Critical care recognition, management and communication skills during an emergency medicine clerkship

Abstract

Background: Medical students need to learn how to recognize and manage critically ill patients; to communicate in critical situations with patients, families, and the healthcare team; and finally, to integrate technical knowledge with communication skills in caring for these patients. Meeting their needs will help prepare them to demonstrate, as physicians, the ability to synthesize information while simultaneously caring for patients, that the American Medical Association recently characterized as vital.

Aims: Responding to these needs, we developed and implemented a curriculum to enable students in a required emergency medicine clerkship to recognize, manage, and simultaneously communicate with critically ill patients.

Methods: The curriculum consisted of lectures and exercises on caring for the critically ill including: an introduction to the systematic approach; an interactive lecture on comprehensive communication; observation and discussion of real patients in the emergency department; participation in a single standardized patient encounter while peers and a faculty member observed them; assessment of students' own videotaped performance of the examination by using critical care and communication/interpersonal skills checklists; and receipt of private feedback based on the checklists from the faculty and the standardized patient. Students evaluated the curriculum at the end of the clerkship.

Results: Complete performance data for 46 students and curriculum evaluation data from 42 students were available. According to faculty assessment, students as a group performed 79.6% (SD 0.15) of the critical care and 70.9% (SD 11.5%) of the communication skills. Students most often demonstrated Basic Interpersonal Skills (97.9%, SD 0.056) and least often demonstrated Empathy skills (41.7%, SD 0.235). Students rated the curriculum positively.

Conclusions: It is feasible to integrate the teaching of communication skills with the recognition and management of critically ill patients. The next step will be to revise the curriculum to address student deficiencies and to evaluate its effectiveness more rigorously.

Introduction

All physicians in practice must be prepared to manage a critically ill patient–that is, a patient who is unstable and requires resuscitation or intervention or a patient who has a rapidly changing medical status that may lead to permanent disability or even death (Water et al. 2005). The final year medical student will also need to be equipped to manage a critical patient once they enter residency, even on the first day. Medical students face a three-fold task in learning how to care for the critically ill patient. They need to learn how to recognize and manage the technical aspects of critical illness including the cognitive skills of pattern recognition, diagnosis, and decision making. They need to learn how to communicate with the critically ill patient, the patient's family, consultants, and the healthcare team. Finally, they need to learn how to integrate their technical knowledge and skills with their communication skills while caring for the critical patient (Kneebone et al. 2005).

Current learning opportunities for medical students in critical care (CC) may be limited in several ways. Although they receive classroom instruction about the recognition and management of the critical patient, students may not be able to apply these principles in a clinical arena due to understandable concerns for patient safety and reimbursement regulations. In the Liaison Council for Medical Education (LCME) questionnaire of 126 accredited medical schools in 2005–2006, only 13 required students to take a formally organized clinical rotation in critical care or intensive care, and only 39 required students to take an emergency medicine rotation (LCME 2006). However, clinical experiences are a vital component when teaching about critical illness (Mann 2002).

Our review of the literature on communication and interpersonal skills (CIPS) revealed that much of the communication instruction that medical schools offer does not focus on communication tasks specific, even unique, to caring for the critically ill patient (Makoul 2001; Hobgood et al. 2002; Duffy et al. 2004; Kalet et al. 2004; Lang et al. 2004). In addition, the Initiative to Transform Medical Education provided by the American Medical Association (AMA) challenged educators to address the following medical education gaps: the physician's ability to rapidly synthesize information while simultaneously caring for patients, the physician's role as a member of the healthcare team, and the physician's ability to communicate effectively in difficult situations and demonstrate a caring manner (AMA 2007).

Roger Kneebone's work addresses communication and interpersonal skills in the performance of medical procedures and provides a template for the integration of these important skills in his teaching and through the use of checklists. But there is little in the medical education literature that discusses how to teach students to integrate communication skills with the full repertoire of skills needed for the medical management of patients, particularly the critically ill. Yet there is an urgent need to do so in order for students to learn to provide high quality and safe patient care. Toward that end, medical educators have been called to provide in-depth learning experiences that simultaneously address the clinical skills of the physician and humanistic aspects of medical care (Kneebone et al. 2005; Kanter et al. 2007).

A rotation in an academic ED can redress omissions in the undergraduate curriculum as mentioned above because it offers students experiences with the critical, undifferentiated patient (Handel et al. 2007). In the ED, students will encounter patients, of varying degrees of acuity, who need medical procedures and who require simultaneous evaluation and treatment, often including resuscitation. To provide requisite care, medical students need to have CIPS tailored to the CC encounter. We therefore developed a curriculum within a required EM clerkship to provide the student a consistent way to approach the care of the critical patient, to carry out communication skills unique to CC, and to integrate technical management skills and communication into a seamless patient care encounter.

Table

Practice points

It is feasible to teach a systematic approach to critical care during a required emergency medicine clerkship. Communication in the critical care encounter is unique and must be integrated in a curriculum to maintain effective and safe patient care. Using interactive teaching methods students should and can be taught to recognize and manage critical patients while integrating the unique and essential communication and interpersonal skills for critical care. Students most often performed skills related to the early recognition and management of airway, breathing and circulatory problems but students need to improve on their use of bedside tests to recognize life-threatening medical conditions, reassessment of the patient's response to treatment, review of records, and interviewing pre-hospital responders. Students showed strong Basic Interpersonal Skills and Efficient Information Gathering but need to improve on their Empathy and Healthcare Team Communication skills.

This paper describes how our curriculum embeds CIPS with the technical skills of managing a critical patient to offer a more in-depth learning experience for the student in a realistic environment. We outline teaching methods including formative assessment with feedback and present students’ evaluation of the curriculum during its first year of implementation.

Methods

Participants and setting

Final year medical students in a required emergency medicine (EM) clerkship from July 2005 through June 2006 at the University of Missouri-Kansas City (UMKC) School of Medicine participated in the curriculum. UMKC is a six-year combined baccalaureate-medical degree program admitting most of its students upon high school graduation. Prior to the EM clerkship, UMKC students have exposure to critical patients through two general internal medicine rotations in Year 4 and Year 5 but do not serve a required CC rotation. Throughout medical school UMKC students have interacted with SPs in three performance-based assessments in Years 1, 3 and 5 and in small groups where SPs help teach communication skills to Year 3 students.

For research and publication purposes about our curriculum, all students in the EM clerkship consented to the use of their performance data and curricular evaluation. The Social Sciences Institutional Review Board approved this work through an expedited review. The curriculum took place for all final year medical students in the ED at Truman Medical Center, a university-affiliated county hospital in downtown Kansas City, Missouri. The ED has an annual census of 60,000 visits and an accredited EM residency.

Objectives and format

The objectives of the curriculum were to enable the students to take a systematic approach to the critical patient, recognize and know how to manage patients with different emergent presentations, know the importance of and perform CIPS for the critical encounter, and integrate the essential CIPS in an authentic patient simulation. The curriculum utilizes active learning exercises such as interactive lectures, observation of real patient care, group discussion, formative assessment of performance in an instructor-administered single-case critical SP encounter, peer assessment and self-assessment, and feedback from faculty, SPs, and peers as methods to teach and reinforce these important skills (Table 1).

Table 1.  Curriculum activities

Activity	Duration and timing	Description and objectives of methods
Lecture: ‘Sick vs. Not Sick’	90 minutes during orientation	An interactive lecture to teach the student a systematic approach to the critical patient, ALERT mnemonic introduced and used to manage 5 cases as a group to demonstrate application
Lecture: ‘Critical Care CIPS’	50 minutes in the first week of the clerkship	Discuss, provide examples of unique critical care CIPS, behaviorally-based CIPS are introduced with examples of how to communicate or demonstrate the specific skill
Observe real critical care encounter during ED clinical shift	Must occur in the first 3 weeks	Student observes care start to finish, fills out a worksheet on the healthcare team approach and actions, documents unique CIPS issue
Small group discussion • Of observed real CC encounter • Prepare students for the SP CC encounter	90 minutes to discuss cases, moderated by author SE, occurs at the beginning of the 4th week, before the CC SP encounter	Group convenes to discuss each CC case, discuss medical management and unique CIPS, review a recorded student case SP assessment, and review expectations of CC SP encounter
Instructor-administered single case SP CC Encounter	4 hours, occurs 1–3 days after the small group discussion above	Each student participates in a mock CC encounter which is videotaped. Peers assess CC actions during the live case. EM faculty discuss the expected CC actions with the group for learning purposes
SP CC encounter assessment and feedback	20–25 minutes with each individual student that occurs immediately following the group CC SP encounter exercise	Private video review with the student examinee, SP, and the two faculty. Provides an opportunity for self-assessment, feedback from faculty and the SP. Each student's CIPS are assessed by using the assessment tool by the student, faculty, and SP

CC = critical care, CIPS = communication and interpersonal skill, SP = standardized patient, EM = emergency medicine.

Curriculum

Two core EM faculty at our institution (the student clerkship director, SE, and the EM residency program director, CS) created and delivered the curriculum. Table 1 summarizes the details of the learning activities used in the curriculum, their duration, and the sequence of the activities.

We first introduced students to the recognition and management of the critical patient with a 90-minute interactive lecture called ‘Sick vs. Not Sick’. One author, SE, provided this lecture each month during orientation. She demonstrated how to evaluate and manage the critical patient and provided a mnemonic, called ALERT, as a tool to illustrate a systematic approach to the patient.

ALERT draws heavily from the Model of the Clinical Practice of Emergency Medicine (Hockenberger et al. 2001; Chapman et al. 2004). It teaches students to merge patient acuity with distinctive physician tasks that include CIPS emphasizing a focused history and physical, the emergency differential diagnosis, observation and reassessment, and important bedside tests to diagnose and manage the patient with more immediacy than in their past clinical experiences. ALERT also teaches the student to order their data-gathering so that they recognize and stabilize the patient's acute condition before moving on in their history or physical examination. Table 2 presents a comprehensive definition of the ALERT and the sequence on how to approach and manage the critical patient.

Table 2.  The ALERT mnemonic. The systematic approach should begin with the actions as listed in order from top to bottom. The student is taught that if during the ‘R’ action they do not see a response to their treatment they should, return to the ‘A’ actions at the beginning

Action	Definition	Descriptors or examples of action expected
A Alert Attending ABCs Apply Access	The first action expected in the systematic approach to the patient: Alert Attending, ABC's, Apply OMI, Access	Alert the Attending, Assess ABC's: airway, breathing, and circulation, and Apply ‘OMI’ for oxygen, monitor, and establish intravenous Access Once an abnormality is found it should be treated immediately. For example, if the patient needs intubation then this intervention should occur before addressing the next step in evaluation
L Look for and treat Life-threatening conditions	Look for life- threatening conditions and treat immediately.	This includes secondary survey for life-threatening injuries in trauma patients, identifying hives or a rash that guides diagnosis and treatment of airway compromise and hypotension, treating dysrhythmias discovered with the monitor is applied, etc. This is where the student administers antibiotics, intravenous fluids, and provides trauma care specific to their assessment Students can consider sending laboratory as they build their differential diagnosis from information obtained above
E Examine Evaluate with bedside tests	This is a focused effort to further develop their differential diagnosis. It is a focused examination using bedside tests to evaluate, diagnose, and manage the critical patient.	Examine briefly-a focused examination to diagnose and manage the patient outside their evaluation of the ABCs above. Evaluate with bedside tests-point-of-care tests not used in their inpatient experiences: ECG, arterial blood gas, urinalysis, urine pregnancy test, ultrasound, hemoglobin, serum glucose determination, portable X-rays, stool for occult blood An emphasis on diagnosis that is more urgent. We provide the examples that acute myocardial infarction, ruptured ectopic pregnancy, and stroke are diagnosed with history and physical and bedside tests, not time-consuming laboratory tests.
R Reassess Response to Rx Responders Review records	Now Reassess patient to see if they are more stable. If yes, then continue. If not, move back to the ‘A’ actions above.	Response to treatment-ask the patient how they are feeling Reassess patient-look for objective findings that the patient is improving such as blood pressure, heart rate, oxygen saturation Responders should be interviewed if the patient is too critical to speak. These include family and witnesses and pre-hospital personnel Review Records–if more information is needed the student should consider reviewing hospital records
T Thorough H&P Test results and treat To: disposition	The patient should be more stable and care can proceed to include a thorough history and physical, tests and further treatment.	Thorough history and physical-now that the patient is stable, more information can be obtained. Test results from the laboratory should be reviewed as they are completed and any abnormalities Treated To-Now that the patient's condition is stable and diagnosis has been differentiated, the patient's disposition should be determined. This includes the admitting service, consultations to be obtained, and bed status

SE concluded the first lecture with an interactive exercise in which she asked the students to work through five classic EM patient cases by applying ALERT. For example, they used the ALERT mnemonic to show how they would work-up a 98 year old woman with altered mental status with the following vital signs: blood pressure 92/54, heart rate 110, respiratory rate 24, temperature 100.8, and oxygen saturation 93%. In the ensuing discussion students generated a differential diagnosis and described the systematic approach to the patient by using ALERT, beginning with the patient's airway, breathing and circulatory status. SE provided the physical examination and test information in response to the students’ requests, and then she asked them to explain how they would manage the patient as they discovered abnormalities.

Next, SE gave a 50-minute lecture on the essential CIPS for the critical patient encounter. The communication skills she introduced were: effective and efficient data-gathering, establishing rapport quickly, demonstrating respect, and achieving a balance between patient-centered and doctor-centered interviewing. The interpersonal skills she emphasized included: providing reassurance, alleviating pain and distress, and establishing a trusting doctor-patient relationship. She defined each skill, discussed why it is important, and gave examples of how to perform the skill. In doing so, she gave students a behaviorally anchored CIPS checklist. The checklist appears in Table 3, and we discuss it further in the section on CIPS assessment.

Table 3.  CIPS checklist

Skill category (number of items)	Definition	Checklist item
Basic interpersonal skills (6)	Demonstration of respect; laying a foundation for a therapeutic relationship with the patient	Introduces self Addresses patient/family by name Allows patient/family to state the chief complaint in their own words Makes frequent eye contact Allows patient/family to finish sentences Does not express personal opinions during interview
Efficient information gathering (3)	How we gather information in a busy or critical environment	Question style/length appropriate for situation/patient condition Consistently uses lay terms Directs interview with specific questions pertinent to patient case
Healthcare team communication (4)	Demonstration of teamwork; the ability to relay information to all members; directing reassessment of patient condition after intervention; sharing current condition with consultants	Directs nurse/healthcare team to reassess the patient's response to intervention Communicates care plan to healthcare team and acknowledges any concerns Verbalizes specific request to the consultant Presentation to consultant includes: Diagnosis, pertinent history and physical findings, test results, interventions, current condition
On-going patient/family communication (4)	Ability to counsel and educate the patient and family; reassessment of patient condition from the patient	Directly questions the patient about their response to treatment Keeps patient/family informed of results Communicates patient care plan to the patient/family Asks patient/family if they have questions
Empathy (5)	Acknowledgement and response to the patient's perspective and concerns; demonstration of caring behavior	Verbally acknowledges patient's pain/complaint immediately Verbally acknowledge the patient's nonverbal gestures Verbally reassures the patient/family Touches patient in reassuring manner (if culturally appropriate) Verbalizes understanding of patient/family's perspective on illness during care

*Checklist skills are grouped in this table by category and not in the sequence as the items appear on the Checklist instrument.

Students then watched the management of a critical patient during a clinical shift in the emergency department with the goal of learning through observation. Each student completed a worksheet to record the ALERT actions of the members of the healthcare team and documented one CIPS example that they found had a positive or negative impact on the care of that patient.

In follow-up, SE led a small group discussion in the third week of the clerkship to review the worksheets students had completed after observing the care of real patients in the emergency department. Students described the ALERT they had observed and discussed the CIPS that impacted patient care. Finally, after reviewing the CIPS checklist, SE showed a videotaped SP encounter to the students to prepare them for the instructor-administered single-case observed critical SP Encounter.

Instructor-administered Single Case Observed Critical SP Encounter

Within one to three days of the group discussion of their observed real patient CC cases and review of the CIPS checklist, students participated in a required, single-case observed SP encounter which we videotaped. Each student examined and managed a SP while their peers observed. The SP presented with one of nine randomly selected CC cases germane to EM. Table 4 presents these cases, each of which we scripted to include CC actions tailored to the patient presentation. Figure 1 offers an example of one of the cases; it describes the Acute Myocardial Infarction SP patient vignette and specifies the requisite CC actions of the ALERT along with CIPS framed for acute myocardial infarction.

Figure 1. Case vignette.

The SP was one of two trained EM residents chosen for their knowledge of how critically ill patients present in the ED. The SP training began with a discussion of the purpose of the curriculum, review of the cases, ways to understand and express the patient's perspective, and ways to respond to the student's communication and management issues of the case. The two-hour session ended with practicing the cases. SP observation of another experienced resident SP portraying cases rounded out the training.

Table 4.  Critical care cases

Patient case (N = 46)	Critical medical actions (% of students performing the skill)	Mean percent correct (SD)
Stroke with airway management (6)	(1) Assesses patient's airway and decides to intubate; (66.67%)	75% (17.48%)
	(2) Assesses breathing; (83.33%)
	(3) Assesses circulation; (100%)
	(4) Works-up altered mental status bedside test (EKG, serum glucose level, oxygen, naloxone, thiamine); (50%)
	(5) Orders computed tomography (CT) of the brain; (83.33%)
	(6) Obtains history from family on ‘Do Not Resuscitate’ (DNR) status (66.67%)
Anaphylactic shock (7)	(1) Assesses and recognizes airway compromise; (100%)	83.33% (19.25%)
	(2) Assesses breathing; (85.71%)
	(3) Assesses circulation signs of critical status; (85.71%)
	(4) Administers epinephrine; (85.71%)
	(5) Orders oxygen, monitor, and intravenous access; (85.71%)
	(6) Communicates with paramedic or witnesses for history of wasp sting (85.71%)
Urosepsis (7)	(1) Assess A, B, Cs and treats the patient's hypotension with a fluid bolus, (100%) work-up the patient's altered mental status and order important bedside test:	83.67% (12.85%)
	(2) Serum glucose, (100%)
	(3) Oxygen saturation, (28.57%)
	(4) Urinalysis, (100%)
	(5) Orders head CT; (71.43%)
	(6) Interviews family for history; (100%)
	(7) Explains results and admission to family (85.71%)
Acute myocardial infarction (7)	(1) Recognizes sick patient and alerts attending, (57.14%)	78.02% (16.27%)
	(2) Take a focused history to include the time of onset of symptoms, (85.71%)
	(3) Circumstances and description of chest pain, (71.43%)
	(4) PMH, medications, allergies; (85.71%)
	(5) Performs focused, appropriate examination; (85.71%)
	(6) Asks for oxygen, monitor, IV; (100%)
	(7) Orders EKG AND chest X-ray; (42.86%)
	(8) Directs nitroglycerin, aspirin; (100%)
	(9) Reassesses patient's pain and response to treatment, (71.43%)
	(10) Reassesses vital signs; (57.14%)
	(11) Interprets the ECG as acute myocardial infarction; (100%)
	(12) Communicates the diagnosis and treatment to the patient, (100%)
	(13) Consults cardiologist (57.14%)
Status asthmaticus (7)	(1) Recognizes respiratory distress and alerts the attending, (85.71%)	76.19% (13.50%)
	(2) Orders oxygen, monitor, IV; (100%)
	(3) Administers nebulizer treatments and intravenous steroids, (100%)
	(4) Orders and interprets arterial blood gas (ABG) correctly; (28.57%)
	(5) Fequently reassesses response to treatment with vital signs; (100%)
	(6) Oepeat and frequent Wright peak flows; (57.14%)
	(7) Reassesses lung examination; (42.86%)
	(8) Asks patient about response to treatment; (71.43%)
	(9) Makes decision to admit (100%)
Ruptured ectopic pregnancy (6)	(1) Recognizes that the patient is in shock and alerts the attending; (83.33%)	77.27% (12.53%)
	(2) Questions about last menstrual period; (83.33%)
	(3) Orders oxygen, monitor, IV; (100%)
	(4) Gives intravenous fluid boluses; (66.67%)
	(5) Orders hemocue (bedside hemoglobin); (66.67%)
	(6) Orders urine pregnancy test; (83.33%)
	(7) Orders ED bedside ultrasound; (100%)
	(8) Reassesses patient vital signs and pain level; (50%)
	(9) Orders second large bore IV; (66.67%)
	(10) Orders type and cross-matched blood; (50%)
	(11) Consults gynecologist promptly (100%)
Upper gastrointestinal bleed (4)	(1) Assesses ABCs and recognizes hypotension; (80%)	75% (8.84%)
	(2) Orders oxygen, monitor, IV; (100%)
	(3) Orders two large bore IVs; (20%)
	(4) Orders type and cross-matched blood; (100%)
	(5) Orders units of blood for possible transfusion; (100%)
	(6) Orders transfusion; (100%)
	(7) Reviews records when patient more stable; (0%)
	(8) Consults in organized fashion to admit the patient to the intensive care unit (ICU) (100%)
Acute appendicitis with an acute abdomen (1)	(1) Recognizes sick patient and alerts attending;	(Fewer than 4 students performed this case)
	(2) Orders oxygen, monitor, IV access;
	(3) Recognizes acute abdomen on examination;
	(4) Treats or verbally addresses the patient's pain;
	(5) Reassesses the patient;
	(6) Consults surgery;
	(7) Deals with a difficult consultant and acts as a patient advocate
Meningococcal meningitis (1)	(1) Recognizes sick patient and alerts attending;	(Fewer than 4 students performed this case)
	(2) Orders oxygen, monitor, IV;
	(3) Orders IV fluid bolus and treats fever;
	(4) Orders appropriate antibiotics when petechial rash is discovered;
	(5) Orders head CT;
	(6) Performs lumbar puncture;
	(7) Reassesses patient frequently;
	(8) Admits the patient to an isolation bed

*In all cases students were expected to alert the attending physician, ask for oxygen, monitor, intravenous access (OMI), assess the patient's airway, breathing, and circulation, and examined the patient closely for other signs of a life-threatening condition. If the SP had positive findings related to the diagnosis for the assessment of any of the above, it was considered a ‘critical action’ to the case.

Two faculty, SE or CS, acted as a standardized nurse, family member, or pre-hospital personnel for each case. Their training and experience consisted of a review of the literature on the use of SPs in teaching and assessment, prior use of SP cases, and attendance at educational conferences on SP use in medical education. They also met with the UMKC School of Medicine SP Coordinator and the SP Trainer who is an actress and who has written multiple cases.

The SP exercise was similar to the process used in EM Oral Boards. At the beginning of the single case SP encounter, each student received a triage sheet on a different patient case and then had to manage the patient as they would in the ED. When a student felt a procedure was necessary, they would inform the standardized nurse; but because the patient was live, the student did not perform or demonstrate any invasive procedures. To maximize opportunities for student learning, peers also observed the student examinee and assessed his/her CC skills and CIPS. At the conclusion of each student's observed SP encounter, the entire group discussed the CC actions specific to each case to emphasize the critical points of recognition and management through an interactive approach.

CC actions assessment

The faculty observer, either SE or CS, when not serving as a standardized actor in the scenario, assessed the student's performance during the SP encounter. She used a checklist containing those CC actions deemed important and tailored to each case and keyed to ALERT; see Table 4 for details. The purpose of this exercise was not to judge performance summatively but to give the group of students a broad range of exposure to multiple cases through observation. The exercise allowed the students the opportunity to practice their systematic approach to the patient in a safe and realistic SP encounter. An example of the CC actions for the Meningitis case as it incorporates the use of the ALERT is as follows. A 44 year-old female presents to the emergency department complaining of headache for three days. The patient is confused. Vital signs are: temperature 102.1, heart rate 120, blood pressure 88/54, respiratory rate 24, and oxygen saturation 97%. The critical care actions for this case are:

• A (ABCs, Alert Attending, Apply, Access)

  • recognizes that the patient is critically ill by assessing airway, breathing, and circulation,

  • determines that the patient is hypotensive,

  • applies oxygen, monitor, intravenous (IV) access,

  • directs IV fluid resuscitation,

  • alerts the attending;

• L (Look for and treat Life-threatening conditions)

  • recognizes the petechial rash and possible Meningococcal meningitis,

  • administers antibiotics,

  • treats fever,

  • considers ordering laboratory based on their differential diagnosis;

• E (Examine and Evaluate with bedside tests)

• performs afocased examination including a neurologic examination,

  • recognizes the patient has altered mental status (AMS) and then directs the nurse to check serum glucose,

  • orders naloxone and thiamine to treat possible causes;

• R (Reassess, response to treatment, responders, records)

  • reassess patient's response to IV fluids by checking blood pressure, heart rate,

  • reassesses treatment of fever by checking a temperature,

  • reassesses treatment of AMS by questioning the patient,

  • if reassessment shows the patient condition has not improved or declined: the student reassesses the ‘A’ actions, OR

  • if reassessment shows improvement: the student proceeds to order additional laboratory,

  • speaks to family or other responders to get a more accurate history,

  • reviews records;

• T (Thorough H&P, Test results, To)

  • now that the patient's condition has improved, the student completes a thorough history and physical,

  • reviews and treats test results,

  • admits the patient to an intensive care isolation bed.

Immediately after the completion of each case, students discussed the expected CC actions so that they could understand the recognition and management concepts.

CIPS assessment

During the development of our curriculum we recognized that an assessment instrument of our communication objectives was essential to demonstrate specific communication behaviors and to measure performance. We also felt that this assessment instrument was an important part of the curriculum to facilitate learning through faculty, SP and self-assessment. We reviewed the literature for a CIPS assessment instrument that was validated for EM, addressed communication with the critical patient, was comprehensive, and covered communication with the patient/family and the healthcare team. We did not find any instrument that was comprehensive enough to meet all of our learning objectives. Therefore we elected to develop a checklist based on available tools in the literature (Rosenzweig et al. 1999; Makoul 2001; Hobgood et al. 2002; Residorff et al. 2003; Chapman et al. 2004; Duffy et al. 2004; Kalet et al. 2004; Lang et al. 2004; CORD 2005; Schirmer et al. 2005; Shayne et al. 2006). The CIPS checklist we developed consists of 22 behaviorally based skills in one of five categories in which the evaluator notes whether the skill was performed or not (Table 3).

To assess student performance in the CC management and CIPS, we used the faculty observer's recorded CC action checklist and CIPS checklist during the single SP encounter. We calculated student performance as a group on the individual CC actions and their performance percentage overall by case. We calculated the percentage of CIPS that students, as a group, demonstrated within each of the five skills categories and for each of the checklist items. Performance percentages of the individual items were also sorted from lowest to highest, and the difference between each item was calculated to look for performance gaps.

Feedback

As mentioned earlier, immediately following the single SP encounter the group of students discussed the CC actions of the case. The two EM faculty moderated the discussion. Group members provided feedback on the student's systematic approach and management of the patient. At the conclusion of the entire SP exercise, the group broke; and each student returned for an individual, private feedback session with the two faculty and SP. All participants viewed the student's videotaped SP encounter and completed a CIPS assessment, including student self-assessment. The discussion that followed the videotape viewing began first with the student's impression of his/her own performance, including self-identified deficits in CC actions and CIPS. The two faculty and the SP further emphasized strengths and weaknesses of the examinee's CC actions and CIPS and provided specific examples of how they could have accomplished each skill during the case. The feedback included instruction from the perspective of the healthcare team members, the patient, and the family.

Curriculum evaluation

Students completed a voluntary, anonymous evaluation of the curriculum by answering specific questions about the lectures and curriculum exercises. Using a 1-5 Likert scale, with 1 being strongly disagree and 5 being strongly agree, students indicated the extent of their agreement with statements about the following: the utility of the ALERT, the realism and fairness of the SP encounter exercise, and the usefulness of the CIPS checklist and the video self-assessment. They also indicated along a 1–5 scale whether they thought the format was, in general, an effective method for teaching CC. We used descriptive statistics (means and standard deviations) to characterize students’ responses to these questions. In addition, students wrote responses to several open-ended questions where they made suggestions to improve the curriculum, listed items they felt were missing from the CIPS assessment tool, and discussed what they specifically liked or disliked about the SP encounter. Two authors, SE and JQ, analysed their comments by using standard qualitative methods with open coding to establish common themes.

Results

Complete CIPS performance data were available for 47, CC performance data for 46, and curriculum evaluation data for 42 of 54 students who participated in the CC encounter. Students who were unable to participate in the entire SP exercise due to required commitments to their medicine continuity clinics were not included in the final results. It was not possible to hold the Instructor-administered SP encounter exercise during some months due to time constraints of the faculty and/or SPs.

The mean percentage of CC actions that students performed overall as a group was 79.6% (SD 0.15). The mean percentage of CC actions that the group performed in each case is presented in Table 4. CC action deficiency was set by using a cutoff performance of less than 80%. Overall, students performed the majority of the CC actions across all cases. While students most often alerted the attending, assessed and managed the ABCs, and ordered oxygen, monitor, and intravenous access (OMI), performance on CC actions varied by case. There were only two cases that students’ mean percent performance of all the CC actions occurred more than 80% of the time: Anaphylactic Shock and Urosepsis. Students performed above the cutoff on 33 out of 60 CC actions. There were nine CC medical actions that 50% or less of students performed and they occurred in the Stroke case, the Urosepsis case, in the Acute Myocardial Infarction case, the Status Asthmaticus case, the Ruptured Ectopic Pregnancy case, and the Upper Gastrointestinal Bleed case.

The mean percentage of CIPS that students performed overall as a group was 70.9% (SD 11.5%). Table 5 contains students’ overall CIPS performance by category, and Table 6 shows their performance by individual checklist item. Students scored above the 80% cutoff score on 9 of the 22 checklist items. Student performance was highest in the category of Basic Interpersonal Skills and Efficient Information Gathering where students performed well above the 80% cutoff in 8 out of the 9 items. The only other item which the students performed well was in the category of Ongoing Patient/Family Communication: students frequently communicated the care plan to the patient/family.

Table 5.  Students’ group performance on CIPS checklist

	Percentage of items performed
Category	Mean (n = 47)	Standard deviation	95% Confidence interval
Basic interpersonal skills	97.9%	5.6%	96.2% to 99.5%
Efficient information gathering	84.4%	21.8%	78.0% to 90.8%
On-going patient/family communication	67.0%	26.1%	59.4% to 74.7%
Healthcare team communication	60.6%	26.4%	52.9% to 68.4%
Empathy	41.7%	23.5%	34.8% to 48.6%

Table 6.  Student group performance by checklist item

Skill category	Checklist item	Mean (n = 47)	Standard deviation	95% Confidence interval
Basic interpersonal skills	Introduces self	100%	0%	N/A*
	Addresses patient/family by name	100%	0%	N/A*
	Allows patient/family to state the chief complaint in their own words	100%	0%	N/A*
	Makes frequent eye contact	98%	14.6%	94% to 102%
	Does not express personal opinions during interview	96%	20.4%	90% to 102%
	Allows the patient/family to finish sentences	94%	24.7%	86% to 101%
Efficient information	Question style/length appropriate for situation/patient condition	98%	14.6%	94% to 102%
Gathering	Directs interview with specific questions pertinent to patient case	91%	28.2%	83% to 100%
	Consistently uses lay terms	64%	48.6%	50% to 78%
Healthcare team communication	Presentation to consultant includes: Diagnosis, pertinent history and physical findings, test results, interventions, current condition	74%	44.1%	62% to 87%
	Verbalizes specific request to the consultant	70%	46.2%	57% to 84%
	Directs the nurse/healthcare team to reassess the patient's response to interventions	57%	50.0%	43% to 72%
	Communicates care plan to healthcare team and acknowledges any concerns	40%	49.6%	26% to 55%
On-going patient/family communication	Communicates patient care plan to the patient/family	83%	38%	72% to 94%
	Asks patient/family if they have questions	66%	47.9%	52% to 80%
	Keeps patient/family informed of results	62%	49.1%	47% to 76%
	Directly questions the patient about their response to treatment	57%	50.0%	43% to 72%
Empathy	Verbalizes understanding of patient/family's perspective on illness during care	51%	50.5%	36% to 66%
	Verbally acknowledges patient's pain/complaint immediately	49%	50.5%	34% to 64%
	Verbally reassures the patient/family	40%	49.6%	26% to 55%
	Touches patient in reassuring manner (if culturally appropriate)	38%	49.1%	24% to 53%
	Verbally acknowledge the patient's nonverbal gestures	30%	46.2%	16% to 43%

*95% confidence intervals could not be determined because standard deviation was 0%.

Student performance was lowest in the Empathy category. In fact, 3 of the least performed checklist items were in the Empathy skill set. In Healthcare Team Communication students least often communicated the care plan and/or acknowledged team member concerns. Students also showed deficiencies in On-going Patient/Family Communication where they often failed to question about response to treatment, share results, and ask if they have questions.

Forty-two students completed the curriculum evaluation. Student evaluation of the curriculum was positive. Students felt the ALERT mnemonic was helpful (M = 4.38, SD 0.854) and reported using it in the ED (M = 4.07, SD 0.973). They also rated the CC encounter exercise as realistic (M = 4.43, SD 0.737) and fair (M = 4.60, SD 0.665). They felt the CIPS checklist was useful (M = 4.24, SD 0.906) and that the curriculum was a good teaching format for CC (M = 4.48, SD 0.773). They thought the use of the video self-assessment was the least valuable component of the curriculum (mean rating = 4.0, SD 1.183).

Students’ written comments indicated that they thought the CIPS assessment tool was complete, and they liked learning about CC with these educational activities. Student remarks on the CC learning activities were, for example:

[This was an] opportunity to care for the types of patients that residents normally saw,

[It] allows you to run through the appropriate (actions) on a sick patient,

It simulates real-life encounters.

Students thought the CIPS checklist was complete. The following quotes illustrate the aspects of the SP encounter that they liked:

The structured examination was a good learning tool along with observing others,

(A) great chance at self and peer-evaluation.

While some students disliked the peer observation of their clinical management of the SPs, they still recognized it as a helpful exercise. They made the same statement about the video self-assessment:

I dislike being videotaped but it was helpful to evaluate (my) own performance.

They themselves liked learning by observing their peers and appreciated the feedback from the attending and SP. Some students liked peer assessment of their CIPS.

Discussion

The literature shows that medical students lack knowledge, confidence, and competence in nearly all aspects of acute care, including the recognition and management of acutely ill patients (Murray et al. 2002; Smith et al. 2007). Recognizing a need for CC teaching in undergraduate medical education, we developed a curriculum emphasizing recognition and management tasks specific to the care of a critical patient and provided a realistic, simulated exercise to practice management principles. Our results identified strengths and weaknesses in student performance of CC actions.

Our results have identified deficiencies in a SP encounter that asked students to integrate their management and communication skills. Students’ performance of empathy skills was particularly weak. A potential explanation for this finding might be that students do not see CIPS, especially empathy, as important in caring for the critically ill. Alternatively, the technical tasks at hand may overwhelm students, to the detriment of using CIPS (Scott et al. 1975; Haq et al. 2004; Kalet et al. 2004; Deveugele et al. 2005). Our results remind us that we as educators must continue to work toward enabling students to develop and maintain strong CIPS to ensure patient safety and satisfaction with the ultimate goal of assisting students to integrate their learning of CIPS along with their learning of medical skills.

As instructors we hoped the learning exercises using interactive lectures, real patient observation, small group discussion, peer observation, faculty and SP feedback, and self-assessment facilitated the students’ learning of CC recognition, management, and CIPS. By using the CC action checklists and CIPS assessment tool to evaluate multiple SP encounters, the students had the opportunity to learn through observation, demonstration, assessment, and feedback. And in turn, they could adapt and model these learned behaviors beyond this curriculum. Student evaluations of the curriculum activities were positive and reflected that they liked and benefited from these learning exercises. They also responded that learning through peer observation and videotape self-assessment of performance was unpleasant but they recognized the value of the exercise.

The self-assessment portion of the curriculum allowed the student to identify specific strengths and weaknesses in their own performance of CC actions and CIPS. Previous results suggest that self-assessment has educational merit both as a measure of one's clinical performance and as a method to further learning and professional development in the medical student (Arnold et al. 1985; Eva & Regehr 2005), particularly when performance standards are clear (Woolliscroft et al. 1993; Gruppen et al. 2000). We hope that by comparing their own performance to an objective standard (the CC and CIPS checklists) the students learned from their self-assessment.

Limitations

We developed and implemented this curriculum with limited resources necessitating the use of physicians as the SP and standardized actors in the single case SP encounter. The use of resident physicians as SPs has not been evaluated in the literature, but we felt our trained resident SP provided medical knowledge and experience that enhanced the portrayal of the critical patient. Further, due to scarce resources, faculty who created the curriculum observed the students’ performances. Their involvement with the curriculum might have biased their observations, but they used checklists rather than rating students with the purpose of providing formative feedback, not summative assessment, of students.

Also due to limited resources, we were unable to develop the curriculum with a pre/post-test design. Since this constrains our ability to measure curriculum effectiveness, an important next step in the future direction of our curriculum activities and data analysis will incorporate a more rigorous study design that will yield baseline as well as post-curriculum performance data.

The students’ SP encounter involved just one case. A more complete assessment of each student's CC actions and CIPS would depend on administering a multi-station examination due to case specificity, with each case having different expected actions. Indeed, we found CC performance of students to be case specific. However, we developed the encounter as a teaching tool so students could learn to integrate a systematic approach to CC evaluation and management with CIPS through direct practice and also through observation of multiple cases. Further, we designed the encounter to offer formative feedback to students and an opportunity for self and peer assessment. A future plan to avoid case specificity may be to have students perform all cases.

Finally, there are measurement issues with our assessment tools. In particular, our CIPS assessment checklist has not been validated so this will also be an important next step in the future direction of our project. Whether CC action and CIPS performance demonstrated during the SP encounter would transfer to the real clinical setting where the performance stakes are higher is an important question that awaits further study.

Conclusion

The curriculum as implemented offers a feasible approach to integrating CIPS with the recognition and management of the critical patient for students in an EM clerkship. Identification of student deficiencies in both critical care management and CIPS points to the ongoing need for further instruction and in-depth learning experiences to integrate technical management and communication skills in undergraduate medical education.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Notes on contributors

Stefanie Ellison

STEFANIE ELLISON, MD is the EM Student Clerkship Director for the University of Missouri-Kansas City School of Medicine.

Christine Sullivan

CHRISTINE SULLIVAN, MD is the EM Residency Program Director for the UMKC School of Medicine.

Jennifer Quaintance

JENNIFER QUAINTANCE, PhD and LOUISE ARNOLD, PhD work for the Office of Medical Education of the UMKC School of Medicine.

Paula Godfrey

PAULA GODFREY, Do is a resident physician standardized patient for the curriculum.