47 DeRienzo CM, Frush K, Barfield ME, et al Handoffs in the era of duty hours reform a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common[.]
e2 65 Anderson JM, Murphy AA, Boyle KB, et al Simulating extracoporeal membrane oxygenation emergencies to improve human performance Part II: assessment of technical and behavioral skills Simul Healthc 2006;1(4):228-232 66 Fanning RM, Gaba DM The role of debriefing in simulation-based learning Simul Healthc 2007;2(2):115-125 67 Kolb D Experiential Learning: Experience as a Source of Learning and Development Upper Saddle River, NJ: Prentice Hall; 1984 68 Percarpio KB, Harris FS, Hatfield BA, et al Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training program improves the cardiopulmonary resuscitation code process Jt Comm J Qual Patient Saf 2010;36(9):424-429, 385 69 Savoldelli GL, Naik VN, Park J, et al Value of Debriefing during simulated crisis management Anesthesiology 2006;105(2):279-285 70 Edelson DP, Litzinger B, Arora V, et al Improving in-hospital cardiac arrest process and outcomes with performance debriefing Arch Intern Med 2008;168(10):1063-1069 71 Cheng A, Hunt EA, Donoghue A, et al Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial JAMA Pediatr 2013;167(6):528-536 72 Eppich W, Cheng A Promoting excellence and reflective learning in simulation development and rationale for a blended approach to health care simulation debriefing Simul Healthc 2015;10(2):106-115 73 Rudolph JW, Simon R, Dufresne RL, et al There’s no such thing as “nonjudgmental” debriefing: theory and method for debriefing with good judgment Simul Healthc 2006;1(1):49-55 74 Raemer D, Anderson M, Cheng A, et al Research regarding debriefing as part of the learning process Simul Healthc 2011;6(7):S52-S57 75 Edelson DP, LaFond CM Deconstructing debriefing for simulationbased education JAMA Pediatr 2013;167(6):586-587 76 Dismukes RK, Gaba DM, Howard SK So many roads: facilitated debriefing in healthcare Simul Healthc 2006;1(1):23-25 77 Ahmed M, Arora S, Russ S, et al Operation debrief: a SHARP improvement in performance feedback in the operating room Ann Surg 2013;258(6):958-963 78 Mullan PC, Wuestner E, Kerr TA, et al Implementation of an in situ qualitative debriefing tool for resuscitations Resuscitation 2013;84(7):946-951 79 Kolbe M, Weiss M, Grote G, et al TeamGAINS: a tool for structured debriefings for simulation-based team trainings BMJ Qual Saf 2013;22:541-553 80 Baker DP, Gustafson S, Beaubien JM, et al Medical team training programs in health care In: Henriksen K, Battles JB, Marks ES, et al, eds Advances in Patient Safety: From Research to Implementation Vol Rockville, MD: Agency for Healthcare Research and Quality; 2005 81 Weaver SJ, Dy SM, Rosen MA, et al Team-training in healthcare: a narrative synthesis of the literature BMJ Qual Saf 2014;23:359-372 82 Thomas EJ Improving teamwork in healthcare: current approaches and the path forward BMJ Qual Saf 2011;20(8):647-650 83 Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JDH, et al Interventions to improve team effectiveness: a systematic review Health Policy 2010;94:183-195 84 Cumin D, Boyd MJ, Webster CS, et al A systematic review of simulation for multidisciplinary team training in operating rooms Simul Healthc 2013;8(3):171-179 85 Weaver SJ, Lyons R, DiazGranados D, et al The anatomy of health care team training and the state of practice: a critical review Acad Med 2010;85(11):1746-1760 86 Eppich WJ, Brannen M, Hunt EA Team training: implications for emergency and critical care pediatrics Curr Opin Pediatr 2008;20:255-260 87 Mayer CM, Cluff L, Lin W, et al Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units Jt Comm J Qual Patient Saf 2011;37(8):365-374 47 DeRienzo CM, Frush K, Barfield ME, et al Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements Acad Med 2012;87(4): 403-410 48 Starmer AJ, Spector ND, Srivastava R, et al Changes in medical errors after implementation of a handoff program N Engl J Med 2014;371:1803-1812 49 Muller M, Jurgens J, Redaelli M, et al Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review BMJ Open 2018;8:e022202 50 ACGME Program Requirements For Graduate Medical Education In Pediatric Critical Care Medicine 2007 https://www.acgme.org/ acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/323_critical_ care_peds_07012013.pdf 51 Cheng A, Rodgers DL, van der Jagt E, et al Evolution of the Pediatric Advanced Life Support course: enhanced learning with a new debriefing tool and web-based module for PALS instructors Pediatr Crit Care Med 2012;13(5):589-595 52 Manser T Teamwork and patient safety in dynamic domains of healthcare: a review of the literature Acta Anaesthesiol Scand 2009; 53:143-151 53 Turner DA, Mink RB, Lee KJ, et al Are pediatric critical care medicine fellowships teaching and evaluating communication and professionalism? Pediatr Crit Care Med 2013;14(5):454-461 54 McGaghie WC, Issenberg SB, Cohen ER, et al Does simulationbased medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence Acad Med 2011;86(6):706-711 55 Mundell W, Kennedy C, Szostek J, Cook D Simulation technology for resuscitation training: A systematic review and metaanalysis Resuscitation 2013;84:1174-1183 56 Cortegiani A, Russotto V, Gregoretti C, Giarratano A, Antonelli M Medical simulation for ICU staff: Does it influence safety of care? Intensive Care Med 2016;42:635 57 Steadman RH, Coates WC, Huang YM et al Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills Crit Care Med 2006;34(1):151-157 58 Merien AE, van de Ven J, Mol BW, et al Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review Obstet Gynecol 2010;115(5):1021-1031 59 Allan CK, Thiagarajan RR, Beke D, et al Simulation-based training delivered directly to the pediatric cardiac intensive care unit engenders preparedness, comfort, and decreased anxiety among multidisciplinary resuscitation teams J Thorac Cardiovasc Surg 2010; 140(3):646-652 60 Gordon JA, Wilkerson WM, Shaffer DW, et al “Practicing” medicine without risk: students’ and educators’ responses to high-fidelity patient simulation Acad Med 2001;76(5):469-472 61 Cuoto TB, Kerrey BT, Taylor RG, et al Teamwork skills in actual, in situ, and in-center pediatric emergencies: performance levels across settings and perceptions of comparative educational impact Simul Healthc 2015;10(5):76-84 62 Shaw DJ, Davidson JE, Smilde RI, Sondoozi T, Agan D Multidisciplinary team training to enhance family communication in the ICU Crit Care Med 2014;42(2):265-271 63 Foronda C, MacWilliams B, McArthur E Interprofessional communication in healthcare: an integrative review Nurse Educ Pract 2016;19:36-40 64 Brum R, Rajani R, Gelandt E, et al Simulation training for extracorporeal membrane oxygenation Ann Card Anaesth 2015;18(2): 185-190 e3 91 Low XM, Horrigan D, Brewster D The effects of team-training in intensive care medicine: a narrative review J Crit Care 2018;48:283289 92 Mayo AT, Williams Woolley A State of the art and science teamwork in health care: maximizing collective intelligence via inclusive collaboration and open communication AMA J Ethics 2016; 18(9):933-940 93 Salas E, Weaver SJ, DiazGranados D, Lyons R, King H Sounding the call for team training in health care: some insights and warnings Acad Med 2009;84(10):S128-S131 88 Van Schaik SM, Plant J, Diane S, et al Interprofessional team training in pediatric resuscitation: a low-cost, in situ simulation program that enhances self-efficacy among participants Clin Pediatr (Phila) 2011;50(9):807-815 89 Stocker M, Allen M, Pool N, et al Impact of an embedded simulation team training programme in a pediatric intensive care unit: a prospective, single centre, longitudinal study Intensive Care Med 2012;38;99-104 90 Katinakis PA, Spronk PE The effects of structural crew resource management (CRM)/medical team work (MTW) training in the ICU: The MTW Impact And Evaluation Study Am J Respir Crit Care Med 2016;193:A3207 e4 Abstract: Recognition of a high rate of medical errors resulting from ineffective communication and teamwork compelled development of strategies and tools to promote situational awareness and a shared mental model in the healthcare setting Using specific design elements in the intensive care unit (ICU) can enhance patient surveillance and nonverbal communication Applying standardized work—such as organized huddles, checklists, and structured rounds—can result in less variability and more consistent communication within multidisciplinary ICU care teams Intentional and ongoing education and assessment of communication skills—such as closed-loop communication using techniques such as simulation and debriefing—is vital Implementation of interdisciplinary team training provides skills that improve teamwork, enhance communication, and contribute to patient safety Key Words: Communication, safety, situational awareness, shared mental model Professionalism in Pediatric Critical Care BRADLEY P FUHRMAN AND LYNN J HERNAN PEARLS • The medical profession is largely self-regulated by a system composed of state medical licensing boards, subspecialty boards, and credentialing and accrediting bodies This system confers many benefits on its members • It is the purview of society to allow us this autonomy • To sustain these professional benefits, which include control of entry into our profession and to maintain the autonomy of our credentialing and accrediting bodies, we must honor our contracts with society • Professionalism is, in its simplest form, putting the patient first, placing altruism before self-interest, as is expected of us • Beyond that, professionalism is a more complete charter that ties altruism to the concrete realities of the doctor-patient relationship and the marketplace in which we practice • The Physician Charter is grounded in the principles of altruism, patient autonomy, and social justice It codifies the physician’s contract with society Profession The Virtuous Doctor Pediatric critical care is a profession To be certified and practice as a pediatric intensivist, one must master several bodies of special knowledge, complete apprenticeships in pediatrics and pediatric critical care, earn various educational certificates, pass examinations (the culmination of which is the American Board of Pediatrics certifying examination in Pediatric Critical Care), and be granted a license to practice by a state medical board Our profession oversees that process much as a guild controls its members and membership As a profession, we train ourselves, test ourselves, credential ourselves, and discipline ourselves We derive many benefits from our status as professionals We are paid as professionals, respected as professionals, and valued by society as professionals The autonomy of our profession is granted and allowed by society There are, accordingly, unwritten contracts between our profession and society In exchange for the benefits that “professionalism” confers and the autonomy, self-governance, and control of licensure that is ceded to us, society expects us to meet its needs within the boundaries of our expertise We gain the advantages listed here because we provide the quality of service that society requires In the end, professionalism is the set of responsibilities and behaviors that fulfill our contracts with society These characteristics exemplify the good and virtuous doctor because that is the model society would hold us to, not because virtue has intrinsic value (though it does), but because deviation from virtue breaks our contract Most would agree as to what characteristics exemplify the good and virtuous doctor We have watched exemplary characters portrayed on television over the years in dramas, comedies, and in advertisements These are the professionals that our parents, our patients, and the rest of society expect us to emulate, imitate, dress like, and act like We have long had a sense of the characteristics portrayed However, over the past several decades, professional medical organizations have obsessed over defining, teaching, assessing, and understanding the behaviors that connote professionalism Now, why is that? 26 Stakes Healthcare now consumes (produces) about 17% of the US gross domestic product.1 It has become increasingly technology intense and engages financial giants in the form of insurers, pharmaceutical companies, device/equipment manufacturers, both freestanding and gigantic nationwide inpatient facilities, and information storage/management enterprises Healthcare employs about 14,000,000 workers,2 some of whom are independent practitioners and many of whom are contracted to large enterprises Two of the largest third-party payers in the United States are Medicare and Medicaid, which together expend 4.7% of the gross domestic product on healthcare Those payments flow from the general tax coffers to physicians and other recipients We now live in a medical marketplace,3 and hear patients referred to by administrators as customers or by insurers as covered lives How physicians manage CHAPTER 4 Professionalism in Pediatric Critical Care patients in this context is of great financial import; thus it should be no surprise that many of the traits characterized as professionalism have financial implications Professionalism has, accordingly, received renewed attention and scrutiny Great Paradox of the Medical Profession A constant tension pervades medicine where principles of selfinterest and altruism coexist.4 In most human endeavors, it is considered appropriate to identify one’s own best interests and make decisions accordingly It is in one’s best interest to obey the law, brush one’s teeth, and to work for a living Yet, it is in the best interest of society for physicians to treat patients altruistically, whether that benefits the professional or not The physician’s pledge to society is to be altruistic in dealing with patients, to put the patient first, before oneself These two principles, self-interest and altruism, are polarized and often conflict With each medical decision comes the question: “Was this for the patient or for the doctor? Whose interest did this serve?” In its simplest sense, professionalism in medicine comes down to putting the patient first Here’s a concrete example: It is am I haven’t slept a wink and I’m hard at work in the pediatric intensive care unit (PICU) trying to finish my documentation so I can catch some shuteye The emergency department (ED) resident calls He has a child with a fever who looks sick (to him) Would I mind taking a look to see if he needs to come to the PICU? What should I do? Go take a look Have him admitted to general pediatrics Hold him in the ED until am when relief arrives for the day shift Just bring him up to the PICU Send him home; it’s just a fever Altruism says: “Go take a look.” That would be best for the patient It could improve the quality of the triage decision and optimize patient care Self-interest says: “2, 3, or and it’s not my problem I’m exhausted.” The professionalism issue here is altruism, “patient first,” but look at the financial overlay The PICU provides expensive care and is a costly resource A decision to admit to the PICU should not be made casually General pediatrics may not be able to safely care for the patient, and a bad outcome may mean patient suffering, additional hospital or patient expense, or a lawsuit Don’t use the hospital if you don’t have to It costs money Holding the patient in the ED is a dissatisfier, will damage the hospital in the eyes of the community, and will interfere with the ED workflow Professionalism is a larger issue than merely resolving the patient first medical paradox; the concept of professionalism received a much more thorough examination in the late 1990s and first decade of the new millennium Many of the groups that regulate medicine on our behalf weighed in Among them were the American Board of Internal Medicine Foundation, the American College of Physicians, the American Society of Internal Medicine, and the European Federation of Internal Medicine, all of which worked together to draft the document “Medical Professionalism in the New Millennium: A Physician Charter.”5 Professionalism, The Physician Charter The Charter adopted three principles and made 10 commitments to fulfill the medical profession’s contract with society: Principle 1: Primacy of Patient Welfare Altruism demands that the patient’s needs be given precedence over self-interest, market forces, societal pressure, and administrative exigency 27 Principle 2: Patient Autonomy Physicians must be honest with their patients and, whenever possible, empower them to make informed decisions Principle 3: Social Justice There should be fair distribution of healthcare resources Commitment 1: Professional Competence Each individual physician must ensure one’s own competence, and the profession as a whole must ensure its members’ competence Professionals are responsible for putting mechanisms in place to ensure lifelong learning, competence, and skills Commitment 2: Honesty with Patients Patients must be completely and honestly informed Medical errors must be acknowledged Mistakes must be analyzed to improve the quality of healthcare Commitment 3: Patient Confidentiality Patient trust demands that confidences be protected Trust is essential to the doctorpatient (patient-doctor) relationship Commitment 4: Appropriate Relations to Patients Patients are inherently vulnerable Professionalism demands that they not be exploited Commitment 5: Improve Quality of Care Not only must we maintain clinical competence, we must work collaboratively to reduce medical errors, increase patient safety, minimize overuse of healthcare resources, and optimize outcomes of care Commitment 6: Improve Access to Care Physicians must strive to reduce barriers to equitable healthcare and to foster uniform and adequate standards of care Commitment 7: Just Distribution of Finite Resources The physician must make wise and cost-effective use of limited resources Commitment 8: Scientific Knowledge Where possible, care should be evidence based Commitment 9: Manage Conflicts of Interest To maintain patient trust, physicians must recognize, disclose, and deal with conflicts of interest that arise in the course of their professional activities Commitment 10: Ensure the Integrity of Professional Responsibilities The profession must define, organize, and ensure the standards of its current and future members Pediatric Intensive Care Unit as a Site for Medical Education and Lifelong Learning The renaissance of interest in professionalism has fostered an endeavor to weave the topic into medical education, build it into curricula, and focus on it in coursework.6 Despite that interest, medical student altruism, social interest, and other qualities of positive social value have been noted to decline as the student progresses through medical school and the early phase of clinical training.7–11 The altruistic freshman is transformed by clinical experiences into the cynical senior It has been argued that this growth of cynicism reflects the gap between what we say as teachers (the formal curriculum) and what we as practitioners (the hidden curriculum).12 When we not “walk the talk,” we plant the seeds of cynicism and nonprofessionalism An example: Dr Blunt and an impressionable medical student are suturing a central line in place Their patient is in a chemically induced coma from self-medication compounded by subsequent hypoxia His story is tragic and the student knows that the teenager deserves sympathy and respect As Dr Blunt ties the last knot he comments, “It would have been easier to get this line in if he ... boards, and credentialing and accrediting bodies This system confers many benefits on its members • It is the purview of society to allow us this autonomy • To sustain these professional benefits,... often conflict With each medical decision comes the question: “Was this for the patient or for the doctor? Whose interest did this serve?” In its simplest sense, professionalism in medicine comes... care: maximizing collective intelligence via inclusive collaboration and open communication AMA J Ethics 2016; 18(9):933-940 93 Salas E, Weaver SJ, DiazGranados D, Lyons R, King H Sounding the call