Three Scenarios to Teach Difficult Discussions in Pediatric Emergency Medicine: Sudden Infant Death, Child Abuse With Domestic Violence, and Medication Error

Abstract

Within an emergency medicine (EM) environment, the pace of clinical care delivery rarely allows time to stop and observe extended interactions between trainees and patients, or to provide feedback on communication skills. Once residency and fellowship conclude, however, these same trainees will be required to manage complicated medical and social interactions independently. In particular, unique challenges in the realm of patient-doctor interaction arise in the field of pediatric emergency medicine (PEM), with most clinical encounters involving both a child and their caregiver. Whether delivering bad news to a family or screening and managing cases of suspected child abuse, child neglect or domestic violence, many physicians report having no formal training in communicating effectively and compassionately under difficult conditions.1–4 It is imperative to consider and prepare future physicians for the emotional relationship between the (pediatric) patient and the family when caring for the family unit, especially in emergent situations and times of crisis. The occurrence of medical error presents another tremendously challenging situation for physicians and requires sophisticated communications skills. Despite clinicians' best preventive and conscientious efforts, various elements can lead to a medical error, and the physicians involved will need to disclose and discuss the event with the family. Once again, few physicians have had formal training in managing these situations.5 To improve training in PEM physician communications during difficult discussions, we created a hybrid medical simulation program, a combination of standardized patients and high-fidelity medical simulation. The primary objective was to educate EM residents and PEM fellows on the communication skills necessary to engage in difficult discussions when caring for children in an emergency department setting. Authors will present three scenarios developed for an educational activity designed to focus on difficult discussion communication skills in PEM. DIFFICULT DISCUSSION COMMUNICATION SKILLS PROGRAM OVERVIEW All sessions took place at a regional medical simulation center. The center conducts a spectrum of simulation- enhanced training programs for numerous specialties and across disciplines: neonatology, pediatrics, EM, internal medicine, obstetrics, teamwork training, disaster preparedness, and combat casualty care. Through direct observation and resident feedback, academic PEM and pediatric critical care faculty identified a need for better communication skills for pediatric trainees in their clinical care institutions. To address this need, training materials for postgraduate medical learners were created, focusing on the critical skills and techniques necessary to navigate through difficult PEM clinical encounters and effectively communicate in an empathic manner with pediatric patients and their families. These three scenarios include including delivering bad news (diagnosis/death), discussion of suspected nonaccidental injury and disclosure of errors. The educational materials developed were all implemented and revised over a 4-year period as part of an EM residency, Pediatric residency and PEM fellowship curriculum in communications. Delivering Bad News Delivering bad news is a difficult and challenging task, one which may be accomplished in a constructive and caring manner. There have been various methods and recommendations on how this can best be accomplished; consensus guidelines for this practice have been previously established.1,6,7 Gaba et al8 reported on using a “death scenario” to reinforce anesthesia crisis resource management skills and behaviors. This adult simulation scenario also focused on communication skills useful in delivering bad news. Other experts agree that an educational program designed to teach these skills should offer opportunities to practice, reflect, and discuss, as well as provide constructive feedback and options for repeated sessions. Performing a carefully scripted and methodically constructed high-fidelity medical simulation with a pediatric mannequin simulator in conjunction with standardized (SP) family member(s) offered all of these opportunities. See Appendix A for scenario outline and assessment form. Screening for Child Abuse and Domestic Violence Emergency physicians are presented with specific responsibilities regarding the welfare of the children in their care. Emergency physicians must recognize not only that child abuse occurs, but that it is not uncommon. Adequate training in recognition of injuries or physical signs that are concerning for abuse and neglect is essential, as is preparation for appropriate management of these situations to protect the patient and any other children who could be at risk.9 Children who are victims of abuse often live in families where there are other forms of violence. Domestic violence is highly correlated with child abuse. In 30% to 60% of families affected by intimate partner violence, children are also directly abused.10,11 The uncomfortable interactions required to screen for situations surrounding child abuse and domestic violence should be handled in a nonaccusatory manner. The hybrid simulation approach of combining high-fidelity mannequins and SPs as pediatric patient and parents, respectively, was applied to teach communication skills surrounding potential child abuse and domestic violence in an EM setting. See Appendix B for scenario outline and assessment form. Disclosure of Medical Error In high-risk industries, such as aviation and healthcare, simulation was initially designed. Despite ongoing efforts across healthcare systems, the reality remains that medical errors still occur, and physicians have an ethical and professional responsibility to disclose medical errors to patients and families.12–14 The Joint Commission has official requirements about medical error disclosure and states that a provider must explain the outcome of any treatment or procedure to either family or patient when the outcome differs significantly from the expected outcome.15 It has also been reported that families prefer disclosure of medical errors.16 Minimal research has been performed to assess skills and strategies specific for disclosure of medical error. One pilot study described the use of SPs as family members in a simulated environment to assess nurses' communication skills related to disclosing medical errors.17 A recent review by Mazor reviewed the current literature regarding medical errors and looked at: (1) the decision to disclose, (2) the process of informing the patient and family, and (3) the consequences of disclosure or nondisclosure.5 After reviewing 825 articles, the overall agreement was that physicians and families agree that medical errors should be disclosed in a timely manner. Several barriers were identified which affected individuals' decisions to disclose medical errors. One of these was lack of training and of consistent guidelines relating to the disclosure process. An example of the latter is reflected in one physician focus group's report that they would choose their words carefully to avoid stating an error had taken place.18 Physicians also indicated a desire to offer an apology but feared increased legal liability, yet review of the literature did not reveal any studies with evidence proving error disclosure lead to increased risk with litigation.5 When parents were asked about error disclosure, the focus groups wanted to know the following in a forthcoming manner: What happened Why it happened What were the implications for their child How would the problem be corrected How future errors would be prevented.18 A study by Garbutt et al19 looked at reporting and disclosing medical errors from both an attending and resident level when working with pediatric patients. The study concluded that communication about medical errors is difficult but essential. The study also commented that training programs should include formal instruction on error disclosure and offer the opportunity to both practice these skills and receive feedback. The third scenario in the difficult discussion simulation program offered participants the opportunity to disclose a medical error and receive direct feedback. This simulation was based on an actual case, with all identifying information removed. See Appendix C for scenario outline and assessment form. PROGRAM IMPLEMENTATION AND LEARNER FEEDBACK Over a 4-year period, the difficult discussions, communication skills training, and three simulation scenarios were conducted for 96 learners. The three scenarios were not performed at the same time, but instead incorporated into educational sessions dealing with a variety of other clinical situations. Our faculty feels this is the more realistic manner in which patients present in the EM setting. After each simulation exercise, the case was debriefed by attending physicians on the staff of the simulation center, using a videotaped format. Techniques for managing pediatric emergencies and specific skills for communicating with families in difficult situations were reviewed, followed by a discussion by the participants and observers. Participants provided scored feedback on how the scenarios met their own learning objectives and their impressions of the simulation-enhanced educational program. The feedback is a standard procedure for all simulations performed at our center. This data collection process has been reviewed by our institution's IRB committee and the data presented has been classified as exempt from additional IRB review. Results from the participants' feedback are summarized in Table 1. The scenarios were very well received by the EM residents, pediatric residents, and PEM fellows. Participants returned “excellent” scores when asked about relevance to training duties. The simulation group also obtained positive feedback on the fidelity of the scenarios and the care environment.Table 1: Participant Feedback From Project Sessions (N = 96)Included with each of the three scenarios are three assessment tools combining a scenario specific critical action checklist and a global competency scale. For details how the global competency scale is scored, see Appendix D.These assessment tools are not currently validated, but are used to assist in providing feedback to learners who participate in the difficult discussion scenarios. The ACGME competencies are included in Appendix D as another possible tool for rating performance during these simulations. If these or other assessment tool were validated, these scenarios, in combination with validated assessment tools could be used to create a program to not only teach the communication skills, but also assess competency levels in managing these difficult discussions. The difficult discussion education program will continue to be offered to EM residents, PEM fellows and pediatric residents, with plans to increase the availability to other audiences. With additional support, this program could be made available to medical students, nurses, and community physicians. The educational goals would remain the same with some minor modifications in the details of the scenarios to appropriately match the skill level and professional background of the individual learners.