Grace C. Huang, MD

Informed consent is one of the ethical, legal, and moral foundations of modern medicine.[1] Key elements of informed consent include: details of the procedure, benefits of the procedure, significant risks involved, likelihood of the outcome if predictable, and alternative therapeutic options.[2] Although rarely identified as such, conversations eliciting patient preferences about cardiopulmonary resuscitation (CPR) are among the most common examples of obtaining informed consent. Nevertheless, discussing CPR preference, often called code status discussions, differs from other examples of obtaining informed consent in 2 important ways. First, they occur well in advance of the potential need for CPR, so that the patient is well enough to participate meaningfully in the discussion. Second, because the default assumption is for patients to undergo the intervention (i.e. CPR), the focus of code status discussions is often on informed refusal, namely a decision about a do not resuscitate(DNR) order.

Since the institution of the Patient Self‐Determination Act in 1990, hospitals are obliged to educate patients about choices regarding end‐of‐life care at the time of hospital admission.[3] In many teaching hospitals, this responsibility falls to the admitting physician, often a trainee, who determines the patient's preferences regarding CPR and documents whether the patient is full code or DNR.

Prior studies have raised concerns about the quality of these conversations, highlighting their superficial nature and revealing trainee dissatisfaction with the results.[4, 5] Importantly, studies have shown that patients are capable of assimilating information about CPR when presented accurately and completely, and that such information can dramatically alter their choices.[6, 7, 8] These findings suggest that patients who are adequately educated will make more informed decisions regarding CPR, and that well‐informed choices about CPR may differ from poorly informed ones.

Although several studies have questioned the quality of code status discussions, none of these studies frames these interactions as examples of informed consent. Therefore, the purpose of the study was to examine the content of code status discussions as reported by internal medicine residents to determine whether they meet the basic tenets of informed consent, thereby facilitating informed decision making.

METHODS

In an iterative, collaborative process, authors A.F.B. and M.K.B. (an internal medicine resident at the time of the study and a board‐certified palliative care specialist/oncologist with experience in survey development, respectively) developed a survey adapted from previously published surveys.[9, 10, 11] The survey solicited respondent demographics, frequency of code status conversations, content of these discussions, and barriers to discussions. The survey instrument can be viewed in the Supporting Information, Appendix A, in the online version of this article. We used a 5‐point frequency scale (almost nevernearly always) for questions regarding: specific aspects of the informed consent related to code status discussions, resident confidence in conducting code status discussions, and barriers to code status discussions. We used a checklist for questions regarding content of code status discussions and patient characteristics influencing code status discussions. Residents provided a numeric percentage answer to 2 knowledge‐based questions of postarrest outcomes: (1) likelihood a patient would survive a witnessed pulseless ventricular tachycardia event and (2) likelihood of survival of a pulseless electrical activity event. The survey was revised by a hospitalist with experience in survey design (G.C.H.). We piloted the survey with 15 residents not part of the subject population and made revisions based on their input.

We sent a link to the online survey over secure email to all 159 internal medicine residents at our urban‐based academic medical center in January 2012. The email described the purpose of the study and stated that participation in the study (or lack thereof) was voluntary, anonymous, and would not have ramifications within the residency program. As part of the recruitment email, we explicitly included the elements of informed consent for the study participants. Not all the questions were mandatory to complete the survey. We sent a reminder e‐mail on a weekly basis for a total of 3 times and closed the survey after 1 month. Our goal was a 60% (N = 95) response rate.

We tabulated the results by question. For analytic purposes, we aligned the content questions with key elements of informed consent as follows: step‐by‐step description of the events (details), patient‐specific likelihood of discharge if resuscitated (benefits), complications of resuscitation (risks), population‐based likelihood of discharge if resuscitated (likelihood), and opportunity for changing code status (alternatives). For the knowledge‐based questions, we deemed the answer correct if it was within 10% (5%) of published statistics from the 2010 national registry of cardiopulmonary resuscitation.[12] We stratified the key elements of informed consent and level of confidence by postgraduate year (PGY), comparing PGY1 residents versus PGY2 and PGY3 residents using ² tests (or Fisher exact test for observations 5). We performed a univariate logistic regression analysis examining the relationship between confidence and reported use of informed consent elements in code discussions. The dependent variable of confidence in sufficient information having been provided for fully informed decision making was dichotomized as most of the time or nearly always versus other responses, whereas the independent variable was dichotomized as residents who reported using all 5 informed consent elements versus those who did not. We analyzed data using Stata 12 (StataCorp, College Station, TX).

The institutional review board of the Beth Israel Deaconess reviewed the study protocol and determined that it was exempt from institutional review board review.

RESULTS

One hundred of 159 (62.3%) internal medicine residents responded to the survey. Of the respondents 93% (N = 93) completed the survey. The 7% (N = 7) who did not complete the survey omitted the knowledge‐based questions and demographics. Approximately half of participants (54%, N = 50) were male. The majority of residents (85%, N = 79) had either occasional or frequent exposure to palliative care, with 10% (N = 9) having completed a palliative care rotation (Table 1).

The vast majority of residents (96%, N = 95) discussed code status with more than 40% of patients they admitted to the hospital (Table 2). Two‐thirds (66%, N = 65) of all residents had the conversation with at least 4 out of 5 (81%99% and 100%) patients they admitted to the hospital. Only 1% (N = 1) of residents who responded to the survey reported conducting code status discussions with 20% or fewer of the patients they admitted to the hospital.

Most residents (66%, N = 66) identified the healthcare proxy or surrogate decision maker most of the time or nearly always. In addition, most residents (62%, N = 62) reminded patients that they could reverse their code status at any time. Almost half included a description of step‐by‐step events during resuscitation (45%, N = 45) or factored in patient's comorbidities (43%, N = 43) when discussing resuscitation at least most of the time. Few residents described complications (31%, N = 31) or outcomes (17%, N = 17) of cardiopulmonary arrests to patients most of the time or nearly always. Most residents did not explore factors such as quality of life, role of depression or physical states worse than death, factors that could potentially affect patient decision making (Table 2). Few (9%, N = 8) internal medicine residents (often or nearly always) offered their opinion regarding a patient's code status.

Many factors influenced residents' decisions to have a code status conversation. At least 85% (N = 86) of residents reported that older age, particular admitting diagnoses, and multiple comorbidities made them more likely to have a code status discussion (see Supporting Table 1 in the online version of this article). Patient race/ethnicity did not influence this decision, with only 1 respondent reporting this factor as relevant.

Residents identified lack of time (49%, N = 49 responding often or nearly always) as the most frequent barrier to having a code status discussion, followed by lack of rapport (29%, N = 29). Lack of experience (6%, N = 6), lack of information about the patient's clinical status (11%, N = 11), and lack of knowledge about outcomes (13%, N = 13) did not represent frequent barriers for residents.

Fifty‐five percent (N = 53) of residents often or nearly always felt confident that they provided enough information for patients to make fully informed decisions about code status, and this did not differ by PGY status (PGY1 vs PGY2/3, P = 0.80, ² test). However, only 8% (N = 8) of residents most of the time or nearly always addressed all 5 key elements of informed consent in reporting the content of their code status discussions. When stratified by training year, PGY2/3 residents were significantly more likely than PGY1 residents to factor in a patient's comorbidities when discussing resuscitation and were also significantly more likely to relay the likelihood of hospital discharge. They were not significantly more likely to discuss other key elements of informed consent (Table 3).

Our subanalysis showed that residents reporting all 5 key elements of informed consent were associated with higher levels of confidence that they had provided enough information to patients for them to make an informed decision (odds ratio of 1.7, 95% confidence interval 1.2‐2.3).

For the first knowledge‐based question about witnessed pulseless ventricular tachycardia, according to the 2010 registry,[12] 64% survived the event (range of responses 1%90%). Six out of 92 (7%) respondents were within 5% of the correct answer. For the second question about survival after unwitnessed pulseless electrical activity, 41.5% survived the event according to the registry (range of responses 1%50%). Three out of 92 (3%) respondents gave estimates within 5% of the correct answer. Figures 1 and 2 display the ranges of responses from residents.

Figure 1

Figure 2

DISCUSSION

We found that although our internal medicine residents frequently have code status discussions with their patients, very few routinely report addressing all 5 key elements of informed consent. Furthermore, residents lack accurate knowledge about the outcomes of CPR, with most tending to underestimate the benefit expected of resuscitation. These deficiencies raise serious concerns about whether patients are receiving all the information essential to making fully informed decisions about their preferences for resuscitation.

The data demonstrate that the residents are routinely discussing code status and regularly discussing some aspects of the procedure itself, such as chest compressions, intubation, or defibrillation; the actual step‐by‐step events of CPR are being described less than half the time. It seems that residents mentally list the possible procedures that may occur in a code without a context for how one intervention would lead to another. Placing CPR into context is important, because studies have shown that more comprehensive discussions or the use of visual aids/videos that depict CPR in more detail improves patients' understanding of CPR and changes their decision about CPR, making them more likely to forego the procedure.[7, 8]

Residents report that they are more likely to have a code status discussion with patient's with multiple comorbidities, suggesting that they take into account information about the patient's clinical condition when deciding with which patients to address code status. They also recognize which patients are at increased risk for an in hospital cardiopulmonary arrest. Additionally, nearly half of residents factor in patient's comorbidities when discussing likelihood of discharge from the hospital, suggesting that they recognize that comorbidities can alter the outcome of CPR. Importantly, however, very few residents describe the likelihood the patient will be discharged from the hospital if resuscitated. Thus, residents in our sample have some insight into the impact of comorbidities on outcomes of CPR, but fail to provide their patients with any information about the outcome of CPR.

One reason residents may not discuss outcomes of CPR is because they do not know the data regarding outcomes. Although few residents reported that lack of knowledge of the risks and outcomes of CPR was a barrier, very few respondents answered the knowledge questions appropriately. Given how few residents gave an accurate estimate of CPR outcomes and simultaneously reported confidence in their code status discussions suggests that many residents fail to recognize their knowledge deficits. This finding corroborates other studies showing that residents don't know what they don't know[10] and may reflect their lack of education on CPR outcomes. Alternatively, some residents who underestimated the outcomes in the examples provided may have done so because, in their experience caring for patients with multiple comorbidites, the outcomes of CPR are in fact poorer than those in the cases described. Outcomes of CPR at our institution might differ from those quoted in the registry. However, given the prevalence of inaccuracy, both for under‐ and overestimation, it seems likely that a true knowledge deficit on the part of the residents still accounts for much of the error and should be a target for education. Understanding CPR outcomes is vital for informed decision making, and studies have shown that when patients have more information, it can substantially affect a patient's decision regarding resuscitation.[7, 13]

Residents are infrequently exploring key determinants that affect a patient's decision‐making process. Only one‐third of residents report discussing quality‐of‐life issues with patients during code status discussions. Understanding an individual patient's values and goals and how he or she describes a good quality of life can help guide the discussion and potential recommendations. For example, some patients may feel it is important to be alive regardless of the physical state, whereas others may feel that if there is not a chance to be independent in their activities of daily living, then they would not want to be resuscitated. By exploring patient's perceptions of what quality of life and physical states worse than death means, residents can better understand and assist in the decision‐making process of their patients.

Our data show that few residents offer a recommendation regarding code status. Thus, residents expect patients to make their own decision with the data provided. At the same time, many residents focus on the details of the procedural components of CPR with little mention of anticipated outcomes or inquiries into key determinants discussed above. Additionally, based on their response to the knowledge‐based questions, residents' estimates of survival, if offered, would be inaccurate. Thus, code status conversations by residents leave patients to make uninformed choices to consent to or refuse resuscitative measures.

When stratified by training year, PGY2/3 residents were significantly more likely than PGY1 residents to discuss likelihood of discharge from the hospital as well as factor in patients' comorbidities when discussing outcomes. Although there is a statistically significant improvement between PGY2/3 residents as compared to PGY1 residents, the numbers still show that most PGY2/3 residents and almost all PGY1 residents do not discuss the likelihood of discharge if resuscitated during code status discussions. In addition, there is no difference reported in other key areas of informed consent. Thus, though there is some improvement as housestaff advance in their training, PGY2 and PGY3 residents still do not discuss all 5 key elements of informed consent significantly more than PGY1 residents.

Our findings suggest an opportunity for additional education regarding how to address code status for internal medicine housestaff. Over half of the respondents reported small group teaching sessions, direct observation and feedback, and exposure to palliative care consultation during their clinical rotations; yet, very few of them included all the key elements of informed consent in their discussions. To address this, our institution is developing additional educational initiatives, including a faculty development program for teaching communication skills, using direct observation and feedback. The orientation didactic lecture series for housestaff now includes a lecture on CPR that highlights the data on outcomes and the importance of putting the step‐by‐step procedures of CPR into the context of potential benefits, such as survival to hospital discharge. The curriculum also includes a module on advance care planning for junior and senior residents during their ambulatory block, using simulation and feedback as part of the teaching methods.

There are limitations to this study. Studies based on surveys are subject to recall and selection bias, and we lack objective assessment of actual code status discussions. Furthermore, the nature of the study may lead to an overestimation of the quality of the code status discussions due to social acceptability bias; yet, our data clearly show that the key elements of informed consent are not included during these conversations. Another limitation is that our subjects were residents at a single institution, and our clinical practice may differ from other academic settings in the teaching environment and culture; yet, our findings mirror similar work done in other locations.[10, 14]

In conclusion, our results demonstrate that residents fail to meet standards of informed consent when discussing code status in that they do not provide sufficient information for patients to make an informed decision regarding resuscitation. Residents would benefit from education aimed at improving their knowledge of CPR outcomes as well as training on how to conduct these conversations effectively. Framing code status discussions as an example of an informed consent may help residents recognize the need for the key elements to be included in these conversations. In addition, training should focus on how to conduct these conversations in an efficient yet effective manner. This will require clear simple language, good communication skills, and training with observation and feedback by specialists trained in this field.

Informed consent is one of the ethical, legal, and moral foundations of modern medicine.[1] Key elements of informed consent include: details of the procedure, benefits of the procedure, significant risks involved, likelihood of the outcome if predictable, and alternative therapeutic options.[2] Although rarely identified as such, conversations eliciting patient preferences about cardiopulmonary resuscitation (CPR) are among the most common examples of obtaining informed consent. Nevertheless, discussing CPR preference, often called code status discussions, differs from other examples of obtaining informed consent in 2 important ways. First, they occur well in advance of the potential need for CPR, so that the patient is well enough to participate meaningfully in the discussion. Second, because the default assumption is for patients to undergo the intervention (i.e. CPR), the focus of code status discussions is often on informed refusal, namely a decision about a do not resuscitate(DNR) order.

Since the institution of the Patient Self‐Determination Act in 1990, hospitals are obliged to educate patients about choices regarding end‐of‐life care at the time of hospital admission.[3] In many teaching hospitals, this responsibility falls to the admitting physician, often a trainee, who determines the patient's preferences regarding CPR and documents whether the patient is full code or DNR.

Prior studies have raised concerns about the quality of these conversations, highlighting their superficial nature and revealing trainee dissatisfaction with the results.[4, 5] Importantly, studies have shown that patients are capable of assimilating information about CPR when presented accurately and completely, and that such information can dramatically alter their choices.[6, 7, 8] These findings suggest that patients who are adequately educated will make more informed decisions regarding CPR, and that well‐informed choices about CPR may differ from poorly informed ones.

Although several studies have questioned the quality of code status discussions, none of these studies frames these interactions as examples of informed consent. Therefore, the purpose of the study was to examine the content of code status discussions as reported by internal medicine residents to determine whether they meet the basic tenets of informed consent, thereby facilitating informed decision making.

METHODS

In an iterative, collaborative process, authors A.F.B. and M.K.B. (an internal medicine resident at the time of the study and a board‐certified palliative care specialist/oncologist with experience in survey development, respectively) developed a survey adapted from previously published surveys.[9, 10, 11] The survey solicited respondent demographics, frequency of code status conversations, content of these discussions, and barriers to discussions. The survey instrument can be viewed in the Supporting Information, Appendix A, in the online version of this article. We used a 5‐point frequency scale (almost nevernearly always) for questions regarding: specific aspects of the informed consent related to code status discussions, resident confidence in conducting code status discussions, and barriers to code status discussions. We used a checklist for questions regarding content of code status discussions and patient characteristics influencing code status discussions. Residents provided a numeric percentage answer to 2 knowledge‐based questions of postarrest outcomes: (1) likelihood a patient would survive a witnessed pulseless ventricular tachycardia event and (2) likelihood of survival of a pulseless electrical activity event. The survey was revised by a hospitalist with experience in survey design (G.C.H.). We piloted the survey with 15 residents not part of the subject population and made revisions based on their input.

We sent a link to the online survey over secure email to all 159 internal medicine residents at our urban‐based academic medical center in January 2012. The email described the purpose of the study and stated that participation in the study (or lack thereof) was voluntary, anonymous, and would not have ramifications within the residency program. As part of the recruitment email, we explicitly included the elements of informed consent for the study participants. Not all the questions were mandatory to complete the survey. We sent a reminder e‐mail on a weekly basis for a total of 3 times and closed the survey after 1 month. Our goal was a 60% (N = 95) response rate.

We tabulated the results by question. For analytic purposes, we aligned the content questions with key elements of informed consent as follows: step‐by‐step description of the events (details), patient‐specific likelihood of discharge if resuscitated (benefits), complications of resuscitation (risks), population‐based likelihood of discharge if resuscitated (likelihood), and opportunity for changing code status (alternatives). For the knowledge‐based questions, we deemed the answer correct if it was within 10% (5%) of published statistics from the 2010 national registry of cardiopulmonary resuscitation.[12] We stratified the key elements of informed consent and level of confidence by postgraduate year (PGY), comparing PGY1 residents versus PGY2 and PGY3 residents using ² tests (or Fisher exact test for observations 5). We performed a univariate logistic regression analysis examining the relationship between confidence and reported use of informed consent elements in code discussions. The dependent variable of confidence in sufficient information having been provided for fully informed decision making was dichotomized as most of the time or nearly always versus other responses, whereas the independent variable was dichotomized as residents who reported using all 5 informed consent elements versus those who did not. We analyzed data using Stata 12 (StataCorp, College Station, TX).

The institutional review board of the Beth Israel Deaconess reviewed the study protocol and determined that it was exempt from institutional review board review.

RESULTS

One hundred of 159 (62.3%) internal medicine residents responded to the survey. Of the respondents 93% (N = 93) completed the survey. The 7% (N = 7) who did not complete the survey omitted the knowledge‐based questions and demographics. Approximately half of participants (54%, N = 50) were male. The majority of residents (85%, N = 79) had either occasional or frequent exposure to palliative care, with 10% (N = 9) having completed a palliative care rotation (Table 1).

The vast majority of residents (96%, N = 95) discussed code status with more than 40% of patients they admitted to the hospital (Table 2). Two‐thirds (66%, N = 65) of all residents had the conversation with at least 4 out of 5 (81%99% and 100%) patients they admitted to the hospital. Only 1% (N = 1) of residents who responded to the survey reported conducting code status discussions with 20% or fewer of the patients they admitted to the hospital.

Most residents (66%, N = 66) identified the healthcare proxy or surrogate decision maker most of the time or nearly always. In addition, most residents (62%, N = 62) reminded patients that they could reverse their code status at any time. Almost half included a description of step‐by‐step events during resuscitation (45%, N = 45) or factored in patient's comorbidities (43%, N = 43) when discussing resuscitation at least most of the time. Few residents described complications (31%, N = 31) or outcomes (17%, N = 17) of cardiopulmonary arrests to patients most of the time or nearly always. Most residents did not explore factors such as quality of life, role of depression or physical states worse than death, factors that could potentially affect patient decision making (Table 2). Few (9%, N = 8) internal medicine residents (often or nearly always) offered their opinion regarding a patient's code status.

Many factors influenced residents' decisions to have a code status conversation. At least 85% (N = 86) of residents reported that older age, particular admitting diagnoses, and multiple comorbidities made them more likely to have a code status discussion (see Supporting Table 1 in the online version of this article). Patient race/ethnicity did not influence this decision, with only 1 respondent reporting this factor as relevant.

Residents identified lack of time (49%, N = 49 responding often or nearly always) as the most frequent barrier to having a code status discussion, followed by lack of rapport (29%, N = 29). Lack of experience (6%, N = 6), lack of information about the patient's clinical status (11%, N = 11), and lack of knowledge about outcomes (13%, N = 13) did not represent frequent barriers for residents.

Fifty‐five percent (N = 53) of residents often or nearly always felt confident that they provided enough information for patients to make fully informed decisions about code status, and this did not differ by PGY status (PGY1 vs PGY2/3, P = 0.80, ² test). However, only 8% (N = 8) of residents most of the time or nearly always addressed all 5 key elements of informed consent in reporting the content of their code status discussions. When stratified by training year, PGY2/3 residents were significantly more likely than PGY1 residents to factor in a patient's comorbidities when discussing resuscitation and were also significantly more likely to relay the likelihood of hospital discharge. They were not significantly more likely to discuss other key elements of informed consent (Table 3).

Our subanalysis showed that residents reporting all 5 key elements of informed consent were associated with higher levels of confidence that they had provided enough information to patients for them to make an informed decision (odds ratio of 1.7, 95% confidence interval 1.2‐2.3).

For the first knowledge‐based question about witnessed pulseless ventricular tachycardia, according to the 2010 registry,[12] 64% survived the event (range of responses 1%90%). Six out of 92 (7%) respondents were within 5% of the correct answer. For the second question about survival after unwitnessed pulseless electrical activity, 41.5% survived the event according to the registry (range of responses 1%50%). Three out of 92 (3%) respondents gave estimates within 5% of the correct answer. Figures 1 and 2 display the ranges of responses from residents.

Figure 1

Figure 2

DISCUSSION

We found that although our internal medicine residents frequently have code status discussions with their patients, very few routinely report addressing all 5 key elements of informed consent. Furthermore, residents lack accurate knowledge about the outcomes of CPR, with most tending to underestimate the benefit expected of resuscitation. These deficiencies raise serious concerns about whether patients are receiving all the information essential to making fully informed decisions about their preferences for resuscitation.

The data demonstrate that the residents are routinely discussing code status and regularly discussing some aspects of the procedure itself, such as chest compressions, intubation, or defibrillation; the actual step‐by‐step events of CPR are being described less than half the time. It seems that residents mentally list the possible procedures that may occur in a code without a context for how one intervention would lead to another. Placing CPR into context is important, because studies have shown that more comprehensive discussions or the use of visual aids/videos that depict CPR in more detail improves patients' understanding of CPR and changes their decision about CPR, making them more likely to forego the procedure.[7, 8]

Residents report that they are more likely to have a code status discussion with patient's with multiple comorbidities, suggesting that they take into account information about the patient's clinical condition when deciding with which patients to address code status. They also recognize which patients are at increased risk for an in hospital cardiopulmonary arrest. Additionally, nearly half of residents factor in patient's comorbidities when discussing likelihood of discharge from the hospital, suggesting that they recognize that comorbidities can alter the outcome of CPR. Importantly, however, very few residents describe the likelihood the patient will be discharged from the hospital if resuscitated. Thus, residents in our sample have some insight into the impact of comorbidities on outcomes of CPR, but fail to provide their patients with any information about the outcome of CPR.

One reason residents may not discuss outcomes of CPR is because they do not know the data regarding outcomes. Although few residents reported that lack of knowledge of the risks and outcomes of CPR was a barrier, very few respondents answered the knowledge questions appropriately. Given how few residents gave an accurate estimate of CPR outcomes and simultaneously reported confidence in their code status discussions suggests that many residents fail to recognize their knowledge deficits. This finding corroborates other studies showing that residents don't know what they don't know[10] and may reflect their lack of education on CPR outcomes. Alternatively, some residents who underestimated the outcomes in the examples provided may have done so because, in their experience caring for patients with multiple comorbidites, the outcomes of CPR are in fact poorer than those in the cases described. Outcomes of CPR at our institution might differ from those quoted in the registry. However, given the prevalence of inaccuracy, both for under‐ and overestimation, it seems likely that a true knowledge deficit on the part of the residents still accounts for much of the error and should be a target for education. Understanding CPR outcomes is vital for informed decision making, and studies have shown that when patients have more information, it can substantially affect a patient's decision regarding resuscitation.[7, 13]

Residents are infrequently exploring key determinants that affect a patient's decision‐making process. Only one‐third of residents report discussing quality‐of‐life issues with patients during code status discussions. Understanding an individual patient's values and goals and how he or she describes a good quality of life can help guide the discussion and potential recommendations. For example, some patients may feel it is important to be alive regardless of the physical state, whereas others may feel that if there is not a chance to be independent in their activities of daily living, then they would not want to be resuscitated. By exploring patient's perceptions of what quality of life and physical states worse than death means, residents can better understand and assist in the decision‐making process of their patients.

Our data show that few residents offer a recommendation regarding code status. Thus, residents expect patients to make their own decision with the data provided. At the same time, many residents focus on the details of the procedural components of CPR with little mention of anticipated outcomes or inquiries into key determinants discussed above. Additionally, based on their response to the knowledge‐based questions, residents' estimates of survival, if offered, would be inaccurate. Thus, code status conversations by residents leave patients to make uninformed choices to consent to or refuse resuscitative measures.

When stratified by training year, PGY2/3 residents were significantly more likely than PGY1 residents to discuss likelihood of discharge from the hospital as well as factor in patients' comorbidities when discussing outcomes. Although there is a statistically significant improvement between PGY2/3 residents as compared to PGY1 residents, the numbers still show that most PGY2/3 residents and almost all PGY1 residents do not discuss the likelihood of discharge if resuscitated during code status discussions. In addition, there is no difference reported in other key areas of informed consent. Thus, though there is some improvement as housestaff advance in their training, PGY2 and PGY3 residents still do not discuss all 5 key elements of informed consent significantly more than PGY1 residents.

Our findings suggest an opportunity for additional education regarding how to address code status for internal medicine housestaff. Over half of the respondents reported small group teaching sessions, direct observation and feedback, and exposure to palliative care consultation during their clinical rotations; yet, very few of them included all the key elements of informed consent in their discussions. To address this, our institution is developing additional educational initiatives, including a faculty development program for teaching communication skills, using direct observation and feedback. The orientation didactic lecture series for housestaff now includes a lecture on CPR that highlights the data on outcomes and the importance of putting the step‐by‐step procedures of CPR into the context of potential benefits, such as survival to hospital discharge. The curriculum also includes a module on advance care planning for junior and senior residents during their ambulatory block, using simulation and feedback as part of the teaching methods.

There are limitations to this study. Studies based on surveys are subject to recall and selection bias, and we lack objective assessment of actual code status discussions. Furthermore, the nature of the study may lead to an overestimation of the quality of the code status discussions due to social acceptability bias; yet, our data clearly show that the key elements of informed consent are not included during these conversations. Another limitation is that our subjects were residents at a single institution, and our clinical practice may differ from other academic settings in the teaching environment and culture; yet, our findings mirror similar work done in other locations.[10, 14]

In conclusion, our results demonstrate that residents fail to meet standards of informed consent when discussing code status in that they do not provide sufficient information for patients to make an informed decision regarding resuscitation. Residents would benefit from education aimed at improving their knowledge of CPR outcomes as well as training on how to conduct these conversations effectively. Framing code status discussions as an example of an informed consent may help residents recognize the need for the key elements to be included in these conversations. In addition, training should focus on how to conduct these conversations in an efficient yet effective manner. This will require clear simple language, good communication skills, and training with observation and feedback by specialists trained in this field.

Informed consent is one of the ethical, legal, and moral foundations of modern medicine.[1] Key elements of informed consent include: details of the procedure, benefits of the procedure, significant risks involved, likelihood of the outcome if predictable, and alternative therapeutic options.[2] Although rarely identified as such, conversations eliciting patient preferences about cardiopulmonary resuscitation (CPR) are among the most common examples of obtaining informed consent. Nevertheless, discussing CPR preference, often called code status discussions, differs from other examples of obtaining informed consent in 2 important ways. First, they occur well in advance of the potential need for CPR, so that the patient is well enough to participate meaningfully in the discussion. Second, because the default assumption is for patients to undergo the intervention (i.e. CPR), the focus of code status discussions is often on informed refusal, namely a decision about a do not resuscitate(DNR) order.

Since the institution of the Patient Self‐Determination Act in 1990, hospitals are obliged to educate patients about choices regarding end‐of‐life care at the time of hospital admission.[3] In many teaching hospitals, this responsibility falls to the admitting physician, often a trainee, who determines the patient's preferences regarding CPR and documents whether the patient is full code or DNR.

Prior studies have raised concerns about the quality of these conversations, highlighting their superficial nature and revealing trainee dissatisfaction with the results.[4, 5] Importantly, studies have shown that patients are capable of assimilating information about CPR when presented accurately and completely, and that such information can dramatically alter their choices.[6, 7, 8] These findings suggest that patients who are adequately educated will make more informed decisions regarding CPR, and that well‐informed choices about CPR may differ from poorly informed ones.

Although several studies have questioned the quality of code status discussions, none of these studies frames these interactions as examples of informed consent. Therefore, the purpose of the study was to examine the content of code status discussions as reported by internal medicine residents to determine whether they meet the basic tenets of informed consent, thereby facilitating informed decision making.

METHODS

In an iterative, collaborative process, authors A.F.B. and M.K.B. (an internal medicine resident at the time of the study and a board‐certified palliative care specialist/oncologist with experience in survey development, respectively) developed a survey adapted from previously published surveys.[9, 10, 11] The survey solicited respondent demographics, frequency of code status conversations, content of these discussions, and barriers to discussions. The survey instrument can be viewed in the Supporting Information, Appendix A, in the online version of this article. We used a 5‐point frequency scale (almost nevernearly always) for questions regarding: specific aspects of the informed consent related to code status discussions, resident confidence in conducting code status discussions, and barriers to code status discussions. We used a checklist for questions regarding content of code status discussions and patient characteristics influencing code status discussions. Residents provided a numeric percentage answer to 2 knowledge‐based questions of postarrest outcomes: (1) likelihood a patient would survive a witnessed pulseless ventricular tachycardia event and (2) likelihood of survival of a pulseless electrical activity event. The survey was revised by a hospitalist with experience in survey design (G.C.H.). We piloted the survey with 15 residents not part of the subject population and made revisions based on their input.

We sent a link to the online survey over secure email to all 159 internal medicine residents at our urban‐based academic medical center in January 2012. The email described the purpose of the study and stated that participation in the study (or lack thereof) was voluntary, anonymous, and would not have ramifications within the residency program. As part of the recruitment email, we explicitly included the elements of informed consent for the study participants. Not all the questions were mandatory to complete the survey. We sent a reminder e‐mail on a weekly basis for a total of 3 times and closed the survey after 1 month. Our goal was a 60% (N = 95) response rate.

We tabulated the results by question. For analytic purposes, we aligned the content questions with key elements of informed consent as follows: step‐by‐step description of the events (details), patient‐specific likelihood of discharge if resuscitated (benefits), complications of resuscitation (risks), population‐based likelihood of discharge if resuscitated (likelihood), and opportunity for changing code status (alternatives). For the knowledge‐based questions, we deemed the answer correct if it was within 10% (5%) of published statistics from the 2010 national registry of cardiopulmonary resuscitation.[12] We stratified the key elements of informed consent and level of confidence by postgraduate year (PGY), comparing PGY1 residents versus PGY2 and PGY3 residents using ² tests (or Fisher exact test for observations 5). We performed a univariate logistic regression analysis examining the relationship between confidence and reported use of informed consent elements in code discussions. The dependent variable of confidence in sufficient information having been provided for fully informed decision making was dichotomized as most of the time or nearly always versus other responses, whereas the independent variable was dichotomized as residents who reported using all 5 informed consent elements versus those who did not. We analyzed data using Stata 12 (StataCorp, College Station, TX).

The institutional review board of the Beth Israel Deaconess reviewed the study protocol and determined that it was exempt from institutional review board review.

RESULTS

One hundred of 159 (62.3%) internal medicine residents responded to the survey. Of the respondents 93% (N = 93) completed the survey. The 7% (N = 7) who did not complete the survey omitted the knowledge‐based questions and demographics. Approximately half of participants (54%, N = 50) were male. The majority of residents (85%, N = 79) had either occasional or frequent exposure to palliative care, with 10% (N = 9) having completed a palliative care rotation (Table 1).

The vast majority of residents (96%, N = 95) discussed code status with more than 40% of patients they admitted to the hospital (Table 2). Two‐thirds (66%, N = 65) of all residents had the conversation with at least 4 out of 5 (81%99% and 100%) patients they admitted to the hospital. Only 1% (N = 1) of residents who responded to the survey reported conducting code status discussions with 20% or fewer of the patients they admitted to the hospital.

Most residents (66%, N = 66) identified the healthcare proxy or surrogate decision maker most of the time or nearly always. In addition, most residents (62%, N = 62) reminded patients that they could reverse their code status at any time. Almost half included a description of step‐by‐step events during resuscitation (45%, N = 45) or factored in patient's comorbidities (43%, N = 43) when discussing resuscitation at least most of the time. Few residents described complications (31%, N = 31) or outcomes (17%, N = 17) of cardiopulmonary arrests to patients most of the time or nearly always. Most residents did not explore factors such as quality of life, role of depression or physical states worse than death, factors that could potentially affect patient decision making (Table 2). Few (9%, N = 8) internal medicine residents (often or nearly always) offered their opinion regarding a patient's code status.

Many factors influenced residents' decisions to have a code status conversation. At least 85% (N = 86) of residents reported that older age, particular admitting diagnoses, and multiple comorbidities made them more likely to have a code status discussion (see Supporting Table 1 in the online version of this article). Patient race/ethnicity did not influence this decision, with only 1 respondent reporting this factor as relevant.

Residents identified lack of time (49%, N = 49 responding often or nearly always) as the most frequent barrier to having a code status discussion, followed by lack of rapport (29%, N = 29). Lack of experience (6%, N = 6), lack of information about the patient's clinical status (11%, N = 11), and lack of knowledge about outcomes (13%, N = 13) did not represent frequent barriers for residents.

Fifty‐five percent (N = 53) of residents often or nearly always felt confident that they provided enough information for patients to make fully informed decisions about code status, and this did not differ by PGY status (PGY1 vs PGY2/3, P = 0.80, ² test). However, only 8% (N = 8) of residents most of the time or nearly always addressed all 5 key elements of informed consent in reporting the content of their code status discussions. When stratified by training year, PGY2/3 residents were significantly more likely than PGY1 residents to factor in a patient's comorbidities when discussing resuscitation and were also significantly more likely to relay the likelihood of hospital discharge. They were not significantly more likely to discuss other key elements of informed consent (Table 3).

Our subanalysis showed that residents reporting all 5 key elements of informed consent were associated with higher levels of confidence that they had provided enough information to patients for them to make an informed decision (odds ratio of 1.7, 95% confidence interval 1.2‐2.3).

For the first knowledge‐based question about witnessed pulseless ventricular tachycardia, according to the 2010 registry,[12] 64% survived the event (range of responses 1%90%). Six out of 92 (7%) respondents were within 5% of the correct answer. For the second question about survival after unwitnessed pulseless electrical activity, 41.5% survived the event according to the registry (range of responses 1%50%). Three out of 92 (3%) respondents gave estimates within 5% of the correct answer. Figures 1 and 2 display the ranges of responses from residents.

Figure 1

Figure 2

DISCUSSION

We found that although our internal medicine residents frequently have code status discussions with their patients, very few routinely report addressing all 5 key elements of informed consent. Furthermore, residents lack accurate knowledge about the outcomes of CPR, with most tending to underestimate the benefit expected of resuscitation. These deficiencies raise serious concerns about whether patients are receiving all the information essential to making fully informed decisions about their preferences for resuscitation.

The data demonstrate that the residents are routinely discussing code status and regularly discussing some aspects of the procedure itself, such as chest compressions, intubation, or defibrillation; the actual step‐by‐step events of CPR are being described less than half the time. It seems that residents mentally list the possible procedures that may occur in a code without a context for how one intervention would lead to another. Placing CPR into context is important, because studies have shown that more comprehensive discussions or the use of visual aids/videos that depict CPR in more detail improves patients' understanding of CPR and changes their decision about CPR, making them more likely to forego the procedure.[7, 8]

Residents report that they are more likely to have a code status discussion with patient's with multiple comorbidities, suggesting that they take into account information about the patient's clinical condition when deciding with which patients to address code status. They also recognize which patients are at increased risk for an in hospital cardiopulmonary arrest. Additionally, nearly half of residents factor in patient's comorbidities when discussing likelihood of discharge from the hospital, suggesting that they recognize that comorbidities can alter the outcome of CPR. Importantly, however, very few residents describe the likelihood the patient will be discharged from the hospital if resuscitated. Thus, residents in our sample have some insight into the impact of comorbidities on outcomes of CPR, but fail to provide their patients with any information about the outcome of CPR.

One reason residents may not discuss outcomes of CPR is because they do not know the data regarding outcomes. Although few residents reported that lack of knowledge of the risks and outcomes of CPR was a barrier, very few respondents answered the knowledge questions appropriately. Given how few residents gave an accurate estimate of CPR outcomes and simultaneously reported confidence in their code status discussions suggests that many residents fail to recognize their knowledge deficits. This finding corroborates other studies showing that residents don't know what they don't know[10] and may reflect their lack of education on CPR outcomes. Alternatively, some residents who underestimated the outcomes in the examples provided may have done so because, in their experience caring for patients with multiple comorbidites, the outcomes of CPR are in fact poorer than those in the cases described. Outcomes of CPR at our institution might differ from those quoted in the registry. However, given the prevalence of inaccuracy, both for under‐ and overestimation, it seems likely that a true knowledge deficit on the part of the residents still accounts for much of the error and should be a target for education. Understanding CPR outcomes is vital for informed decision making, and studies have shown that when patients have more information, it can substantially affect a patient's decision regarding resuscitation.[7, 13]

Residents are infrequently exploring key determinants that affect a patient's decision‐making process. Only one‐third of residents report discussing quality‐of‐life issues with patients during code status discussions. Understanding an individual patient's values and goals and how he or she describes a good quality of life can help guide the discussion and potential recommendations. For example, some patients may feel it is important to be alive regardless of the physical state, whereas others may feel that if there is not a chance to be independent in their activities of daily living, then they would not want to be resuscitated. By exploring patient's perceptions of what quality of life and physical states worse than death means, residents can better understand and assist in the decision‐making process of their patients.

Our data show that few residents offer a recommendation regarding code status. Thus, residents expect patients to make their own decision with the data provided. At the same time, many residents focus on the details of the procedural components of CPR with little mention of anticipated outcomes or inquiries into key determinants discussed above. Additionally, based on their response to the knowledge‐based questions, residents' estimates of survival, if offered, would be inaccurate. Thus, code status conversations by residents leave patients to make uninformed choices to consent to or refuse resuscitative measures.

When stratified by training year, PGY2/3 residents were significantly more likely than PGY1 residents to discuss likelihood of discharge from the hospital as well as factor in patients' comorbidities when discussing outcomes. Although there is a statistically significant improvement between PGY2/3 residents as compared to PGY1 residents, the numbers still show that most PGY2/3 residents and almost all PGY1 residents do not discuss the likelihood of discharge if resuscitated during code status discussions. In addition, there is no difference reported in other key areas of informed consent. Thus, though there is some improvement as housestaff advance in their training, PGY2 and PGY3 residents still do not discuss all 5 key elements of informed consent significantly more than PGY1 residents.

Our findings suggest an opportunity for additional education regarding how to address code status for internal medicine housestaff. Over half of the respondents reported small group teaching sessions, direct observation and feedback, and exposure to palliative care consultation during their clinical rotations; yet, very few of them included all the key elements of informed consent in their discussions. To address this, our institution is developing additional educational initiatives, including a faculty development program for teaching communication skills, using direct observation and feedback. The orientation didactic lecture series for housestaff now includes a lecture on CPR that highlights the data on outcomes and the importance of putting the step‐by‐step procedures of CPR into the context of potential benefits, such as survival to hospital discharge. The curriculum also includes a module on advance care planning for junior and senior residents during their ambulatory block, using simulation and feedback as part of the teaching methods.

There are limitations to this study. Studies based on surveys are subject to recall and selection bias, and we lack objective assessment of actual code status discussions. Furthermore, the nature of the study may lead to an overestimation of the quality of the code status discussions due to social acceptability bias; yet, our data clearly show that the key elements of informed consent are not included during these conversations. Another limitation is that our subjects were residents at a single institution, and our clinical practice may differ from other academic settings in the teaching environment and culture; yet, our findings mirror similar work done in other locations.[10, 14]

In conclusion, our results demonstrate that residents fail to meet standards of informed consent when discussing code status in that they do not provide sufficient information for patients to make an informed decision regarding resuscitation. Residents would benefit from education aimed at improving their knowledge of CPR outcomes as well as training on how to conduct these conversations effectively. Framing code status discussions as an example of an informed consent may help residents recognize the need for the key elements to be included in these conversations. In addition, training should focus on how to conduct these conversations in an efficient yet effective manner. This will require clear simple language, good communication skills, and training with observation and feedback by specialists trained in this field.

Today's medical students will enter practice over the next decade and inherit the escalating costs of the US healthcare system. Approximately 30% of healthcare costs, or $750 billion dollars annually, are spent on unnecessary tests or procedures.[1] High healthcare costs combined with calls to eliminate waste, improve patient safety, and increase quality[2] are driving our healthcare system to evolve from a fee‐based system to a value‐based system. Additionally, many patients are being harmed by overtesting and the stress associated with rising healthcare bills. Financial risk has increasingly shifted to patients in the form of higher deductibles and reduced caps, and medical indebtedness is the number 1 risk for bankruptcy.[3, 4] False positive results of low‐yield diagnostic tests lead to additional testing, anxiety, excess radiation exposure, and unnecessary invasive procedures.[5] To minimize harm to patients, evidence must guide physicians in their ordering behavior. In addition, any care plan a physician develops should be individualized to incorporate patients' values and preferences. Unfortunately, medical students, who are at an impressionable stage in their careers, frequently observe overtesting and unnecessary treatment behaviors in their clinical encounters.[6] Instead, our medical students and trainees must be prepared to deliver patient care that is evidence based, patient centered, and cost conscious. They must become effective stewards of limited healthcare resources.

To help prepare our students for this evolving healthcare paradigm, we created a new tool called SOAP‐V (Subjective‐Objective‐Assessment‐PlanValue), designed to embed discussion of healthcare value into medical student oral presentations and note writing. Students are encouraged to use this tool at the point of care to bring up value concepts with physicians and residents as part of medical decision making. In so doing, we propose that medical students can serve as change agents to shift physician practice at our academic medical centers to focus on healthcare value. This article describes the SOAP‐V tool, contains links to educational materials to help hospitalists and other clinician educators to implement this tool, and provides preliminary findings and reflections.

INNOVATION

SOAP‐V was conceived at the Millennium Conference on Teaching High‐Value Care, which was sponsored by the Beth Israel Deaconess Medical Center Shapiro Institute for Education and Research, the Association of American Medical Colleges, and the American College of Physicians. Educators from several medical schools decided to form a group to specifically consider ways to train medical students and residents in the concept of high‐value care (HVC), which is framed as improving patient outcomes while decreasing patient cost and harm.[7] Our group recognized several challenges in teaching HVC. First, physician practice habits are influenced by the way they are trained,[8] yet faculty who teach those future physicians frequently have not themselves been taught, nor do they consistently practice HVC.[9] Second, we needed to teach students the requisite HVC knowledge, attitudes, and skills, and therefore wanted to provide opportunities to not only learn, but practice, HVC, preferably in authentic patient experiences to optimize their learning.[10, 11] Third, we recognized that adding another teaching task to the already oversubscribed day of an attending might understandably be met with resistance. We envisioned a tool that could be used with minimal or no faculty training, could be attached to authentic patient experiences, and based on LEAN‐Six Sigma principles,[12] would be embedded in the normal workflow. Furthermore, we considered social networking principles, such as those described by Christakis and Fowler that describe how an individual's behavior impacts behaviors of those surrounding them,[13] and hoped to empower medical students to serve as change agents. Medical students could initiate discussions of value concepts at the point of care in a way that challenges a heavily entrenched test‐ordering culture and encourages other members of the team to balance potential benefit with harms and cost. Following the conference, the group held bimonthly phone conferences and subsequently developed the SOAP‐V tool, created teaching materials, and planned a research project on SOAP‐V.

SOAP‐V modifies the traditional SOAP (Subjective‐Objective‐Assessment‐Plan) oral presentation or medical note, to include value (V). It serves as a cognitive forcing function designed to create a pause and promote discussions of HVC during patient delivery. It prompts the student to ask 3 value questions: (1) Before choosing an intervention, have I considered whether the result would change management? (2) Have I incorporated the patient's goals and values, and considered the potential harm of the intervention compared to alternatives? (3) What is the known and potential cost of the intervention, both immediate and downstream? The student gathers information during the patient interview and brings back the information to the team during rounds where management decisions are made.

In the summer of 2014, we launched an institutional review boardapproved, multi‐institutional study to implement SOAP‐V at Penn State College of Medicine, Harvard Medical School, and Case Western Reserve University School of Medicine for third‐year medical students during their internal medicine clerkships. Students in the intervention arm participated in an interactive workshop on SOAP‐V. Authors S.F., S.G., and C.D.P., who serve as clerkship directors in internal medicine, provided student training for each cohort of intervention students at the beginning of each rotation on general medicine inpatient wards. The workshop began with trigger videos that demonstrate pressures encountered by a student on rounds that might lead to overuse.[14] Following a discussion on overuse and methods to avoid overuse, the students were introduced to the SOAP‐V framework, watched a video of a student modeling a SOAP‐V presentation on rounds,[15] and engaged in a SOAP‐V role play. They received a SOAP‐V pocket card as well as a Web link to Healthcare Bluebook[16] to research costs. An outline of the session and associated materials can be found in an online attachment.[17] The students then used the SOAP‐V tool during inpatient rounds. We advised supervising faculty that students might present using a SOAP‐V format, and provided them with a SOAP‐V card, but we did not provide faculty development on SOAP‐V. Students participating in the control arm did not receive training specific to SOAP‐V.

Students in intervention and control arms at each school were surveyed on their attitudes toward HVC at the beginning of the clerkship year and then again at the completion of the medicine clerkship via a 19‐item questionnaire soliciting perceptions and self‐reported practices in HVC. Intervention arm students received biweekly e‐mail links that allowed them to anonymously document their use of SOAP‐V, as well as an end‐of‐clerkship open‐ended question about the usefulness of SOAP‐V. We analyzed questionnaire results using McNemar's test for paired data.

PRELIMINARY FINDINGS

The preintervention attitudinal survey (n = 226) demonstrated that although 90% of medical students agreed on the importance of considering costs of treatments, only 50% felt comfortable bringing up cost considerations with their team, and 50% considered costs to the healthcare system in clinical decisions. An interim analysis of the available data at 6 months (response rate approximately 50% across sites) showed that students in the intervention arm reported increased agreement with the phrases, I have the power to address the economic healthcare crisis (pre‐37%, post‐65%, P = 0.046); I would be comfortable initiating a discussion about unnecessary tests or treatments with my team, (pre‐46%, post‐85%, P = 0.027); and In my clinical decisions, I consider the potential costs to the healthcare system (pre‐41%, post‐60%, P = 0.023) compared to control arm students, who showed no significant differences pre‐ versus postrotation in these 3 domains (Figure 1).

Figure 1

To date, biweekly surveys and direct observation of rounds have verified student use of SOAP‐V. Student comments have included: Allowed me the ability to raise important issues with the team while feeling like I was helping my patients and the healthcare system. A great principle that I used almost daily. Great to implement this at such a young stage in my med career. Broadened my perspective on the role of a physician.

SOAP‐V has inspired some of our medical students to consider value in healthcare more closely. In a notable example, a SOAP‐Vtrained student admitted a young man with lymphadenopathy, pulmonary infiltrates, and weight loss who underwent an extensive and costly workup including liver biopsy, bronchoscopy, and multiple computed tomography and positron emission tomography scans and was eventually diagnosed with sarcoidosis. The SOAP‐Vtrained student reviewed the patient's workup, estimated that the team spent more than $6000 to make the diagnosis, and recommended a more cost‐effective approach.

Common barriers experienced by the pilot sites included time constraints limiting discussion of value, variability in perceived receptivity depending on team leadership, and student confidence in initiating this dialogue. Solutions included underscoring the notion that value discussions can be brief, may be appropriately initiated by any member of the team, and may have an effect on choice of management and/or patient preference issues that can make medical care more efficient and effective. Resident and faculty physicians were made aware of the intervention, and encouraged to support students in using the SOAP‐V tool.

CONCLUSION

SOAP‐V was successfully implemented within the inpatient internal medicine clerkship at 3 academic institutions. Our preliminary results demonstrate that students can use this framework to apply considerations of high‐value, cost‐conscious care in their medical decision making and to promote discussion of these concepts during rounds with their inpatient teams. Students in the intervention arm report greater comfort discussing unnecessary tests and treatments with their team and a greater likelihood to consider potential costs to the healthcare system. Additionally, these students commented that the SOAP‐V framework broadened their perspective on their role as a physician in curbing costs, and that they felt more empowered to address the economic healthcare crisis. The next phase of our project will involve conducting end‐of‐year surveys to evaluate whether SOAP‐V has a persistent impact on the frequency and quality of value discussions on rounds, as well as students' attitudes about cost consciousness. We will also gauge whether resident and faculty attitudes about HVC have changed as a result of the intervention.

Our SOAP‐V student training was provided in a 1‐hour session. We believe that the ease of training and the simplicity of the SOAP‐V framework permit SOAP‐V to be easily transferred for use by residents, medical students in other clerkships, and other healthcare learners. Additional research is needed to demonstrate this expanded use and prove sustainability. An additional important question is whether use of SOAP‐V by students and residents results in reductions in unnecessary costs. Future educational efforts will include embedding the SOAP‐V tool in other clerkships and promoting the SOAP‐V tool within corresponding residencies in both hospital and outpatient clinic settings and analyzing potential reductions in wasteful spending.

It is generally conceived that medical students learn the information they are taught, and are impacted by the culture in which they reside; multiple studies bear this out.[18, 19] However, students may also be change agents. Our students will inherit the healthcare systems of the future. We must empower them to change the status quo. There can be tremendous utility in employing such a bottom up approach to process improvement. What a student discusses today may spark the resident (or faculty) to consider in their own workflow tomorrow. In this way, we envision that the SOAP‐V is a tool by which ideas concerning HVC can be generated and shared at the point of care. It is our hope that this straightforward intervention is one that may slowly change the culture and perhaps eventually the practice patterns of our academic medical centers.

Today's medical students will enter practice over the next decade and inherit the escalating costs of the US healthcare system. Approximately 30% of healthcare costs, or $750 billion dollars annually, are spent on unnecessary tests or procedures.[1] High healthcare costs combined with calls to eliminate waste, improve patient safety, and increase quality[2] are driving our healthcare system to evolve from a fee‐based system to a value‐based system. Additionally, many patients are being harmed by overtesting and the stress associated with rising healthcare bills. Financial risk has increasingly shifted to patients in the form of higher deductibles and reduced caps, and medical indebtedness is the number 1 risk for bankruptcy.[3, 4] False positive results of low‐yield diagnostic tests lead to additional testing, anxiety, excess radiation exposure, and unnecessary invasive procedures.[5] To minimize harm to patients, evidence must guide physicians in their ordering behavior. In addition, any care plan a physician develops should be individualized to incorporate patients' values and preferences. Unfortunately, medical students, who are at an impressionable stage in their careers, frequently observe overtesting and unnecessary treatment behaviors in their clinical encounters.[6] Instead, our medical students and trainees must be prepared to deliver patient care that is evidence based, patient centered, and cost conscious. They must become effective stewards of limited healthcare resources.

To help prepare our students for this evolving healthcare paradigm, we created a new tool called SOAP‐V (Subjective‐Objective‐Assessment‐PlanValue), designed to embed discussion of healthcare value into medical student oral presentations and note writing. Students are encouraged to use this tool at the point of care to bring up value concepts with physicians and residents as part of medical decision making. In so doing, we propose that medical students can serve as change agents to shift physician practice at our academic medical centers to focus on healthcare value. This article describes the SOAP‐V tool, contains links to educational materials to help hospitalists and other clinician educators to implement this tool, and provides preliminary findings and reflections.

INNOVATION

SOAP‐V was conceived at the Millennium Conference on Teaching High‐Value Care, which was sponsored by the Beth Israel Deaconess Medical Center Shapiro Institute for Education and Research, the Association of American Medical Colleges, and the American College of Physicians. Educators from several medical schools decided to form a group to specifically consider ways to train medical students and residents in the concept of high‐value care (HVC), which is framed as improving patient outcomes while decreasing patient cost and harm.[7] Our group recognized several challenges in teaching HVC. First, physician practice habits are influenced by the way they are trained,[8] yet faculty who teach those future physicians frequently have not themselves been taught, nor do they consistently practice HVC.[9] Second, we needed to teach students the requisite HVC knowledge, attitudes, and skills, and therefore wanted to provide opportunities to not only learn, but practice, HVC, preferably in authentic patient experiences to optimize their learning.[10, 11] Third, we recognized that adding another teaching task to the already oversubscribed day of an attending might understandably be met with resistance. We envisioned a tool that could be used with minimal or no faculty training, could be attached to authentic patient experiences, and based on LEAN‐Six Sigma principles,[12] would be embedded in the normal workflow. Furthermore, we considered social networking principles, such as those described by Christakis and Fowler that describe how an individual's behavior impacts behaviors of those surrounding them,[13] and hoped to empower medical students to serve as change agents. Medical students could initiate discussions of value concepts at the point of care in a way that challenges a heavily entrenched test‐ordering culture and encourages other members of the team to balance potential benefit with harms and cost. Following the conference, the group held bimonthly phone conferences and subsequently developed the SOAP‐V tool, created teaching materials, and planned a research project on SOAP‐V.

SOAP‐V modifies the traditional SOAP (Subjective‐Objective‐Assessment‐Plan) oral presentation or medical note, to include value (V). It serves as a cognitive forcing function designed to create a pause and promote discussions of HVC during patient delivery. It prompts the student to ask 3 value questions: (1) Before choosing an intervention, have I considered whether the result would change management? (2) Have I incorporated the patient's goals and values, and considered the potential harm of the intervention compared to alternatives? (3) What is the known and potential cost of the intervention, both immediate and downstream? The student gathers information during the patient interview and brings back the information to the team during rounds where management decisions are made.

In the summer of 2014, we launched an institutional review boardapproved, multi‐institutional study to implement SOAP‐V at Penn State College of Medicine, Harvard Medical School, and Case Western Reserve University School of Medicine for third‐year medical students during their internal medicine clerkships. Students in the intervention arm participated in an interactive workshop on SOAP‐V. Authors S.F., S.G., and C.D.P., who serve as clerkship directors in internal medicine, provided student training for each cohort of intervention students at the beginning of each rotation on general medicine inpatient wards. The workshop began with trigger videos that demonstrate pressures encountered by a student on rounds that might lead to overuse.[14] Following a discussion on overuse and methods to avoid overuse, the students were introduced to the SOAP‐V framework, watched a video of a student modeling a SOAP‐V presentation on rounds,[15] and engaged in a SOAP‐V role play. They received a SOAP‐V pocket card as well as a Web link to Healthcare Bluebook[16] to research costs. An outline of the session and associated materials can be found in an online attachment.[17] The students then used the SOAP‐V tool during inpatient rounds. We advised supervising faculty that students might present using a SOAP‐V format, and provided them with a SOAP‐V card, but we did not provide faculty development on SOAP‐V. Students participating in the control arm did not receive training specific to SOAP‐V.

Students in intervention and control arms at each school were surveyed on their attitudes toward HVC at the beginning of the clerkship year and then again at the completion of the medicine clerkship via a 19‐item questionnaire soliciting perceptions and self‐reported practices in HVC. Intervention arm students received biweekly e‐mail links that allowed them to anonymously document their use of SOAP‐V, as well as an end‐of‐clerkship open‐ended question about the usefulness of SOAP‐V. We analyzed questionnaire results using McNemar's test for paired data.

PRELIMINARY FINDINGS

The preintervention attitudinal survey (n = 226) demonstrated that although 90% of medical students agreed on the importance of considering costs of treatments, only 50% felt comfortable bringing up cost considerations with their team, and 50% considered costs to the healthcare system in clinical decisions. An interim analysis of the available data at 6 months (response rate approximately 50% across sites) showed that students in the intervention arm reported increased agreement with the phrases, I have the power to address the economic healthcare crisis (pre‐37%, post‐65%, P = 0.046); I would be comfortable initiating a discussion about unnecessary tests or treatments with my team, (pre‐46%, post‐85%, P = 0.027); and In my clinical decisions, I consider the potential costs to the healthcare system (pre‐41%, post‐60%, P = 0.023) compared to control arm students, who showed no significant differences pre‐ versus postrotation in these 3 domains (Figure 1).

Figure 1

To date, biweekly surveys and direct observation of rounds have verified student use of SOAP‐V. Student comments have included: Allowed me the ability to raise important issues with the team while feeling like I was helping my patients and the healthcare system. A great principle that I used almost daily. Great to implement this at such a young stage in my med career. Broadened my perspective on the role of a physician.

SOAP‐V has inspired some of our medical students to consider value in healthcare more closely. In a notable example, a SOAP‐Vtrained student admitted a young man with lymphadenopathy, pulmonary infiltrates, and weight loss who underwent an extensive and costly workup including liver biopsy, bronchoscopy, and multiple computed tomography and positron emission tomography scans and was eventually diagnosed with sarcoidosis. The SOAP‐Vtrained student reviewed the patient's workup, estimated that the team spent more than $6000 to make the diagnosis, and recommended a more cost‐effective approach.

Common barriers experienced by the pilot sites included time constraints limiting discussion of value, variability in perceived receptivity depending on team leadership, and student confidence in initiating this dialogue. Solutions included underscoring the notion that value discussions can be brief, may be appropriately initiated by any member of the team, and may have an effect on choice of management and/or patient preference issues that can make medical care more efficient and effective. Resident and faculty physicians were made aware of the intervention, and encouraged to support students in using the SOAP‐V tool.

CONCLUSION

SOAP‐V was successfully implemented within the inpatient internal medicine clerkship at 3 academic institutions. Our preliminary results demonstrate that students can use this framework to apply considerations of high‐value, cost‐conscious care in their medical decision making and to promote discussion of these concepts during rounds with their inpatient teams. Students in the intervention arm report greater comfort discussing unnecessary tests and treatments with their team and a greater likelihood to consider potential costs to the healthcare system. Additionally, these students commented that the SOAP‐V framework broadened their perspective on their role as a physician in curbing costs, and that they felt more empowered to address the economic healthcare crisis. The next phase of our project will involve conducting end‐of‐year surveys to evaluate whether SOAP‐V has a persistent impact on the frequency and quality of value discussions on rounds, as well as students' attitudes about cost consciousness. We will also gauge whether resident and faculty attitudes about HVC have changed as a result of the intervention.

Our SOAP‐V student training was provided in a 1‐hour session. We believe that the ease of training and the simplicity of the SOAP‐V framework permit SOAP‐V to be easily transferred for use by residents, medical students in other clerkships, and other healthcare learners. Additional research is needed to demonstrate this expanded use and prove sustainability. An additional important question is whether use of SOAP‐V by students and residents results in reductions in unnecessary costs. Future educational efforts will include embedding the SOAP‐V tool in other clerkships and promoting the SOAP‐V tool within corresponding residencies in both hospital and outpatient clinic settings and analyzing potential reductions in wasteful spending.

It is generally conceived that medical students learn the information they are taught, and are impacted by the culture in which they reside; multiple studies bear this out.[18, 19] However, students may also be change agents. Our students will inherit the healthcare systems of the future. We must empower them to change the status quo. There can be tremendous utility in employing such a bottom up approach to process improvement. What a student discusses today may spark the resident (or faculty) to consider in their own workflow tomorrow. In this way, we envision that the SOAP‐V is a tool by which ideas concerning HVC can be generated and shared at the point of care. It is our hope that this straightforward intervention is one that may slowly change the culture and perhaps eventually the practice patterns of our academic medical centers.

Today's medical students will enter practice over the next decade and inherit the escalating costs of the US healthcare system. Approximately 30% of healthcare costs, or $750 billion dollars annually, are spent on unnecessary tests or procedures.[1] High healthcare costs combined with calls to eliminate waste, improve patient safety, and increase quality[2] are driving our healthcare system to evolve from a fee‐based system to a value‐based system. Additionally, many patients are being harmed by overtesting and the stress associated with rising healthcare bills. Financial risk has increasingly shifted to patients in the form of higher deductibles and reduced caps, and medical indebtedness is the number 1 risk for bankruptcy.[3, 4] False positive results of low‐yield diagnostic tests lead to additional testing, anxiety, excess radiation exposure, and unnecessary invasive procedures.[5] To minimize harm to patients, evidence must guide physicians in their ordering behavior. In addition, any care plan a physician develops should be individualized to incorporate patients' values and preferences. Unfortunately, medical students, who are at an impressionable stage in their careers, frequently observe overtesting and unnecessary treatment behaviors in their clinical encounters.[6] Instead, our medical students and trainees must be prepared to deliver patient care that is evidence based, patient centered, and cost conscious. They must become effective stewards of limited healthcare resources.

To help prepare our students for this evolving healthcare paradigm, we created a new tool called SOAP‐V (Subjective‐Objective‐Assessment‐PlanValue), designed to embed discussion of healthcare value into medical student oral presentations and note writing. Students are encouraged to use this tool at the point of care to bring up value concepts with physicians and residents as part of medical decision making. In so doing, we propose that medical students can serve as change agents to shift physician practice at our academic medical centers to focus on healthcare value. This article describes the SOAP‐V tool, contains links to educational materials to help hospitalists and other clinician educators to implement this tool, and provides preliminary findings and reflections.

INNOVATION

SOAP‐V was conceived at the Millennium Conference on Teaching High‐Value Care, which was sponsored by the Beth Israel Deaconess Medical Center Shapiro Institute for Education and Research, the Association of American Medical Colleges, and the American College of Physicians. Educators from several medical schools decided to form a group to specifically consider ways to train medical students and residents in the concept of high‐value care (HVC), which is framed as improving patient outcomes while decreasing patient cost and harm.[7] Our group recognized several challenges in teaching HVC. First, physician practice habits are influenced by the way they are trained,[8] yet faculty who teach those future physicians frequently have not themselves been taught, nor do they consistently practice HVC.[9] Second, we needed to teach students the requisite HVC knowledge, attitudes, and skills, and therefore wanted to provide opportunities to not only learn, but practice, HVC, preferably in authentic patient experiences to optimize their learning.[10, 11] Third, we recognized that adding another teaching task to the already oversubscribed day of an attending might understandably be met with resistance. We envisioned a tool that could be used with minimal or no faculty training, could be attached to authentic patient experiences, and based on LEAN‐Six Sigma principles,[12] would be embedded in the normal workflow. Furthermore, we considered social networking principles, such as those described by Christakis and Fowler that describe how an individual's behavior impacts behaviors of those surrounding them,[13] and hoped to empower medical students to serve as change agents. Medical students could initiate discussions of value concepts at the point of care in a way that challenges a heavily entrenched test‐ordering culture and encourages other members of the team to balance potential benefit with harms and cost. Following the conference, the group held bimonthly phone conferences and subsequently developed the SOAP‐V tool, created teaching materials, and planned a research project on SOAP‐V.

SOAP‐V modifies the traditional SOAP (Subjective‐Objective‐Assessment‐Plan) oral presentation or medical note, to include value (V). It serves as a cognitive forcing function designed to create a pause and promote discussions of HVC during patient delivery. It prompts the student to ask 3 value questions: (1) Before choosing an intervention, have I considered whether the result would change management? (2) Have I incorporated the patient's goals and values, and considered the potential harm of the intervention compared to alternatives? (3) What is the known and potential cost of the intervention, both immediate and downstream? The student gathers information during the patient interview and brings back the information to the team during rounds where management decisions are made.

In the summer of 2014, we launched an institutional review boardapproved, multi‐institutional study to implement SOAP‐V at Penn State College of Medicine, Harvard Medical School, and Case Western Reserve University School of Medicine for third‐year medical students during their internal medicine clerkships. Students in the intervention arm participated in an interactive workshop on SOAP‐V. Authors S.F., S.G., and C.D.P., who serve as clerkship directors in internal medicine, provided student training for each cohort of intervention students at the beginning of each rotation on general medicine inpatient wards. The workshop began with trigger videos that demonstrate pressures encountered by a student on rounds that might lead to overuse.[14] Following a discussion on overuse and methods to avoid overuse, the students were introduced to the SOAP‐V framework, watched a video of a student modeling a SOAP‐V presentation on rounds,[15] and engaged in a SOAP‐V role play. They received a SOAP‐V pocket card as well as a Web link to Healthcare Bluebook[16] to research costs. An outline of the session and associated materials can be found in an online attachment.[17] The students then used the SOAP‐V tool during inpatient rounds. We advised supervising faculty that students might present using a SOAP‐V format, and provided them with a SOAP‐V card, but we did not provide faculty development on SOAP‐V. Students participating in the control arm did not receive training specific to SOAP‐V.

Students in intervention and control arms at each school were surveyed on their attitudes toward HVC at the beginning of the clerkship year and then again at the completion of the medicine clerkship via a 19‐item questionnaire soliciting perceptions and self‐reported practices in HVC. Intervention arm students received biweekly e‐mail links that allowed them to anonymously document their use of SOAP‐V, as well as an end‐of‐clerkship open‐ended question about the usefulness of SOAP‐V. We analyzed questionnaire results using McNemar's test for paired data.

PRELIMINARY FINDINGS

The preintervention attitudinal survey (n = 226) demonstrated that although 90% of medical students agreed on the importance of considering costs of treatments, only 50% felt comfortable bringing up cost considerations with their team, and 50% considered costs to the healthcare system in clinical decisions. An interim analysis of the available data at 6 months (response rate approximately 50% across sites) showed that students in the intervention arm reported increased agreement with the phrases, I have the power to address the economic healthcare crisis (pre‐37%, post‐65%, P = 0.046); I would be comfortable initiating a discussion about unnecessary tests or treatments with my team, (pre‐46%, post‐85%, P = 0.027); and In my clinical decisions, I consider the potential costs to the healthcare system (pre‐41%, post‐60%, P = 0.023) compared to control arm students, who showed no significant differences pre‐ versus postrotation in these 3 domains (Figure 1).

Figure 1

To date, biweekly surveys and direct observation of rounds have verified student use of SOAP‐V. Student comments have included: Allowed me the ability to raise important issues with the team while feeling like I was helping my patients and the healthcare system. A great principle that I used almost daily. Great to implement this at such a young stage in my med career. Broadened my perspective on the role of a physician.

SOAP‐V has inspired some of our medical students to consider value in healthcare more closely. In a notable example, a SOAP‐Vtrained student admitted a young man with lymphadenopathy, pulmonary infiltrates, and weight loss who underwent an extensive and costly workup including liver biopsy, bronchoscopy, and multiple computed tomography and positron emission tomography scans and was eventually diagnosed with sarcoidosis. The SOAP‐Vtrained student reviewed the patient's workup, estimated that the team spent more than $6000 to make the diagnosis, and recommended a more cost‐effective approach.

Common barriers experienced by the pilot sites included time constraints limiting discussion of value, variability in perceived receptivity depending on team leadership, and student confidence in initiating this dialogue. Solutions included underscoring the notion that value discussions can be brief, may be appropriately initiated by any member of the team, and may have an effect on choice of management and/or patient preference issues that can make medical care more efficient and effective. Resident and faculty physicians were made aware of the intervention, and encouraged to support students in using the SOAP‐V tool.

CONCLUSION

SOAP‐V was successfully implemented within the inpatient internal medicine clerkship at 3 academic institutions. Our preliminary results demonstrate that students can use this framework to apply considerations of high‐value, cost‐conscious care in their medical decision making and to promote discussion of these concepts during rounds with their inpatient teams. Students in the intervention arm report greater comfort discussing unnecessary tests and treatments with their team and a greater likelihood to consider potential costs to the healthcare system. Additionally, these students commented that the SOAP‐V framework broadened their perspective on their role as a physician in curbing costs, and that they felt more empowered to address the economic healthcare crisis. The next phase of our project will involve conducting end‐of‐year surveys to evaluate whether SOAP‐V has a persistent impact on the frequency and quality of value discussions on rounds, as well as students' attitudes about cost consciousness. We will also gauge whether resident and faculty attitudes about HVC have changed as a result of the intervention.

Our SOAP‐V student training was provided in a 1‐hour session. We believe that the ease of training and the simplicity of the SOAP‐V framework permit SOAP‐V to be easily transferred for use by residents, medical students in other clerkships, and other healthcare learners. Additional research is needed to demonstrate this expanded use and prove sustainability. An additional important question is whether use of SOAP‐V by students and residents results in reductions in unnecessary costs. Future educational efforts will include embedding the SOAP‐V tool in other clerkships and promoting the SOAP‐V tool within corresponding residencies in both hospital and outpatient clinic settings and analyzing potential reductions in wasteful spending.

It is generally conceived that medical students learn the information they are taught, and are impacted by the culture in which they reside; multiple studies bear this out.[18, 19] However, students may also be change agents. Our students will inherit the healthcare systems of the future. We must empower them to change the status quo. There can be tremendous utility in employing such a bottom up approach to process improvement. What a student discusses today may spark the resident (or faculty) to consider in their own workflow tomorrow. In this way, we envision that the SOAP‐V is a tool by which ideas concerning HVC can be generated and shared at the point of care. It is our hope that this straightforward intervention is one that may slowly change the culture and perhaps eventually the practice patterns of our academic medical centers.

In the last decade, natural disasters such as the Indonesian tsunami of 2004, Hurricane Katrina in 2004, and the Pakistani earthquake of 2005 have brought attention to the importance of diverse but complementary medical professional roles in humanitarian medical aid.14 Natural disasters that cause significant physical trauma to large populations often necessitate initial multidisciplinary responder teams comprised of surgeons, anesthesiologists, emergency medicine physicians, surgical technologists, nurses, psychiatrists, and public health specialists. Their roles are to manage life‐threatening injuries, provide immediate triage, help affected individuals deal with intense psychological shock, and address critical population‐based needs such as water, food, and sanitation. Meanwhile, general medical, pediatric, rehabilitative, and long‐term psychiatric services often constitute a secondary tier of disaster response, providing postsurgical care, managing acute medical illnesses, mitigating psychological trauma, rehabilitating injuries, and providing vaccinations to at‐risk individuals. Hospitalists can play an important role in postcatastrophe recovery services as experts in acute care, stewards of care transitions, and drivers of systems improvement.

The earthquake that occurred January 12, 2010 in Haiti is a dramatic illustration of the importance of a multidisciplinary approach to disaster relief. The 7.0‐magnitude earthquake near Port‐au‐Prince ravaged an already crippled health care system, severely damaging the country's primary academic medical center, and killed the entire class of second‐year nursing students. The death toll has been estimated to be nearly one‐quarter of a million people.5 Victims awaiting surgery, recovering from surgery, or in need of other immediate medical attention quickly inundated any existing health facilities. The following stories describe the authors' respective experiences in Haiti after the earthquake.

JC: I arrived 4 days after the earthquake to a hospital outside of Port‐au‐Prince, spared from destruction, but filled with hundreds of patients with crush injuries and severe fractures. On rounds with the surgical team, I observed that venous thromboembolism (VTE) prophylaxis had not yet been initiated, and I was concerned that patients might die from pulmonary embolism. In the overwhelming urgency of providing life‐saving surgery to as many patients as possible, this simple measure had been overlooked. After discussion with our team and our Haitian medical colleagues, we initiated subcutaneous heparin on all eligible patients and made arrangements to receive further shipments of heparin to accommodate the influx of patients.

A nearby school and church had been annexed into makeshift extensions of the hospital wards. The volume and pace of incoming injuries was such that as soon as a patient was taken to surgery, another patient would often take his or her place in the bed. The rapid movement of patients to and from x‐ray, surgery, and postsurgical care created challenges around effective and accurate communication among multiple care providers. We decided that nonsurgical personnel would triage newly arriving patients and round on patients daily. Each nonsurgical physician was responsible for staffing a particular location. This zone‐defense approach ensured that the surgeons maximized their time in the operating rooms. We also instituted a basic system of portable medical records kept with each patient at all times, allowing personnel to easily and quickly assess care given to date, and to write notes and orders.

Presurgical and postsurgical wound infections became a common event, with the risk of ensuing sepsis. Antibiotic use was dependent on the preferences of individual surgeons and also on the available supply. As a result, antimicrobial treatments were highly variable and sometimes inadequate. The internists on the team proposed standard antibiotic guidelines for open fractures, for contaminated wounds, and for postoperative wounds; these regimens were approved and implemented by Haitian staff and the rest of the team.

Internists recognized the first complications of rhabdomyolysis from crush injuries and delays in receiving medical attention. Malaise, oliguria, and volume overload were often the only clues we had for severe renal failure. We had a functional lab capable of checking complete blood counts, urinalysis and creatinine, but we had a limited supply of serum potassium assays. We only used the latter in confirmed cases of rhabdomyolysis, and on several occasions we diagnosed severe hyperkalemia. Using bedside automated electrical defibrillation devices for monitoring, we sustained these patients on calcium gluconate until they could be transferred to an external dialysis unit run by Mdecins Sans Frontires in Port‐au‐Prince.6 As the number of rhabdomyolysis cases increased, we instigated creatinine rounds on patients arriving with large crush injuries, and we evaluated urine output daily until patients were clinically stable from this threat. We also helped the Haitian staff treat the omnipresent problem of pain and advised renal dosing of medications in renal failure and elderly patients.

GH: The situation 3 months after the earthquake was medically less dire but highlights the evolving importance of generalists in the aftermath of the quake.710 For many Haitian patients, the earthquake had become a universal point of reference for their symptomatology. Anorexia, amenorrhea, headaches, epigastric pain, even fungating soft tissue masses, were all reported to be depi tranbleman t a (since the earthquake) and were often somatic manifestations of a psychologically devastating event. At a hospital in Carrefour, I cared for patients presenting with dramatic sequelae of chronic diseases that had been undertreated due to the destruction of the Haitian medical infrastructurehypertensive coma, diabetic ketoacidosis, cerebral malaria, decompensated liver disease, and severe chronic anemia (including a patient with a hemoglobin of 3 mg/dL). I encountered many patients with infections exacerbated by excessive crowding in tent communities, such as typhoid and tuberculosis. At this particular hospital, priorities appropriately placed on surgical and postsurgical care required the team to devise creative solutions for the care and placement of medical patients, such as restructuring the emergency department and creating a rehabilitation tent on the hospital grounds. While few Haitian internists were present, a number of Haitian obstetricians were on site and helped manage medical conditions within the scope of their experience, such as hypertension, abdominal pain, and genitourinary infections. The expatriate orthopedic surgeons on site sought the consultative skills of hospitalists for preoperative management, postoperative complications, and comorbid conditions.

This hospital was largely sustained by rotating teams of volunteers, which underscored the importance of establishing a flexible system that would accommodate the turnover of personnel and fluctuating levels of professional expertise. The team used a tiered model for acute care delivery designating responsibilities based on the number of nurses, physicians, and other providers available. We collaborated with Haitian physicians to establish a routine of handoff rounds. Finally, we created and centralized documentation such as clinical protocols, contact numbers, and helpful tips for our successors.

Hospitalists have valuable skills to offer in medical responses to natural catastrophes.5 Our fluency with acute care environments becomes a pluripotent asset in disaster relief. Our experiences in assessing acuity are vital in assisting with inpatient triage. Our familiarity with the comanagement model facilitates partnership with other disciplines to optimize the distribution of skill sets without neglecting the overall well‐being of patients. Our clinical expertise in treating the vulnerable elderly, VTE, renal failure, pain management, postoperative infections, sepsis, and many other conditions can bolster medical relief efforts, even when the foremost need is surgical. The hospitalist's core competencies in healthcare systems11 can support recovery initiatives in medical facilities, particularly in the domains of drug safety, resource allocation, information management, team‐based methods, and care transitions. Our respective experiences also suggest the potential value of hospitalists in domestic, in addition to international, disaster response initiatives. Since large‐scale calamities may result in the hospitalization of overwhelming numbers of victims,12 hospitalists may be well‐positioned to assist our emergency medicine and public health colleagues, who currently (and fittingly) lead domestic efforts in disaster relief.

Tragedies like the earthquake in Haiti serve as a sobering reminder that a comprehensive multidisciplinary approach is required as medical disaster relief shifts from a life‐saving focus to one of life‐preserving care.13, 14 Hospitalists can play a vital role in these restorative efforts.

In the last decade, natural disasters such as the Indonesian tsunami of 2004, Hurricane Katrina in 2004, and the Pakistani earthquake of 2005 have brought attention to the importance of diverse but complementary medical professional roles in humanitarian medical aid.14 Natural disasters that cause significant physical trauma to large populations often necessitate initial multidisciplinary responder teams comprised of surgeons, anesthesiologists, emergency medicine physicians, surgical technologists, nurses, psychiatrists, and public health specialists. Their roles are to manage life‐threatening injuries, provide immediate triage, help affected individuals deal with intense psychological shock, and address critical population‐based needs such as water, food, and sanitation. Meanwhile, general medical, pediatric, rehabilitative, and long‐term psychiatric services often constitute a secondary tier of disaster response, providing postsurgical care, managing acute medical illnesses, mitigating psychological trauma, rehabilitating injuries, and providing vaccinations to at‐risk individuals. Hospitalists can play an important role in postcatastrophe recovery services as experts in acute care, stewards of care transitions, and drivers of systems improvement.

The earthquake that occurred January 12, 2010 in Haiti is a dramatic illustration of the importance of a multidisciplinary approach to disaster relief. The 7.0‐magnitude earthquake near Port‐au‐Prince ravaged an already crippled health care system, severely damaging the country's primary academic medical center, and killed the entire class of second‐year nursing students. The death toll has been estimated to be nearly one‐quarter of a million people.5 Victims awaiting surgery, recovering from surgery, or in need of other immediate medical attention quickly inundated any existing health facilities. The following stories describe the authors' respective experiences in Haiti after the earthquake.

JC: I arrived 4 days after the earthquake to a hospital outside of Port‐au‐Prince, spared from destruction, but filled with hundreds of patients with crush injuries and severe fractures. On rounds with the surgical team, I observed that venous thromboembolism (VTE) prophylaxis had not yet been initiated, and I was concerned that patients might die from pulmonary embolism. In the overwhelming urgency of providing life‐saving surgery to as many patients as possible, this simple measure had been overlooked. After discussion with our team and our Haitian medical colleagues, we initiated subcutaneous heparin on all eligible patients and made arrangements to receive further shipments of heparin to accommodate the influx of patients.

A nearby school and church had been annexed into makeshift extensions of the hospital wards. The volume and pace of incoming injuries was such that as soon as a patient was taken to surgery, another patient would often take his or her place in the bed. The rapid movement of patients to and from x‐ray, surgery, and postsurgical care created challenges around effective and accurate communication among multiple care providers. We decided that nonsurgical personnel would triage newly arriving patients and round on patients daily. Each nonsurgical physician was responsible for staffing a particular location. This zone‐defense approach ensured that the surgeons maximized their time in the operating rooms. We also instituted a basic system of portable medical records kept with each patient at all times, allowing personnel to easily and quickly assess care given to date, and to write notes and orders.

Presurgical and postsurgical wound infections became a common event, with the risk of ensuing sepsis. Antibiotic use was dependent on the preferences of individual surgeons and also on the available supply. As a result, antimicrobial treatments were highly variable and sometimes inadequate. The internists on the team proposed standard antibiotic guidelines for open fractures, for contaminated wounds, and for postoperative wounds; these regimens were approved and implemented by Haitian staff and the rest of the team.

Internists recognized the first complications of rhabdomyolysis from crush injuries and delays in receiving medical attention. Malaise, oliguria, and volume overload were often the only clues we had for severe renal failure. We had a functional lab capable of checking complete blood counts, urinalysis and creatinine, but we had a limited supply of serum potassium assays. We only used the latter in confirmed cases of rhabdomyolysis, and on several occasions we diagnosed severe hyperkalemia. Using bedside automated electrical defibrillation devices for monitoring, we sustained these patients on calcium gluconate until they could be transferred to an external dialysis unit run by Mdecins Sans Frontires in Port‐au‐Prince.6 As the number of rhabdomyolysis cases increased, we instigated creatinine rounds on patients arriving with large crush injuries, and we evaluated urine output daily until patients were clinically stable from this threat. We also helped the Haitian staff treat the omnipresent problem of pain and advised renal dosing of medications in renal failure and elderly patients.

GH: The situation 3 months after the earthquake was medically less dire but highlights the evolving importance of generalists in the aftermath of the quake.710 For many Haitian patients, the earthquake had become a universal point of reference for their symptomatology. Anorexia, amenorrhea, headaches, epigastric pain, even fungating soft tissue masses, were all reported to be depi tranbleman t a (since the earthquake) and were often somatic manifestations of a psychologically devastating event. At a hospital in Carrefour, I cared for patients presenting with dramatic sequelae of chronic diseases that had been undertreated due to the destruction of the Haitian medical infrastructurehypertensive coma, diabetic ketoacidosis, cerebral malaria, decompensated liver disease, and severe chronic anemia (including a patient with a hemoglobin of 3 mg/dL). I encountered many patients with infections exacerbated by excessive crowding in tent communities, such as typhoid and tuberculosis. At this particular hospital, priorities appropriately placed on surgical and postsurgical care required the team to devise creative solutions for the care and placement of medical patients, such as restructuring the emergency department and creating a rehabilitation tent on the hospital grounds. While few Haitian internists were present, a number of Haitian obstetricians were on site and helped manage medical conditions within the scope of their experience, such as hypertension, abdominal pain, and genitourinary infections. The expatriate orthopedic surgeons on site sought the consultative skills of hospitalists for preoperative management, postoperative complications, and comorbid conditions.

This hospital was largely sustained by rotating teams of volunteers, which underscored the importance of establishing a flexible system that would accommodate the turnover of personnel and fluctuating levels of professional expertise. The team used a tiered model for acute care delivery designating responsibilities based on the number of nurses, physicians, and other providers available. We collaborated with Haitian physicians to establish a routine of handoff rounds. Finally, we created and centralized documentation such as clinical protocols, contact numbers, and helpful tips for our successors.

Hospitalists have valuable skills to offer in medical responses to natural catastrophes.5 Our fluency with acute care environments becomes a pluripotent asset in disaster relief. Our experiences in assessing acuity are vital in assisting with inpatient triage. Our familiarity with the comanagement model facilitates partnership with other disciplines to optimize the distribution of skill sets without neglecting the overall well‐being of patients. Our clinical expertise in treating the vulnerable elderly, VTE, renal failure, pain management, postoperative infections, sepsis, and many other conditions can bolster medical relief efforts, even when the foremost need is surgical. The hospitalist's core competencies in healthcare systems11 can support recovery initiatives in medical facilities, particularly in the domains of drug safety, resource allocation, information management, team‐based methods, and care transitions. Our respective experiences also suggest the potential value of hospitalists in domestic, in addition to international, disaster response initiatives. Since large‐scale calamities may result in the hospitalization of overwhelming numbers of victims,12 hospitalists may be well‐positioned to assist our emergency medicine and public health colleagues, who currently (and fittingly) lead domestic efforts in disaster relief.

Tragedies like the earthquake in Haiti serve as a sobering reminder that a comprehensive multidisciplinary approach is required as medical disaster relief shifts from a life‐saving focus to one of life‐preserving care.13, 14 Hospitalists can play a vital role in these restorative efforts.

In the last decade, natural disasters such as the Indonesian tsunami of 2004, Hurricane Katrina in 2004, and the Pakistani earthquake of 2005 have brought attention to the importance of diverse but complementary medical professional roles in humanitarian medical aid.14 Natural disasters that cause significant physical trauma to large populations often necessitate initial multidisciplinary responder teams comprised of surgeons, anesthesiologists, emergency medicine physicians, surgical technologists, nurses, psychiatrists, and public health specialists. Their roles are to manage life‐threatening injuries, provide immediate triage, help affected individuals deal with intense psychological shock, and address critical population‐based needs such as water, food, and sanitation. Meanwhile, general medical, pediatric, rehabilitative, and long‐term psychiatric services often constitute a secondary tier of disaster response, providing postsurgical care, managing acute medical illnesses, mitigating psychological trauma, rehabilitating injuries, and providing vaccinations to at‐risk individuals. Hospitalists can play an important role in postcatastrophe recovery services as experts in acute care, stewards of care transitions, and drivers of systems improvement.

The earthquake that occurred January 12, 2010 in Haiti is a dramatic illustration of the importance of a multidisciplinary approach to disaster relief. The 7.0‐magnitude earthquake near Port‐au‐Prince ravaged an already crippled health care system, severely damaging the country's primary academic medical center, and killed the entire class of second‐year nursing students. The death toll has been estimated to be nearly one‐quarter of a million people.5 Victims awaiting surgery, recovering from surgery, or in need of other immediate medical attention quickly inundated any existing health facilities. The following stories describe the authors' respective experiences in Haiti after the earthquake.

JC: I arrived 4 days after the earthquake to a hospital outside of Port‐au‐Prince, spared from destruction, but filled with hundreds of patients with crush injuries and severe fractures. On rounds with the surgical team, I observed that venous thromboembolism (VTE) prophylaxis had not yet been initiated, and I was concerned that patients might die from pulmonary embolism. In the overwhelming urgency of providing life‐saving surgery to as many patients as possible, this simple measure had been overlooked. After discussion with our team and our Haitian medical colleagues, we initiated subcutaneous heparin on all eligible patients and made arrangements to receive further shipments of heparin to accommodate the influx of patients.

A nearby school and church had been annexed into makeshift extensions of the hospital wards. The volume and pace of incoming injuries was such that as soon as a patient was taken to surgery, another patient would often take his or her place in the bed. The rapid movement of patients to and from x‐ray, surgery, and postsurgical care created challenges around effective and accurate communication among multiple care providers. We decided that nonsurgical personnel would triage newly arriving patients and round on patients daily. Each nonsurgical physician was responsible for staffing a particular location. This zone‐defense approach ensured that the surgeons maximized their time in the operating rooms. We also instituted a basic system of portable medical records kept with each patient at all times, allowing personnel to easily and quickly assess care given to date, and to write notes and orders.

Presurgical and postsurgical wound infections became a common event, with the risk of ensuing sepsis. Antibiotic use was dependent on the preferences of individual surgeons and also on the available supply. As a result, antimicrobial treatments were highly variable and sometimes inadequate. The internists on the team proposed standard antibiotic guidelines for open fractures, for contaminated wounds, and for postoperative wounds; these regimens were approved and implemented by Haitian staff and the rest of the team.

Internists recognized the first complications of rhabdomyolysis from crush injuries and delays in receiving medical attention. Malaise, oliguria, and volume overload were often the only clues we had for severe renal failure. We had a functional lab capable of checking complete blood counts, urinalysis and creatinine, but we had a limited supply of serum potassium assays. We only used the latter in confirmed cases of rhabdomyolysis, and on several occasions we diagnosed severe hyperkalemia. Using bedside automated electrical defibrillation devices for monitoring, we sustained these patients on calcium gluconate until they could be transferred to an external dialysis unit run by Mdecins Sans Frontires in Port‐au‐Prince.6 As the number of rhabdomyolysis cases increased, we instigated creatinine rounds on patients arriving with large crush injuries, and we evaluated urine output daily until patients were clinically stable from this threat. We also helped the Haitian staff treat the omnipresent problem of pain and advised renal dosing of medications in renal failure and elderly patients.

GH: The situation 3 months after the earthquake was medically less dire but highlights the evolving importance of generalists in the aftermath of the quake.710 For many Haitian patients, the earthquake had become a universal point of reference for their symptomatology. Anorexia, amenorrhea, headaches, epigastric pain, even fungating soft tissue masses, were all reported to be depi tranbleman t a (since the earthquake) and were often somatic manifestations of a psychologically devastating event. At a hospital in Carrefour, I cared for patients presenting with dramatic sequelae of chronic diseases that had been undertreated due to the destruction of the Haitian medical infrastructurehypertensive coma, diabetic ketoacidosis, cerebral malaria, decompensated liver disease, and severe chronic anemia (including a patient with a hemoglobin of 3 mg/dL). I encountered many patients with infections exacerbated by excessive crowding in tent communities, such as typhoid and tuberculosis. At this particular hospital, priorities appropriately placed on surgical and postsurgical care required the team to devise creative solutions for the care and placement of medical patients, such as restructuring the emergency department and creating a rehabilitation tent on the hospital grounds. While few Haitian internists were present, a number of Haitian obstetricians were on site and helped manage medical conditions within the scope of their experience, such as hypertension, abdominal pain, and genitourinary infections. The expatriate orthopedic surgeons on site sought the consultative skills of hospitalists for preoperative management, postoperative complications, and comorbid conditions.

This hospital was largely sustained by rotating teams of volunteers, which underscored the importance of establishing a flexible system that would accommodate the turnover of personnel and fluctuating levels of professional expertise. The team used a tiered model for acute care delivery designating responsibilities based on the number of nurses, physicians, and other providers available. We collaborated with Haitian physicians to establish a routine of handoff rounds. Finally, we created and centralized documentation such as clinical protocols, contact numbers, and helpful tips for our successors.

Hospitalists have valuable skills to offer in medical responses to natural catastrophes.5 Our fluency with acute care environments becomes a pluripotent asset in disaster relief. Our experiences in assessing acuity are vital in assisting with inpatient triage. Our familiarity with the comanagement model facilitates partnership with other disciplines to optimize the distribution of skill sets without neglecting the overall well‐being of patients. Our clinical expertise in treating the vulnerable elderly, VTE, renal failure, pain management, postoperative infections, sepsis, and many other conditions can bolster medical relief efforts, even when the foremost need is surgical. The hospitalist's core competencies in healthcare systems11 can support recovery initiatives in medical facilities, particularly in the domains of drug safety, resource allocation, information management, team‐based methods, and care transitions. Our respective experiences also suggest the potential value of hospitalists in domestic, in addition to international, disaster response initiatives. Since large‐scale calamities may result in the hospitalization of overwhelming numbers of victims,12 hospitalists may be well‐positioned to assist our emergency medicine and public health colleagues, who currently (and fittingly) lead domestic efforts in disaster relief.

Tragedies like the earthquake in Haiti serve as a sobering reminder that a comprehensive multidisciplinary approach is required as medical disaster relief shifts from a life‐saving focus to one of life‐preserving care.13, 14 Hospitalists can play a vital role in these restorative efforts.

There is little scientific evidence about professional help‐seeking behavior among resident physicians. Although junior physicians have many sources of information available to them in the course of clinical practiceprint materials, internet resources, curbside consultations, and advice from senior residents and facultywe have little empirical knowledge about when, why, and how physician trainees ask for help.

To study this phenomenon, we examined the use of a medical procedure service (MPS) by resident physicians. The MPS is an inpatient service at a Boston teaching hospital that provides education, supervision, and evaluation of internal medicine residents who perform common bedside procedures; it has been described previously.1 Residents who call the MPS review an online curriculum with self‐assessment quizzes, perform procedures with faculty supervision and feedback, and assess their own performance using online checklists. This program has been available to internal medicine residents since 2002. In a previous study, we found that residents reported greater comfort performing bedside procedures when they used the procedure service, when the operator was a postgraduate year (PGY)2 or PGY3 resident (compared to PGY1 residents), and while placing central venous catheters (CVCs) (compared to thoracenteses).2

The goal of the current study was to examine help‐seeking behavior among resident physicians as they placed CVCs and performed thoracenteses. We interpreted the decision to use the MPS to indicate that the resident successfully sought and received assistance from pulmonary attending physicians or interventional pulmonary fellows. We hypothesized that: (1) residents earlier in their training would choose to use the procedure service due to their relative lack of experience; (2) they would seek consultation when the procedure was performed in high‐risk patients, as indicated by the number of comorbidities, presence of medications that increase the risk of bleeding, and treatment in an intensive care unit; and (3) residents would be less likely to call the MPS for urgent or emergent situations, when timely assistance may be difficult to obtain. To examine the potentially confounding influence of procedures supervised by non‐MPS physicians, we also investigated differences between informally supervised procedures (i.e. by a non‐MPS attending or fellow) and unsupervised procedures (i.e. no attending or fellow supervision) to determine whether any significant differences in their characteristics existed.

Methods

Results

Discussion

To understand professional help‐seeking behavior by internal medicine resident physicians, we studied factors associated with the use of a MPS for performing 2 common bedside procedures. We found that residents used the MPS more often when they performed procedures on patients with more comorbidities and less often during urgent or emergent procedures.

These results are consistent with our hypothesis that residents use formal supervision when caring for high‐risk patients. We had also hypothesized that they would seek the MPS for patients on medications that increase the risk of bleeding, but this was not borne out. One possible explanation is that invasive procedures on anticoagulated patients may be deferred or avoided. Additionally, we did not collect prothrombin times nor platelet count, which may represent better proxies for coagulopathy. Our hypothesis that residents would not seek the MPS for urgent and emergent procedures was confirmed; the time delay between contacting the faculty member and performing the procedure may have inhibited or obviated consultation of the MPS. We hypothesized that interns would use the MPS preferentially; we found instead that level of training did not influence use of the MPS. A resident early in training may struggle with the balance between autonomy and supervision, wanting instead to establish himself as able to solve clinical problems independently and by seeking consultation only as a last resort. Alternatively, interns may be primarily supervised by their residents and may seek expert assistance only for particularly challenging or high‐risk cases. Additionally, as newcomers to the training program, they may not be well acquainted with the role and availability of the service (although periodic announcements were made throughout the year). Our examination of procedures not supervised by the MPS showed that informally supervised and unsupervised procedures are quite similar to each other; the inverse relationship between informal supervision and patient gender is difficult to explain and may be spurious.

To our knowledge, only 1 author has postulated a theoretical foundation for help‐seeking in trainees, depicted in the context of the patient‐resident‐attending triadic relationship.4 The mature help‐seeker, whether patient, resident, or attending, is willing to confront problems, receptive to new information, able to acknowledge dependence on expertise, and able to apply new input with self‐reliance. However, little is known about how this model manifests itself empirically in professional help‐seeking or what the optimal conditions of faculty supervision are. One observational study suggested that faculty who spent more time on hospital floors created environments with higher resident satisfaction scores, higher perceived quality of patient care, and, paradoxically, increased perceptions of autonomy.5 These results are consistent with our previous work showing that residents' comfort with bedside procedures increased with use of the MPS.2 In the related field of consultation medicine, 2 studies6, 7 showed that family practitioners prefer to consult internal medicine subspecialists over general internists. One of these studies7 demonstrated that the primary need was for a consultant with technical (ie, procedural) skills. Our use of MPS faculty who are specifically skilled in performing medical procedures appears to be consistent with this observation that specific technical expertise is valued over general supervision or guidance.

How can we best design formal procedural supervision programs that allow residents to obtain help when they need it? In addition to fostering mature help‐seeking behavior, help‐giving requires: (1) an environment that encourages help‐seeking; (2) a mechanism to provide assistance when and where it is needed; (3) supervisors with technical expertise; and (4) supervision that supports learning, skill acquisition, and graduated autonomy. It is difficult to devise mechanisms that include all of these elements. For instance, 24‐hour per day faculty coverage may be logistically challenging and expensive. Physicians with technical expertise may not be good teachers despite faculty development on procedural teaching. Obstacles to successful help‐seeking may include differences in residents' and supervisors' perceptions about the need for supervision. For example, a supervisor may be available and willing to assist, but the resident may feel capable of performing independently. When assistance is provided, residents and supervisors may differ in their perceptions of the quality of supervision.8 Ultimately, any educational intervention to increase supervision must confront a cultural norm of self‐sufficiency among many residency programs, in which managing a situation without assistance is equated with competence. To address this issue, our hospital has mandated the use of the MPS for all bedside procedures since 2005 and staffed the program 24 hours a day, in recognition of the potential risk of procedural complications9, 10 among inexperienced trainees.

This study has several limitations. We had a small number of thoracenteses. The study was not designed or powered to examine differences in complication rates among MPS and non‐MPS procedures. Because we represent a single institution, our findings may not be generalizable to other teaching hospitals or nonteaching settings. Our data on procedure characteristics were ascertained through resident self‐reports and, though typically submitted in a timely way, are subject to recall bias. In particular, discrepancies in the reported level of urgency may have affected our results about the time‐dependent nature of help‐seeking. Additionally, our findings about the types of patients about which residents seek consultation are somewhat at odds; use of the modified Deyo criteria to adjust for clinical severity weighs chronic conditions heavily and may translate into complication risk, but the level of urgency may better reflect the acuity of the clinical presentation. We could not distinguish between resident‐supervised procedures and those performed without supervision because of limited data. We also acknowledge the possibility that some non‐MPS faculty (classified for the study as informal supervisors) may serendipitously provide an equal quality of supervision that our MPS faculty did, by being present throughout the procedure and giving structured and valuable feedback.

Nevertheless, our results suggest that many residents do seek formal help appropriately when they perform procedures on the sickest patients, recognizing the risk and technical difficulty associated with bedside procedures in these patients. Our results also point to a greater area of inquiry: how do we optimally address the help‐seeking needs among trainee physicians? How do we create an environment in which help‐seeking is encouraged? How do we overcome the logistical barriers of providing timely assistance to residents, particularly at times of greatest need (urgent or emergent procedures)? How do we confront a longstanding culture in which independence is equated with competence, especially as it relates to procedural skills? A better understanding of how the widespread availability of programs like our MPS would affect the residents' use of supervision in general may guide the design of resident curricula and the development of mechanisms to ensure safe and effective clinical care.

There is little scientific evidence about professional help‐seeking behavior among resident physicians. Although junior physicians have many sources of information available to them in the course of clinical practiceprint materials, internet resources, curbside consultations, and advice from senior residents and facultywe have little empirical knowledge about when, why, and how physician trainees ask for help.

To study this phenomenon, we examined the use of a medical procedure service (MPS) by resident physicians. The MPS is an inpatient service at a Boston teaching hospital that provides education, supervision, and evaluation of internal medicine residents who perform common bedside procedures; it has been described previously.1 Residents who call the MPS review an online curriculum with self‐assessment quizzes, perform procedures with faculty supervision and feedback, and assess their own performance using online checklists. This program has been available to internal medicine residents since 2002. In a previous study, we found that residents reported greater comfort performing bedside procedures when they used the procedure service, when the operator was a postgraduate year (PGY)2 or PGY3 resident (compared to PGY1 residents), and while placing central venous catheters (CVCs) (compared to thoracenteses).2

The goal of the current study was to examine help‐seeking behavior among resident physicians as they placed CVCs and performed thoracenteses. We interpreted the decision to use the MPS to indicate that the resident successfully sought and received assistance from pulmonary attending physicians or interventional pulmonary fellows. We hypothesized that: (1) residents earlier in their training would choose to use the procedure service due to their relative lack of experience; (2) they would seek consultation when the procedure was performed in high‐risk patients, as indicated by the number of comorbidities, presence of medications that increase the risk of bleeding, and treatment in an intensive care unit; and (3) residents would be less likely to call the MPS for urgent or emergent situations, when timely assistance may be difficult to obtain. To examine the potentially confounding influence of procedures supervised by non‐MPS physicians, we also investigated differences between informally supervised procedures (i.e. by a non‐MPS attending or fellow) and unsupervised procedures (i.e. no attending or fellow supervision) to determine whether any significant differences in their characteristics existed.

Methods

Results

Discussion

To understand professional help‐seeking behavior by internal medicine resident physicians, we studied factors associated with the use of a MPS for performing 2 common bedside procedures. We found that residents used the MPS more often when they performed procedures on patients with more comorbidities and less often during urgent or emergent procedures.

These results are consistent with our hypothesis that residents use formal supervision when caring for high‐risk patients. We had also hypothesized that they would seek the MPS for patients on medications that increase the risk of bleeding, but this was not borne out. One possible explanation is that invasive procedures on anticoagulated patients may be deferred or avoided. Additionally, we did not collect prothrombin times nor platelet count, which may represent better proxies for coagulopathy. Our hypothesis that residents would not seek the MPS for urgent and emergent procedures was confirmed; the time delay between contacting the faculty member and performing the procedure may have inhibited or obviated consultation of the MPS. We hypothesized that interns would use the MPS preferentially; we found instead that level of training did not influence use of the MPS. A resident early in training may struggle with the balance between autonomy and supervision, wanting instead to establish himself as able to solve clinical problems independently and by seeking consultation only as a last resort. Alternatively, interns may be primarily supervised by their residents and may seek expert assistance only for particularly challenging or high‐risk cases. Additionally, as newcomers to the training program, they may not be well acquainted with the role and availability of the service (although periodic announcements were made throughout the year). Our examination of procedures not supervised by the MPS showed that informally supervised and unsupervised procedures are quite similar to each other; the inverse relationship between informal supervision and patient gender is difficult to explain and may be spurious.

To our knowledge, only 1 author has postulated a theoretical foundation for help‐seeking in trainees, depicted in the context of the patient‐resident‐attending triadic relationship.4 The mature help‐seeker, whether patient, resident, or attending, is willing to confront problems, receptive to new information, able to acknowledge dependence on expertise, and able to apply new input with self‐reliance. However, little is known about how this model manifests itself empirically in professional help‐seeking or what the optimal conditions of faculty supervision are. One observational study suggested that faculty who spent more time on hospital floors created environments with higher resident satisfaction scores, higher perceived quality of patient care, and, paradoxically, increased perceptions of autonomy.5 These results are consistent with our previous work showing that residents' comfort with bedside procedures increased with use of the MPS.2 In the related field of consultation medicine, 2 studies6, 7 showed that family practitioners prefer to consult internal medicine subspecialists over general internists. One of these studies7 demonstrated that the primary need was for a consultant with technical (ie, procedural) skills. Our use of MPS faculty who are specifically skilled in performing medical procedures appears to be consistent with this observation that specific technical expertise is valued over general supervision or guidance.

How can we best design formal procedural supervision programs that allow residents to obtain help when they need it? In addition to fostering mature help‐seeking behavior, help‐giving requires: (1) an environment that encourages help‐seeking; (2) a mechanism to provide assistance when and where it is needed; (3) supervisors with technical expertise; and (4) supervision that supports learning, skill acquisition, and graduated autonomy. It is difficult to devise mechanisms that include all of these elements. For instance, 24‐hour per day faculty coverage may be logistically challenging and expensive. Physicians with technical expertise may not be good teachers despite faculty development on procedural teaching. Obstacles to successful help‐seeking may include differences in residents' and supervisors' perceptions about the need for supervision. For example, a supervisor may be available and willing to assist, but the resident may feel capable of performing independently. When assistance is provided, residents and supervisors may differ in their perceptions of the quality of supervision.8 Ultimately, any educational intervention to increase supervision must confront a cultural norm of self‐sufficiency among many residency programs, in which managing a situation without assistance is equated with competence. To address this issue, our hospital has mandated the use of the MPS for all bedside procedures since 2005 and staffed the program 24 hours a day, in recognition of the potential risk of procedural complications9, 10 among inexperienced trainees.

This study has several limitations. We had a small number of thoracenteses. The study was not designed or powered to examine differences in complication rates among MPS and non‐MPS procedures. Because we represent a single institution, our findings may not be generalizable to other teaching hospitals or nonteaching settings. Our data on procedure characteristics were ascertained through resident self‐reports and, though typically submitted in a timely way, are subject to recall bias. In particular, discrepancies in the reported level of urgency may have affected our results about the time‐dependent nature of help‐seeking. Additionally, our findings about the types of patients about which residents seek consultation are somewhat at odds; use of the modified Deyo criteria to adjust for clinical severity weighs chronic conditions heavily and may translate into complication risk, but the level of urgency may better reflect the acuity of the clinical presentation. We could not distinguish between resident‐supervised procedures and those performed without supervision because of limited data. We also acknowledge the possibility that some non‐MPS faculty (classified for the study as informal supervisors) may serendipitously provide an equal quality of supervision that our MPS faculty did, by being present throughout the procedure and giving structured and valuable feedback.

Nevertheless, our results suggest that many residents do seek formal help appropriately when they perform procedures on the sickest patients, recognizing the risk and technical difficulty associated with bedside procedures in these patients. Our results also point to a greater area of inquiry: how do we optimally address the help‐seeking needs among trainee physicians? How do we create an environment in which help‐seeking is encouraged? How do we overcome the logistical barriers of providing timely assistance to residents, particularly at times of greatest need (urgent or emergent procedures)? How do we confront a longstanding culture in which independence is equated with competence, especially as it relates to procedural skills? A better understanding of how the widespread availability of programs like our MPS would affect the residents' use of supervision in general may guide the design of resident curricula and the development of mechanisms to ensure safe and effective clinical care.

There is little scientific evidence about professional help‐seeking behavior among resident physicians. Although junior physicians have many sources of information available to them in the course of clinical practiceprint materials, internet resources, curbside consultations, and advice from senior residents and facultywe have little empirical knowledge about when, why, and how physician trainees ask for help.

To study this phenomenon, we examined the use of a medical procedure service (MPS) by resident physicians. The MPS is an inpatient service at a Boston teaching hospital that provides education, supervision, and evaluation of internal medicine residents who perform common bedside procedures; it has been described previously.1 Residents who call the MPS review an online curriculum with self‐assessment quizzes, perform procedures with faculty supervision and feedback, and assess their own performance using online checklists. This program has been available to internal medicine residents since 2002. In a previous study, we found that residents reported greater comfort performing bedside procedures when they used the procedure service, when the operator was a postgraduate year (PGY)2 or PGY3 resident (compared to PGY1 residents), and while placing central venous catheters (CVCs) (compared to thoracenteses).2

The goal of the current study was to examine help‐seeking behavior among resident physicians as they placed CVCs and performed thoracenteses. We interpreted the decision to use the MPS to indicate that the resident successfully sought and received assistance from pulmonary attending physicians or interventional pulmonary fellows. We hypothesized that: (1) residents earlier in their training would choose to use the procedure service due to their relative lack of experience; (2) they would seek consultation when the procedure was performed in high‐risk patients, as indicated by the number of comorbidities, presence of medications that increase the risk of bleeding, and treatment in an intensive care unit; and (3) residents would be less likely to call the MPS for urgent or emergent situations, when timely assistance may be difficult to obtain. To examine the potentially confounding influence of procedures supervised by non‐MPS physicians, we also investigated differences between informally supervised procedures (i.e. by a non‐MPS attending or fellow) and unsupervised procedures (i.e. no attending or fellow supervision) to determine whether any significant differences in their characteristics existed.

Methods

Results

Discussion

To understand professional help‐seeking behavior by internal medicine resident physicians, we studied factors associated with the use of a MPS for performing 2 common bedside procedures. We found that residents used the MPS more often when they performed procedures on patients with more comorbidities and less often during urgent or emergent procedures.

These results are consistent with our hypothesis that residents use formal supervision when caring for high‐risk patients. We had also hypothesized that they would seek the MPS for patients on medications that increase the risk of bleeding, but this was not borne out. One possible explanation is that invasive procedures on anticoagulated patients may be deferred or avoided. Additionally, we did not collect prothrombin times nor platelet count, which may represent better proxies for coagulopathy. Our hypothesis that residents would not seek the MPS for urgent and emergent procedures was confirmed; the time delay between contacting the faculty member and performing the procedure may have inhibited or obviated consultation of the MPS. We hypothesized that interns would use the MPS preferentially; we found instead that level of training did not influence use of the MPS. A resident early in training may struggle with the balance between autonomy and supervision, wanting instead to establish himself as able to solve clinical problems independently and by seeking consultation only as a last resort. Alternatively, interns may be primarily supervised by their residents and may seek expert assistance only for particularly challenging or high‐risk cases. Additionally, as newcomers to the training program, they may not be well acquainted with the role and availability of the service (although periodic announcements were made throughout the year). Our examination of procedures not supervised by the MPS showed that informally supervised and unsupervised procedures are quite similar to each other; the inverse relationship between informal supervision and patient gender is difficult to explain and may be spurious.

To our knowledge, only 1 author has postulated a theoretical foundation for help‐seeking in trainees, depicted in the context of the patient‐resident‐attending triadic relationship.4 The mature help‐seeker, whether patient, resident, or attending, is willing to confront problems, receptive to new information, able to acknowledge dependence on expertise, and able to apply new input with self‐reliance. However, little is known about how this model manifests itself empirically in professional help‐seeking or what the optimal conditions of faculty supervision are. One observational study suggested that faculty who spent more time on hospital floors created environments with higher resident satisfaction scores, higher perceived quality of patient care, and, paradoxically, increased perceptions of autonomy.5 These results are consistent with our previous work showing that residents' comfort with bedside procedures increased with use of the MPS.2 In the related field of consultation medicine, 2 studies6, 7 showed that family practitioners prefer to consult internal medicine subspecialists over general internists. One of these studies7 demonstrated that the primary need was for a consultant with technical (ie, procedural) skills. Our use of MPS faculty who are specifically skilled in performing medical procedures appears to be consistent with this observation that specific technical expertise is valued over general supervision or guidance.

How can we best design formal procedural supervision programs that allow residents to obtain help when they need it? In addition to fostering mature help‐seeking behavior, help‐giving requires: (1) an environment that encourages help‐seeking; (2) a mechanism to provide assistance when and where it is needed; (3) supervisors with technical expertise; and (4) supervision that supports learning, skill acquisition, and graduated autonomy. It is difficult to devise mechanisms that include all of these elements. For instance, 24‐hour per day faculty coverage may be logistically challenging and expensive. Physicians with technical expertise may not be good teachers despite faculty development on procedural teaching. Obstacles to successful help‐seeking may include differences in residents' and supervisors' perceptions about the need for supervision. For example, a supervisor may be available and willing to assist, but the resident may feel capable of performing independently. When assistance is provided, residents and supervisors may differ in their perceptions of the quality of supervision.8 Ultimately, any educational intervention to increase supervision must confront a cultural norm of self‐sufficiency among many residency programs, in which managing a situation without assistance is equated with competence. To address this issue, our hospital has mandated the use of the MPS for all bedside procedures since 2005 and staffed the program 24 hours a day, in recognition of the potential risk of procedural complications9, 10 among inexperienced trainees.

This study has several limitations. We had a small number of thoracenteses. The study was not designed or powered to examine differences in complication rates among MPS and non‐MPS procedures. Because we represent a single institution, our findings may not be generalizable to other teaching hospitals or nonteaching settings. Our data on procedure characteristics were ascertained through resident self‐reports and, though typically submitted in a timely way, are subject to recall bias. In particular, discrepancies in the reported level of urgency may have affected our results about the time‐dependent nature of help‐seeking. Additionally, our findings about the types of patients about which residents seek consultation are somewhat at odds; use of the modified Deyo criteria to adjust for clinical severity weighs chronic conditions heavily and may translate into complication risk, but the level of urgency may better reflect the acuity of the clinical presentation. We could not distinguish between resident‐supervised procedures and those performed without supervision because of limited data. We also acknowledge the possibility that some non‐MPS faculty (classified for the study as informal supervisors) may serendipitously provide an equal quality of supervision that our MPS faculty did, by being present throughout the procedure and giving structured and valuable feedback.

Nevertheless, our results suggest that many residents do seek formal help appropriately when they perform procedures on the sickest patients, recognizing the risk and technical difficulty associated with bedside procedures in these patients. Our results also point to a greater area of inquiry: how do we optimally address the help‐seeking needs among trainee physicians? How do we create an environment in which help‐seeking is encouraged? How do we overcome the logistical barriers of providing timely assistance to residents, particularly at times of greatest need (urgent or emergent procedures)? How do we confront a longstanding culture in which independence is equated with competence, especially as it relates to procedural skills? A better understanding of how the widespread availability of programs like our MPS would affect the residents' use of supervision in general may guide the design of resident curricula and the development of mechanisms to ensure safe and effective clinical care.