West J Emerg Med. 2012;13(6):543

Jerome R Hoffman: and Hemal K Kanzaria: argue that efforts to reduce overdiagnosis and overtreatment should focus on changing professional and public attitudes towards medical error and uncertainty.

Introduction

Physicians need to be able to communicate the myriad of management options clearly to patients and engage them in their health care decisions, even in the fast-paced environment of the emergency department. Shared decision making (SDM) is an effective communication strategy for physicians to share diagnostic uncertainty, avoid potentially harmful tests, and solicit patients' preferences for their care. Role-playing with just-in-time feedback is an effective method to learn and practice SDM before having these conversations with patients.

Methods

This flipped classroom workshop featured precourse materials and an in-class session incorporating a short lecture outlining a framework for SDM, followed by role-playing through patient scenarios. Learners took turns playing the physician or patient role and received feedback on their communication skills while in the physician role. A faculty examiner subsequently assessed skill attainment using a simulated patient encounter and checklist of critical actions.

Results

The workshop was an interactive and effective way to teach SDM to 28 PGY 1 and PGY 2 emergency medicine residents. Two months after attending the workshop, over 75% of the first-year residents were able to complete all the elements of the SDM process in a simulated patient encounter; four residents required no prompting by the examiner.

Discussion

A communications workshop that incorporates role-playing with different patient encounters is an interactive way to teach SDM for the emergency setting. Residents early in their clinical training can benefit from learning and practicing SDM in a simulated setting.

Between 1997 and 2011, there was a nearly 50 percent reduction in US emergency department mortality rates for adults. This trend likely has many causes, related to advances in palliative, prehospital, and emergency care.

Objective

There has been a rise in advanced diagnostic imaging (ADI) use in the emergency department (ED). Increased utilization may contribute to longer length of stay (LOS), but prior reports have not considered improved methods for modeling skewed LOS data.

Methods

The 2010 National Hospital Ambulatory Medical Care Survey data were analyzed by 5 common ED chief complaints. Generalized linear model (GLM) was compared to quantile and ordinary least squares (OLS) regression to evaluate the association between ADI and ED LOS. Receipt of computed tomography or magnetic resonance imaging was the primary exposure. Emergency department LOS was the primary outcome.

Results

Of the 33,685 ED visits analyzed, 17% involved ADI. The median LOS for patients without ADI was 138 minutes compared to 252 minutes for those who received ADI. Overall, GLM offered the most unbiased estimates, although it provided similar adjusted point estimates to OLS for the marginal change in LOS associated with ADI. The effect of imaging differed by LOS quantile, especially for patients with abdominal pain, fever, and back symptoms.

Conclusions

Generalized linear model offered an improved modeling approach compared to OLS and quantile regression. Consideration of such techniques may facilitate a more complete view of the effect of ADI on ED LOS.

The use of computed tomographic scanning in blunt head trauma has increased dramatically in recent years without an accompanying rise in the prevalence of injury or hospital admission for serious conditions. Because computed tomography is neither harmless nor inexpensive, researchers have attempted to optimize utilization, largely through research that describes which clinical variables predict intracranial injury, and use this information to develop clinical decision instruments. Although such techniques may be useful when the benefits and harms of each strategy (neuroimaging vs observation) are quantifiable and amenable to comparison, the exact magnitude of these benefits and harms remains unknown in this clinical scenario. We believe that most clinical decision instrument development efforts are misguided insofar as they ignore critical, nonclinical factors influencing the decision to image. In this article, we propose a conceptual model to illustrate how clinical and nonclinical factors influence emergency physicians making this decision. We posit that elements unrelated to standard clinical factors, such as personality of the physician, fear of litigation and of missed diagnoses, patient expectations, and compensation method, may have equal or greater impact on actual decision making than traditional clinical factors. We believe that 3 particular factors deserve special consideration for further research: fear of error/malpractice, financial incentives, and patient engagement. Acknowledgement and study of these factors will be essential if we are to understand how emergency physicians truly make these decisions and how test-ordering behavior can be modified.