the community hospital. There were two patients with similar heart failure presentations, one white and affluent, and another African-American, and of lower income. Residents described how differences between them and their patient often can make it difficult to build rapport and pushes them out of their “comfort zone”. Conversely, the residents also observed how similarities in cultural identity enhanced familiarity, relatability, and facilitated at a sense of comradery with their patients.
- Residents perceived that the underlying reasons for challenging patient encounters were related to differences in: Social Behaviors, Values, Mistrust, Health literacy or language barriers.
- Here a resident reflects on social interactions with a particular minority population:
- Residents also described how cultural differences affected the care provided: This led commonly to: more time with the patient, and more tests ordered.
- Next, I’d like to spend some time on how residents’ ability to care for diverse patients was influenced by the residency program, which consists clinical training, the people, and the structured curriculum.
- Overwhelmingly, residents reported that working in diverse clinically settings: broadened their perspectives on cultures unfamiliar to them (cultural practices, parenting styles, language/slang), and increased their confidence in being able to care for a broader variety of patients. Residents also felt that their training environments would be a post-residency asset because it improved their marketability, and helped them feel more informed in deciding which clinical setting they preferred.
- However, residents also described their frustration with working with underserved populations and within those hospital settings. One residents explains: (read quote)
- The residents also commented on another aspect of the residency program, the make up of the faculty, and how that can have a positive affect in shaping residency culture and their ability to communicate with a diverse patient populations: (see 2nd quote)
- Here a resident describes the positive influence the residency curriculum had on their confidence and ability to address the patient’s needs through an experience taking care of a transgender patient that initially presented to the ED with altered mental status. In the quote a resident says: (see quote) However, overall deliberate instruction was less commonly described. Residents frequently commented that their communication behaviors were shaped indirectly through modeling senior residents or faculty.
- *One coder noted that their personal knowledge gained from working closely with the residents made it possible for her to identify some of the participants, despite anonymized transcripts, which may have influence their deductive interpretations.
- Emergency Medicine Residency training programs should prepare residents to face the complex challenge of adapting to the varied and evolving needs the diverse patient populations they are expected to serve. Cultural differences between the medical provider and their patients are not uncommon, and can lead to challenging interactions. However, resident confidence improves with exposure and familiarity with diverse populations. Gaining residents perspective on potential teaching and assessment strategies can inform the development of novel educational approaches to enhance residents communication and interpersonal skillset
- Lastly, residents discussed potential approaches to enhance their ability to communicate and assess their milestone achievement. Common approaches were: gaining feedback from direct observation from attendings/patients/nursing staff, simulated exercises, and encouraging self-reflection when faced with difficult patient interactions (i.e., case-based discussions or through a designated faculty mentors). Residents also encouraged targeted instruction to improve knowledge of resources available in the hospital and community, gang awareness, religious preferences of nearby populations, and transgender patient discussions.
- Residents discussed the ways they adapted their care: Common approaches were related to communication style (asking more questions related to social history, paying attention to their body language, eliciting barriers, inquiring about personal background, and avoiding jargon) as well as utilizing ancillary staff, such as social workers and care managers.
- Accreditation Council for Graduate Medical Education (ACGME) milestone competencies set standards related to the development of Professional values and Interpersonal communication to ensure residents demonstrate compassion, effective communication, and respect to their patients.