The 15 resident sessions that were reviewed included (5 female residents; 5 residents from each class year. A total of 24 residents (8 females; 8 from each class) and 10 attendings (6 females; 7 MDs, 2 psychologists, and 1 nurse practitioner) participated in the conversations and were included in the analysis.
Norms of Practice Regarding Essential Functions of a Visit
From the perspectives of both attendings and residents, there are six critical norms of practice expected of residents:
1) Residents should prepare for the visit before entering the room. The participants valued knowing that a resident had reviewed charts and the paper slip that patients completed before the appointment. One attending commented, "I think it was good that he referenced the stuff the patient had already filled out. I think that lets the patient know that he’s taken time to review her stuff."
It was found it unacceptable when residents appeared to be unaware of why a patient was there or only guessed at the reason. One resident reflected, "I went to the computer and was trying to [look up] more information. I was thinking maybe I should have been more prepared before I stepped in." On the other hand, some residents argued that with a packed schedule, being prepared can be difficult. One resident explained, “sometimes it’s tough to look up 20 patients, and know everything.”
2) Negotiating the agenda for the visit is recommended. The participants valued residents starting a visit by setting the agenda, which can be done by illustrating and clarifying reasons for the appointment. An attending noted, "I think overall he’s done pretty well setting an agenda for the visit. He was finding out if the patient has any concerns and then setting a plan." Residents noticed that when there was no clear agenda, the visit would sometimes go out of control. A resident reflected, "[Five minutes into the visit] I was noticing that I didn’t have a set agenda. So, it needed to happen then since it wasn’t flowing naturally from the conversation."
3) Eliciting sufficient patient history is essential. The participants valued when residents gathered necessary information by asking the right questions. Taking a good history can mean screening for symptoms and risk factors, especially those associated with serious consequences or mental illnesses, which are often overlooked. It can also mean asking about social history and weight loss as well as medications. Residents and attendings both pointed out suboptimal practices in this regard. For example, one attending remarked, "I mean, if somebody has a [Patient Health Questionnaire] PHQ of 25 you have to ask, ‘Do you want to hurt yourself? Do you want to kill yourself or anybody else?’ ” Regarding the same incident where suicidality was overlooked, the resident reflected, "(I should have obtained) more information and gotten a full history. I had no idea she was suicidal. I completely glanced over the PHQ9. I didn’t catch that."
Participants thought it was not useful to ask open-ended questions with patients who are not linear. On the other end of the spectrum, they also found it inappropriate to fail to ask for more explanation or assess symptoms in a rigid, formulaic way. While attendings and residents sometimes agreed about what to ask and how, that was not always the case. For example, an attending once remarked, "I think [the resident] is patient, I probably would not ask any open-ended questions. I’d ask yes/no type questions, especially when she starts off on those tangents." But, during the resident reviewing the session, the resident had a different position and explained, "I think I got all the information that I wanted, but it took a little while. I could have potentially just kept asking/redirecting questions."
4) Patients should have proper examinations. The participants valued a resident telling patients what to expect before a thorough exam, with attention to aspects that would be relevant to the problem at hand. They also appreciated when findings were explained in real-time. One peer resident remarked, "She explained what she was doing [in] real-time. She initially started with medical lingo, but then broke it down a bit to more layman’s terms."
Both residents and attendings paid attention to inappropriate examination techniques, and attendings were particularly concerned about insufficient exams or lack of diligence. An attending pointed out, "Probably not getting nose to nose with the patient when you do your eye exam. When he pulled away, he checked her left eye with his right eye!"
5) Making the diagnosis correctly is of primary importance.The participants expressed satisfaction when residents considered differential diagnoses. Residents were particularly impressed when a peer had recognized the root of the problem even with a poorly presented history. All the participants criticized incorrect diagnoses or relying solely on history without an adequate physical exam. Regarding one incident, the attending said, "If the patient comes in to us and the fracture’s not healing, I’m not thinking diabetes. (Another attending) I’m thinking, ‘Where’s your splint?!’ ” During the resident session, the resident shared that he had given less than optimal management plan. They said, "I did the x-ray, and it was a month out, and he still, it wasn’t healing, so then I thought maybe he had diabetes. They gave him a finger splint, so I told him to use it at work to prevent any further injury. After work, I told him to take it off and try exercising a little bit!"
Residents and attendings did not always maintain an agreement. For example, while attendings criticized a resident not being thorough, a resident mentioned reliance on gestalt feelings. For example, incident, the attending once was concerned, "He sort of nailed in on carpal tunnel very fast, which I think is probably at the very top, differential. It’s almost as if he had the diagnosis in his mind, and he was trying to confirm it with the questions that he asked." But, during the resident review session, the resident explained, "I was going with more of a gestalt feeling about it as opposed to following history, physical, etc. It doesn’t sound like there was any traumatic history. It doesn’t sound like there was any compromise in terms of function, no ER visits, no x-rays, nothing that was red flags to me at that point. I felt comfortable doing that."
6) Carrying out proper management of health conditions. The participants expected residents to prescribe the right medicine, develop a targeted plan, and do whatever else was needed, including providing information and counseling patients appropriately. Participants noted that residents should make their thoughts explicit to patients. They also should ensure that communication is at levels appropriate for the patient’s educational attainment. For example, an attending remarked, "I think it was good that she used specific instructions and wrote them down for the family." Regarding the same interaction, a peer resident commented, "The counseling was good. It was specific and giving clear instructions at the appropriate educational level."
The participants criticized when residents did not thoroughly address problems, gave hurried or inaccurate recommendations, or developed plans without measures to ensure follow-through. They also considered a resident’s avoidance of complicated health problems unacceptable. One resident reflected, “He has a panic attack, but I don’t really want to address that, because he’s not going to get benzos from me. That’s what was going through my mind. ‘Let’s just try and glaze over this’ because I don’t want to give him benzos. I recognized it as a panic attack, but I also recognized it in my head that that would warrant benzos, which I don’t want to give him. I wanted to gloss over that and say, ‘Are you still seeing your counselor? Good. She’ll take care of that.’ Which isn’t good."
Attendings further criticized residents for failing to use specific communication strategies. However, the reviewed residents were occasionally able to rationally justify not using a particular approach within the context of the interactions with the patients. For example, an attending exclaimed, "It would be helpful to have the patient use teach-back, ‘Can you tell me what the top three things are that I’ve asked you to do to take care of this wound?’ ” But, the resident provided contradictory, yet valuable insight when he said, "[The patient] was finishing my sentences, almost. That’s how I knew, ‘Okay, he knows what I’m saying.’ ”
Tensions Caused by Differing Values During a Visit
The analysis identified five themes related to tensions between differing values.
1) Addressing problems while building relationships. The participants judged visits heavily on the success of addressing problems while simultaneously building a relationship as a goal in and of itself. Attendings considered that residents did well if they spent time addressing what mattered to a patient’s health, while residents gave differing explanations for omissions in this regard. One attending remarked, "In a patient you’ve never seen before, you’re trying to build this relationship from the start. It would be helpful if you were showing that you were engaged and passionate about what’s going on with the patient." Regarding the same session, the reviewed resident commented, "I felt that it was important to address that problem being that it’s my first OB visit with her. I felt that if I focused on the pregnancy and were not addressing her complaint, I probably wouldn’t be doing justice to her. Also in terms of building that rapport, it would probably reflect poorly on that."
2) Performing duties within a reasonable time frame. Participants considered residents to be doing a good job if they dealt with multiple problems or built rapport in a short period of time. They recognized the potential conflict between time constraints and building rapport. They appreciated the residents who were time-efficient without compromising rapport. Participants criticized time-consuming habits such as using pen and paper for notes or attempting to address all problems in one visit. Regarding one visit, an attending commented, “It’s just a lot longer than it needs to be. It was an hour by the time he went to talk to [a preceptor]." The reviewed resident had a similar position when they saw their video, "I completely agree with [peer]. The stuff I spent 10 minutes talking about, I could have probably done three minutes. I can improve on that."
3) Completing tasks on the computer without compromising conversation. The participants extensively discussed the use of computers in exam rooms. They looked positively on residents who asked for a patient’s permission before using the computer. Further, they thought that computers are best kept to one side so they would not form a barrier and residents could stay engaged while typing. Residents who are adept in this area maintain eye contact and sit facing patients, preferably at eye level. While they complete visit-related tasks on the computer, they maintain a genuine conversation, evidenced by reassuring sounds, paraphrasing, using reflection, and using teach-back, among other techniques. Participants agreed that computers could be particularly helpful for sharing results such as X-rays with patients or for obtaining information, such as medication dosages. However, they criticized when residents stared at the computer, acted in a hurry, or took detailed notes rather than brief reminders, especially when patients shared intimate information. For example, one attending commented, "It feels like the visit is not focused on her as much as. He is on his computer, and I feel that ‘I am trying to get my notes done,’ that’s the impression I got. ‘Just want to get over it and get done,’ kind of feeling." In a separate session, the reviewed resident remarked, “I’m wondering, ‘What am I looking at?’ All the time, when I’m looking at on the screen. Yeah, I look at it too much."
4) Supporting patient autonomy while asserting boundaries. The participants accepted that residents can lay the groundwork for expectations and set boundaries and that residents can practice medicine only within the limits of their values and beliefs. They noted that residents could respectfully say no to prescribing certain medications, such as controlled substances. Here is one attending observing, "He may be trying to lay all this groundwork so he can say, ‘This is why I’m not going to give you what you want.’ The patient’s using [drugs]. ‘I’m prepping you for this. [This] is why I’m not going to do what I already said I wasn’t going to do.’ ” Similarly, a peer remarked on the same encounter that his peer, "[was] setting boundaries."
Participants expected residents to acknowledge a patient’s interest in treatment. Residents should support patients in making appropriate changes when the patient is ready. Participants felt that patients should be given options so that doctors can identify their true preferences. Here is one peer resident commenting, "She figured out the patient preference and gave her all the options." Also, participants criticized residents for not confronting patients who avoided engaging in a serious conversation about their health.
5) Acting autonomously without jeopardizing patient care. The participants all understood that residents could encounter situations where they do not know what to do. In these cases, they expected residents to formulate plans and, if they are unsure how to proceed, ask their attending. Here is one example as an intern reflected, "[The patient is] on two SSRIs! I think I was a little confused at that point. I was like, ‘why! [But] this is my first visit, who am I to question them. But, this doesn’t seem right’. I went to go follow up with one of the attendings and get their opinion. In the back of my mind, I’m like ‘I don’t think you should be on two different SSRIs.’ ”
Residents were criticized for not seeking instruction with complicated conditions and, instead, making decisions on their own. On the other hand, attendings criticized residents who gave up their autonomy by deferring to supervising doctors for decisions. The participants expected residents to rely less on preceptors as they advanced in their training. They also pointed to situations when engaging the attending could have empowered residents to advocate for theier patient. Without seeking support, the resident was left to mange patients alone, and at times, with substandard plans. In one example, the attending noted, "She goes and shoots herself, and they find out she was just at the doctor’s office - ‘cause I’m sure [the preceptor] didn’t get this as, ‘Hey! She’s got major depression with suicidal ideation.’ ” In another example, the attending noted, "It seems like the patient is saying, ‘This is painful, I’m not able to be on [light duty], there is no such thing as light duty unless he [was] totally taken off of the floor, which requires a physician’s note, which he’s never had. Everything he does cause more trauma to his finger. It seems strange that the patient was saying, ‘I need your help. I need your help!’ And [the resident] is like, ‘Oh well, okay, well…’ ”