286: Clinical Teaching In a Busy Emergency Department: Interruptions During Case Presentations

Abstract

In the emergency department (ED) of a teaching hospital, attending physicians are challenged to instruct medical students and residents while simultaneously caring for critically ill patients. Thus, they must balance the need to quickly devise patient assessments and plans with their responsibility to devote time toward teaching students. Studies have only recently begun to quantify and characterize interruptions occurring in the ED. Our objectives were to determine the frequency and nature of interruptions by the training physician that occur when medical trainees perform oral case presentations (OCPs). This was a prospective observational study which took place from June 2009 through August 2009 in the ED of a large academic medical center. A convenience sample of house officers and fourth-year medical students were observed during OCPs with attending physicians. None of these physicians or students were aware of the purpose of the study. They were informed only that a second-year medical student was observing case presentations as part of his/her summer elective. As many different attending physicians as possible were sampled while maintaining equal hours of observation for each daily shift. The student completed a simple data sheet after each case presentation and recorded OCP duration, interruption frequencies, and interruption types. An “interruption” was defined as any event that caused the learner to stop the OCP for longer than 2 seconds, and only interruptions initiated by the teaching physician were recorded. Effects of learner level or time of day on frequency of interruption were evaluated using analysis of variance, with statistical significance at the p < 0.05 level. A total of 570 case presentations were observed during the study period; involving 53 EM faculty, 52 house staff and 11 medical students. The mean duration of presentation was 3.4 + 2.2 minutes (range 0.5 to 14 minutes). There were a total of 1739 interruptions during case presentations; mean 3.0 (+ 2.4) interruptions per presentation or 0.94 (+ 0.70) interruptions per minute. At least one interruption occurred in 94% of OCPs, with a maximum of 16. The interruptions were categorized as follows: interruptions by faculty (88%), phone calls (4%), questions by nursing staff (7%), ECG interpretation (1%), and orders on other patients (1%). The majority of faculty interruptions (55%) involved questions about history or exam findings or injection of teaching points. In 37% of OCPs, attending physicians interrupted to give an assessment and/or a treatment plan before the learner had done so. The number of interruptions (per OCP) and duration of OCP varied by learner level of training (p < 0.01), with more experienced learners giving shorter presentations and being interrupted less often. Neither frequency nor number (per OCP) of interruptions was statistically different by time of day. The education of students and residents occurs primarily during case presentations to ED faculty, an environment in which interruptions frequently occur. The majority of these interruptions are driven by the faculty themselves and vary by the learner level of training. These interruptions can be potentially beneficial, such as the injection of timely teaching points or clarification of clinical findings.