The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–6, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.11.102
Education PATIENT PERCEPTIONS OF ULTRASOUND EDUCATIONAL SCANS IN THE EMERGENCY DEPARTMENT Katja Goldflam, MD,* Rebecca R. Goett, MD,† Resa E. Lewiss, MD, RDMS,‡ Theodore C. Bania, MD,‡ and Turandot Saul, MD, RDMS‡ *Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, †Department of Geriatrics and Palliative Medicine, Brown Alpert School of Medicine, Providence, Rhode Island, and ‡Department of Emergency Medicine, St. Luke’s - Roosevelt Hospital Center, New York, New York Reprint Address: Katja Goldflam, Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519
, Abstract—Background: Emergency medicine residents may perform bedside ultrasound (BUS) scans that are carried out solely for educational purposes. This may lead to confusion on the part of patients, as the implications in the context of their medical care may be unclear. Study Objectives: We hypothesized that a scripted introduction would improve understanding of the objectives and limitations of educational BUS. Methods: A perceptual survey was completed by a prospectively enrolled convenience sample of patients in two emergency departments. In phase 1, fifty patients completed the survey after their educational BUS. During phase 2, sonographers were provided with a oneparagraph scripted introduction to use and 50 additional patients were recruited. Group data were analyzed using chi-squared tests, Kruskal-Wallis, and t-test. Results: There were no statistical differences in demographics between the two groups. The scripted introduction changed several survey responses by a statistically significant amount for questions including whether their clinician ordered the study, whether it was part of their medical care, and whether it would be part of their medical record (p < 0.01). The responses as to whether they would tell their doctor that they had an ultrasound done were not significantly changed by the script (p = 0.86). Conclusion: This study demonstrates that the use of a scripted introduction regarding the purpose of educational BUS improved patient understanding of the objectives and limitations of such scans. There were still areas where the scripted introduction did not change pa-
tient’s perception of the educational BUS scan. Elsevier Inc.
Ó 2014
, Keywords—ultrasound; education; emergency medicine; patient perceptions; bedside ultrasound
INTRODUCTION Bedside teaching has been an integral part of medical education since the origin of the profession. Bedside ultrasound (BUS) teaching as part of emergency medicine residency training is unique in that it may include imaging studies performed on patients solely for the purpose of educating residents in the various applications of emergency ultrasound (‘‘educational scans’’). Whereas most other learning in the emergency department (ED), for example, history-taking and procedures performed by residents or medical students, occurs in the context of direct medical care of the patient, ultrasound scans performed for teaching purposes may have no direct relevance to the patient’s presenting complaint or medical evaluation. Patient perceptions and understanding of these educational encounters likely vary, as these scans often are not clearly differentiated by the health care provider from scans that are performed for diagnostic or clinically indicated purposes. Although patients feel it is important for
RECEIVED: 16 July 2013; FINAL SUBMISSION RECEIVED: 1 October 2013; ACCEPTED: 17 November 2013 1
2
them to know their physician’s level of training, a minority of them actually understand the hierarchy of the medical training system, particularly those patients with less than a high school level of education (1,2). Bedside teaching overall has enjoyed widespread acceptance by patients and is a critical component of medical education. The ED setting provides learners with excellent educational opportunities given the high volume and acuity (3). Emphasis has been placed on making patients comfortable during such teaching encounters, by ensuring that they understand the process and are not left with unanswered questions (4). It has been suggested that effective patient–doctor communication may play a role in improving patient health outcomes (5). Furthermore, a legal precedent has been set that liability can exist for the emotional distress caused by incorrect reassurance from a diagnostic imaging study despite a lack of physical negligence (6). During a typical educational encounter at our institution, the resident approaches the patient, explains that they are learning to integrate ultrasound into patient care, and requests verbal consent to perform an educational BUS. The resident then performs the BUS on various parts of the patient’s anatomy that may or may not be related to the chief complaint. During this process the resident is learning to identify certain structures and sonographic findings. If an abnormality is found, this information is shared with the treating emergency physician, who then makes a decision regarding management of the finding. When no gross abnormalities are found, such educational scans do not become part of the patient’s medical record and no actions are taken based on the images obtained. Furthermore, ultrasound taught in the emergency setting may give only a limited evaluation of the patient’s anatomy and, as such, should in no way be used to exclude various disease processes that may be further elucidated on a complete sonographic evaluation performed in the radiology department. Importance Frequently, the limitations of BUS are either not clearly explained to patients prior to performing the educational scan or patients may misunderstand their purpose. A concern therefore exists that patients may be discharged with a false sense of reassurance of a ‘‘clean bill of health.’’ Goals of This Investigation Although studies have been published on patient perceptions of bedside teaching and on patients’ perceptions of radiologic studies, to our knowledge there are no studies on patient understanding of the limitations of emergency BUS, especially in the setting of a purely
K. Goldflam et al.
educational scan that is not clinically indicated (7,8). Our primary objective in this study was to evaluate patient understanding of educational BUS examinations with the primary outcome of a statistically significant change in survey answers prior to and after utilizing a standardized scripted introduction. MATERIALS AND METHODS Study Design and Setting We conducted a prospective convenience study at two large urban teaching hospitals with both an emergency medicine residency as well as an emergency ultrasound fellowship. Resident physicians perform educational BUS examinations during their required ultrasound rotation. The Institutional Review Board approved this study. Selection of Participants Patients are usually selected for educational scans based on their estimated time in the department, minimal interference with medical care, level of distress (i.e., patients able to tolerate the scan without increasing discomfort), and willingness to participate. All patients who gave consent to participate were included in the data analysis. Patients younger than 18 years, prisoners, patients in acute distress, and those not literate in English were excluded. Interventions The study took place in two phases. During phase 1, residents were not prompted how to approach the patient or what to say prior to performing the BUS examination. During this phase, 50 patients were enrolled and completed the survey after their bedside evaluation. During phase 2 of the study, residents performing the BUS were given a scripted introduction to use when explaining the purpose of the educational BUS scan: ‘‘I am part of the ultrasound team here in the emergency department. I am learning how to ultrasound different parts of the human body. This is not part of your medical care, but for my learning. The doctor taking care of you today did not order this scan and it will not be part of your medical record. If I do find something abnormal I will let you and your doctor know, however, ultrasound can only look at the big picture and can not always tell if there is something wrong with the body part that we are scanning.’’
Methods and Measurements Resident sonographers were asked to let one of the study coordinators know after they had performed an educational BUS. The resident sonographers were not made
Perceptions of Ultrasound Scans
aware of the purpose of the research study, nor were they given access or allowed to read the study survey form. The study coordinators consisted of two attending physicians, one emergency ultrasound fellow, and one postgraduate year-2 emergency medicine resident. The study coordinators did not enroll patients in whose BUS they were personally involved as teachers. A convenience sample of patients was approached for enrollment whenever a study coordinator was available and made aware that an educational BUS had been performed. The patient completed the survey after the educational BUS scan was concluded. Measured Outcomes Fifty patients were enrolled in each phase to compare the survey responses prior to and after introduction of the script.
3 Table 1. Demographics
Age Gender Male Female Race Asian Hispanic Caucasian Black Other First language English Other
Pre Script n = 50
Post Script n = 50
43 (average)
44 (average)
27 (54%) 23 (46%)
23 (46%) 27 (54%)
5 (10%) 9 (18%) 15 (30%) 17 (34%) 4 (8%)
1 (2%) 12 (24%) 18 (34%) 17 (34%) 2 (4%)
40 (80%) 10 (20%)
45 (90%) 5 (10%)
formed in the ED purely as part of resident education. The ultrasound performed in most cases was unrelated to the patient’s chief complaint in the ED. Prior to the introduction of a standardized script, most patients
Analysis Chi-squared analysis was used for dichotomous and categorical variables. Standardized adjusted residuals were calculated for each of the cells to determine which cell differences contribute to the chi-squared test results. Student’s t-test was used for analysis of continuous variables. RESULTS There was no statistical significance between the two groups for age, gender, race, income, education, and first language (Table 1). In response to ‘‘the BUS was ordered by the doctor in charge of your care,’’ the script decreased ‘‘yes’’ responses (50% to 12%) and increased ‘‘no’’ responses (24% to 84%) (p < 0.01). In response to ‘‘the BUS is part of the medical record,’’ the script decreased ‘‘yes’’ responses (52% to 12%) and increased ‘‘no’’ responses (18% to 62%) (p < 0.01). In response to ‘‘BUS is part of your medical care in the ED,’’ the script decreased ‘‘yes’’ responses (72% to 26%) and increased ‘‘no’’ responses (14% to 66%) (p < 0.01). In response to the purpose of BUS, the script decreased the responses ‘‘to help make a decision about my care’’ (48% to 12%) and increased the responses ‘‘to help those doing the BUS learn’’ (22% to 67%) (p < 0.01). In response to ‘‘would you tell another doctor you had an ultrasound done?,’’ we were unable to detect a change in ‘‘yes’’ responses (74% to 70%), and ‘‘no’’ responses (14% to 18%) (p = 0.86) (Figure 1). DISCUSSION In this study, we aimed to evaluate patient perceptions and understanding of educational BUS scans per-
Figure 1. Results of patient surveys.
4
who had an educational BUS thought it was ordered by their clinician, was part of their medical care, and would be part of their medical record. Without a standardized script, patients were confused as to the implications of the educational BUS for the medical care provided. Specifically, patient understanding was poor for the indications of the ultrasound and the use of the information obtained from the ultrasound in the context of their medical care. Understanding in these areas improved significantly when a standardized script was used. However, some patients continued to believe their educational BUS were ordered by their clinician, were part of their medical care, and would be part of their medical record. In addition, with or without the script many patients stated that, if seen by another health care provider, they would still tell that provider that they had an ultrasound performed; it is unclear if patients would specify to their provider whether they had received an educational or diagnostic ultrasound. This could lead to an inappropriate evaluation by the second provider. For example, in a patient with abdominal pain, a computed tomography (CT) scan may be selected as the study of choice based on the false assumption that a complete diagnostic abdominal ultrasound has been performed. The use of a scripted closure that explains to the patient if any abnormalities were noted, that their treating physician was notified, and if follow-up imaging would be recommended, might also improve patients’ understanding. Recognition of the importance and need for clear communication between doctors and patients is not a novel concept in the medical profession. In 1978, Reynolds published her descriptive study of 100 surgical inpatients and suggested a need for better communication between doctors and patients with regard to information about illness and the investigations performed (9). Lehmann et al. suggested, in their randomized control trial of bedside case presentations in inpatient medical patients, that physicians should be particularly careful with less well-educated patients to avoid medical jargon and to fully explain patient care plans (7). Chesson et al. reported from their 12-item questionnaire of a convenience sample of outpatients presenting for ultrasound, CT, or magnetic resonance imaging that most were not well informed as to the specific examination being performed and the reason for the testing (8). Lloyd et al. reported on trained observer evaluations of emergency medicine senior house officer communications with patients. Common weaknesses observed that are relevant to our study include use of closed-ended questions, use of medical jargon, poor negotiation and explanation of the treatment plan, and limited exploration of patients’ thoughts and concerns (10). Direct observation and feedback was felt to be effective in changing behaviors by the house officer; therefore, an intervention to be considered
K. Goldflam et al.
for future training of our residents and fellows would be direct observation and feedback when they are first introducing the concepts and implications of an educational bedside scan. It has been reported that patients will consent to simple procedures (intravenous placement, suturing, and splinting) performed by medical students (1). This could arguably be extrapolated to novice sonographers and bedside ultrasound. Even so, whereas a concern may be that a fuller explanation could result in some patients denying residents their educational opportunity, the primary goal should always be open communication with and informed consent from our patients to any bedside teaching procedure. Recently, the Accreditation Council for Graduate Medical Education designated patient-centered communication as one of 23 milestones under the Next Accreditation System for all emergency medicine residencies. A level-3 competency requires that the resident ‘‘manage the expectations of those who receive care in the ED and use communication methods that minimize the potential for stress, conflict, and misunderstanding ’’ (11). Educational BUS is an area rife with possibility for just such ‘‘misunderstanding,’’ and residents need to be made aware of this potential and their obligation to ensure their patients’ correct comprehension of the situation. Limitations Several limitations exist in this study. Non-English speakers present a known barrier to communication that is beyond the scope of this study. In particular, the presence and nonpresence of certified translators, the degree of provider and patient facility with the other’s language, and the specific conversations for which translation services may or may not have been used all had the potential to considerably confound the interpretation of the end points sought here. For this reason, patients illiterate in English were excluded from the study population. Additionally, the sickest patients are often not capable of facile communication or may have been in too much discomfort to be appropriate candidates for the study. These patients, however, do frequently get educational scans, as they are often more likely to have pathology of didactic value. The conversations between the physician and patient that were reflected in these survey results would not be expected to take place regularly in patients at the higher-severity end of the spectrum of illness. Although our sample size is relatively small, and a convenience sample due to the limited availability of study coordinators, we feel that it is representative of the patient population in our institution as a whole. What may be less representative of the various practice styles in academic EDs around the country is the way
Perceptions of Ultrasound Scans
our institution approaches educational BUS. Many facilities place greater restrictions on which patients may be scanned by residents, frequently requiring that any patient scanned for educational purposes must also have a confirmatory study, whether CT or ultrasound, performed either in the ED or within a certain timeframe (therefore including inpatient studies on admitted patients). This may help resolve the concerns for patients getting false reassurance from an educational BUS; however, it does not address patient understanding of the purpose of the educational scan. CONCLUSIONS The ED provides a unique environment rich with bedside educational opportunities. Moreover, it is the optimal showcase for patient-centered care and the performance of procedures such as ultrasound. Our study highlights how, frequently, physicians may not be communicating in a clear and transparent fashion with their patients. In summary, patients’ understanding of educational BUS is low when the bedside ultrasonographer does not use a specific informational introduction. BUS may therefore give patients a false sense of reassurance of a ‘‘clean bill of health.’’ This study demonstrates that the use of a scripted introduction regarding the purpose of educational BUS improves understanding of the objectives and limitations of such scans; however, there were still areas where the scripted introduction did not change patients’ perceptions of the educational BUS scan or may
5
have done some only in a limited fashion. A future case control study could focus on patients’ understanding of terminology, and the physicians’ word choices, as well as comprehension in different populations with different levels of health literacy.
REFERENCES 1. Santen S, Rotter TS, Hemphill RR. Patients do not know the level of training of their doctors because doctors do not tell them. J Gen Intern Med 2008;23:607–10. 2. Hemphill RR, Santen S, Rountree CB, et al. Patients’ understanding of the roles of interns, residents, and attending physicians in the emergency department. Acad Emerg Med 1999;6:339–44. 3. Aldeen AZ, Gisondi M. Bedside teaching in the emergency department. Acad Emerg Med 2006;13:860–6. 4. Janicik RW, Fletcher KE. Teaching at the bedside: a new model. Med Teach 2003;25:127–30. 5. Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J 1995;152:1423–33. 6. Toney v. Chester County Hospital, 36 A.3d 83 (2011). Supreme Court of the State of Pennsylvania, Decided December 22, 2011. 7. Lehmann LS, Brancati FL, Chen MC, et al. The effect of bedside case presentations on patients’ perceptions of their medical care. N Engl J Med 1997;336:1150–5. 8. Chesson R, McKenzie G, Mathers S. What do patients know about ultrasound, CT and MRI? Clin Radiol 2002;57:477–82. 9. Reynolds M. No news is bad news: patients’ views about communication in hospital. Br Med J 1978;1:1673–6. 10. Lloyd G, Skarratts D, Robinson N, et al. Communication skills training for emergency department senior house officers—a qualitative study. J Accid Emerg Med 2000;17:246–50. 11. Society for Academic Emergency Medicine. Emergency medicine milestones. Available at: https://www.abem.org/public/docs/defaultsource/migrated-documents-and-files/em-milestones.pdf?sfvrsn=4. Accessed November 15, 2012.
6
K. Goldflam et al.
ARTICLE SUMMARY 1. Why is this topic important? Ultrasound has increasing utility within the emergency department, and the education of residents and medical students on bedside ultrasound has become an essential part of medical teaching. Patients’ understanding of their health care encounters can be poor, especially in the context of medical training. 2. What does this study attempt to show? This study demonstrates that patients’ perceptions of educational ultrasound performed by trainees at the bedside can be altered by the use of a scripted introduction. 3. What are the key findings? Patients have a poor baseline understanding of the purpose of bedside educational ultrasound scans. This understanding was improved by the use of a scripted introduction. 4. How is patient care impacted? Patients may misinterpret the significance of bedside educational ultrasounds in the context of their medical care and their physician’s decision-making process. By using a scripted or other more comprehensive introduction, trainees practicing bedside ultrasounds can avoid leaving patients with an incorrect understanding of the educational scan.
http://dx.doi.org/10.1016/j.jemermed.2013.11.102
Education PATIENT PERCEPTIONS OF ULTRASOUND EDUCATIONAL SCANS IN THE EMERGENCY DEPARTMENT Katja Goldflam, MD,* Rebecca R. Goett, MD,† Resa E. Lewiss, MD, RDMS,‡ Theodore C. Bania, MD,‡ and Turandot Saul, MD, RDMS‡ *Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, †Department of Geriatrics and Palliative Medicine, Brown Alpert School of Medicine, Providence, Rhode Island, and ‡Department of Emergency Medicine, St. Luke’s - Roosevelt Hospital Center, New York, New York Reprint Address: Katja Goldflam, Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT 06519
, Abstract—Background: Emergency medicine residents may perform bedside ultrasound (BUS) scans that are carried out solely for educational purposes. This may lead to confusion on the part of patients, as the implications in the context of their medical care may be unclear. Study Objectives: We hypothesized that a scripted introduction would improve understanding of the objectives and limitations of educational BUS. Methods: A perceptual survey was completed by a prospectively enrolled convenience sample of patients in two emergency departments. In phase 1, fifty patients completed the survey after their educational BUS. During phase 2, sonographers were provided with a oneparagraph scripted introduction to use and 50 additional patients were recruited. Group data were analyzed using chi-squared tests, Kruskal-Wallis, and t-test. Results: There were no statistical differences in demographics between the two groups. The scripted introduction changed several survey responses by a statistically significant amount for questions including whether their clinician ordered the study, whether it was part of their medical care, and whether it would be part of their medical record (p < 0.01). The responses as to whether they would tell their doctor that they had an ultrasound done were not significantly changed by the script (p = 0.86). Conclusion: This study demonstrates that the use of a scripted introduction regarding the purpose of educational BUS improved patient understanding of the objectives and limitations of such scans. There were still areas where the scripted introduction did not change pa-
tient’s perception of the educational BUS scan. Elsevier Inc.
Ó 2014
, Keywords—ultrasound; education; emergency medicine; patient perceptions; bedside ultrasound
INTRODUCTION Bedside teaching has been an integral part of medical education since the origin of the profession. Bedside ultrasound (BUS) teaching as part of emergency medicine residency training is unique in that it may include imaging studies performed on patients solely for the purpose of educating residents in the various applications of emergency ultrasound (‘‘educational scans’’). Whereas most other learning in the emergency department (ED), for example, history-taking and procedures performed by residents or medical students, occurs in the context of direct medical care of the patient, ultrasound scans performed for teaching purposes may have no direct relevance to the patient’s presenting complaint or medical evaluation. Patient perceptions and understanding of these educational encounters likely vary, as these scans often are not clearly differentiated by the health care provider from scans that are performed for diagnostic or clinically indicated purposes. Although patients feel it is important for
RECEIVED: 16 July 2013; FINAL SUBMISSION RECEIVED: 1 October 2013; ACCEPTED: 17 November 2013 1
2
them to know their physician’s level of training, a minority of them actually understand the hierarchy of the medical training system, particularly those patients with less than a high school level of education (1,2). Bedside teaching overall has enjoyed widespread acceptance by patients and is a critical component of medical education. The ED setting provides learners with excellent educational opportunities given the high volume and acuity (3). Emphasis has been placed on making patients comfortable during such teaching encounters, by ensuring that they understand the process and are not left with unanswered questions (4). It has been suggested that effective patient–doctor communication may play a role in improving patient health outcomes (5). Furthermore, a legal precedent has been set that liability can exist for the emotional distress caused by incorrect reassurance from a diagnostic imaging study despite a lack of physical negligence (6). During a typical educational encounter at our institution, the resident approaches the patient, explains that they are learning to integrate ultrasound into patient care, and requests verbal consent to perform an educational BUS. The resident then performs the BUS on various parts of the patient’s anatomy that may or may not be related to the chief complaint. During this process the resident is learning to identify certain structures and sonographic findings. If an abnormality is found, this information is shared with the treating emergency physician, who then makes a decision regarding management of the finding. When no gross abnormalities are found, such educational scans do not become part of the patient’s medical record and no actions are taken based on the images obtained. Furthermore, ultrasound taught in the emergency setting may give only a limited evaluation of the patient’s anatomy and, as such, should in no way be used to exclude various disease processes that may be further elucidated on a complete sonographic evaluation performed in the radiology department. Importance Frequently, the limitations of BUS are either not clearly explained to patients prior to performing the educational scan or patients may misunderstand their purpose. A concern therefore exists that patients may be discharged with a false sense of reassurance of a ‘‘clean bill of health.’’ Goals of This Investigation Although studies have been published on patient perceptions of bedside teaching and on patients’ perceptions of radiologic studies, to our knowledge there are no studies on patient understanding of the limitations of emergency BUS, especially in the setting of a purely
K. Goldflam et al.
educational scan that is not clinically indicated (7,8). Our primary objective in this study was to evaluate patient understanding of educational BUS examinations with the primary outcome of a statistically significant change in survey answers prior to and after utilizing a standardized scripted introduction. MATERIALS AND METHODS Study Design and Setting We conducted a prospective convenience study at two large urban teaching hospitals with both an emergency medicine residency as well as an emergency ultrasound fellowship. Resident physicians perform educational BUS examinations during their required ultrasound rotation. The Institutional Review Board approved this study. Selection of Participants Patients are usually selected for educational scans based on their estimated time in the department, minimal interference with medical care, level of distress (i.e., patients able to tolerate the scan without increasing discomfort), and willingness to participate. All patients who gave consent to participate were included in the data analysis. Patients younger than 18 years, prisoners, patients in acute distress, and those not literate in English were excluded. Interventions The study took place in two phases. During phase 1, residents were not prompted how to approach the patient or what to say prior to performing the BUS examination. During this phase, 50 patients were enrolled and completed the survey after their bedside evaluation. During phase 2 of the study, residents performing the BUS were given a scripted introduction to use when explaining the purpose of the educational BUS scan: ‘‘I am part of the ultrasound team here in the emergency department. I am learning how to ultrasound different parts of the human body. This is not part of your medical care, but for my learning. The doctor taking care of you today did not order this scan and it will not be part of your medical record. If I do find something abnormal I will let you and your doctor know, however, ultrasound can only look at the big picture and can not always tell if there is something wrong with the body part that we are scanning.’’
Methods and Measurements Resident sonographers were asked to let one of the study coordinators know after they had performed an educational BUS. The resident sonographers were not made
Perceptions of Ultrasound Scans
aware of the purpose of the research study, nor were they given access or allowed to read the study survey form. The study coordinators consisted of two attending physicians, one emergency ultrasound fellow, and one postgraduate year-2 emergency medicine resident. The study coordinators did not enroll patients in whose BUS they were personally involved as teachers. A convenience sample of patients was approached for enrollment whenever a study coordinator was available and made aware that an educational BUS had been performed. The patient completed the survey after the educational BUS scan was concluded. Measured Outcomes Fifty patients were enrolled in each phase to compare the survey responses prior to and after introduction of the script.
3 Table 1. Demographics
Age Gender Male Female Race Asian Hispanic Caucasian Black Other First language English Other
Pre Script n = 50
Post Script n = 50
43 (average)
44 (average)
27 (54%) 23 (46%)
23 (46%) 27 (54%)
5 (10%) 9 (18%) 15 (30%) 17 (34%) 4 (8%)
1 (2%) 12 (24%) 18 (34%) 17 (34%) 2 (4%)
40 (80%) 10 (20%)
45 (90%) 5 (10%)
formed in the ED purely as part of resident education. The ultrasound performed in most cases was unrelated to the patient’s chief complaint in the ED. Prior to the introduction of a standardized script, most patients
Analysis Chi-squared analysis was used for dichotomous and categorical variables. Standardized adjusted residuals were calculated for each of the cells to determine which cell differences contribute to the chi-squared test results. Student’s t-test was used for analysis of continuous variables. RESULTS There was no statistical significance between the two groups for age, gender, race, income, education, and first language (Table 1). In response to ‘‘the BUS was ordered by the doctor in charge of your care,’’ the script decreased ‘‘yes’’ responses (50% to 12%) and increased ‘‘no’’ responses (24% to 84%) (p < 0.01). In response to ‘‘the BUS is part of the medical record,’’ the script decreased ‘‘yes’’ responses (52% to 12%) and increased ‘‘no’’ responses (18% to 62%) (p < 0.01). In response to ‘‘BUS is part of your medical care in the ED,’’ the script decreased ‘‘yes’’ responses (72% to 26%) and increased ‘‘no’’ responses (14% to 66%) (p < 0.01). In response to the purpose of BUS, the script decreased the responses ‘‘to help make a decision about my care’’ (48% to 12%) and increased the responses ‘‘to help those doing the BUS learn’’ (22% to 67%) (p < 0.01). In response to ‘‘would you tell another doctor you had an ultrasound done?,’’ we were unable to detect a change in ‘‘yes’’ responses (74% to 70%), and ‘‘no’’ responses (14% to 18%) (p = 0.86) (Figure 1). DISCUSSION In this study, we aimed to evaluate patient perceptions and understanding of educational BUS scans per-
Figure 1. Results of patient surveys.
4
who had an educational BUS thought it was ordered by their clinician, was part of their medical care, and would be part of their medical record. Without a standardized script, patients were confused as to the implications of the educational BUS for the medical care provided. Specifically, patient understanding was poor for the indications of the ultrasound and the use of the information obtained from the ultrasound in the context of their medical care. Understanding in these areas improved significantly when a standardized script was used. However, some patients continued to believe their educational BUS were ordered by their clinician, were part of their medical care, and would be part of their medical record. In addition, with or without the script many patients stated that, if seen by another health care provider, they would still tell that provider that they had an ultrasound performed; it is unclear if patients would specify to their provider whether they had received an educational or diagnostic ultrasound. This could lead to an inappropriate evaluation by the second provider. For example, in a patient with abdominal pain, a computed tomography (CT) scan may be selected as the study of choice based on the false assumption that a complete diagnostic abdominal ultrasound has been performed. The use of a scripted closure that explains to the patient if any abnormalities were noted, that their treating physician was notified, and if follow-up imaging would be recommended, might also improve patients’ understanding. Recognition of the importance and need for clear communication between doctors and patients is not a novel concept in the medical profession. In 1978, Reynolds published her descriptive study of 100 surgical inpatients and suggested a need for better communication between doctors and patients with regard to information about illness and the investigations performed (9). Lehmann et al. suggested, in their randomized control trial of bedside case presentations in inpatient medical patients, that physicians should be particularly careful with less well-educated patients to avoid medical jargon and to fully explain patient care plans (7). Chesson et al. reported from their 12-item questionnaire of a convenience sample of outpatients presenting for ultrasound, CT, or magnetic resonance imaging that most were not well informed as to the specific examination being performed and the reason for the testing (8). Lloyd et al. reported on trained observer evaluations of emergency medicine senior house officer communications with patients. Common weaknesses observed that are relevant to our study include use of closed-ended questions, use of medical jargon, poor negotiation and explanation of the treatment plan, and limited exploration of patients’ thoughts and concerns (10). Direct observation and feedback was felt to be effective in changing behaviors by the house officer; therefore, an intervention to be considered
K. Goldflam et al.
for future training of our residents and fellows would be direct observation and feedback when they are first introducing the concepts and implications of an educational bedside scan. It has been reported that patients will consent to simple procedures (intravenous placement, suturing, and splinting) performed by medical students (1). This could arguably be extrapolated to novice sonographers and bedside ultrasound. Even so, whereas a concern may be that a fuller explanation could result in some patients denying residents their educational opportunity, the primary goal should always be open communication with and informed consent from our patients to any bedside teaching procedure. Recently, the Accreditation Council for Graduate Medical Education designated patient-centered communication as one of 23 milestones under the Next Accreditation System for all emergency medicine residencies. A level-3 competency requires that the resident ‘‘manage the expectations of those who receive care in the ED and use communication methods that minimize the potential for stress, conflict, and misunderstanding ’’ (11). Educational BUS is an area rife with possibility for just such ‘‘misunderstanding,’’ and residents need to be made aware of this potential and their obligation to ensure their patients’ correct comprehension of the situation. Limitations Several limitations exist in this study. Non-English speakers present a known barrier to communication that is beyond the scope of this study. In particular, the presence and nonpresence of certified translators, the degree of provider and patient facility with the other’s language, and the specific conversations for which translation services may or may not have been used all had the potential to considerably confound the interpretation of the end points sought here. For this reason, patients illiterate in English were excluded from the study population. Additionally, the sickest patients are often not capable of facile communication or may have been in too much discomfort to be appropriate candidates for the study. These patients, however, do frequently get educational scans, as they are often more likely to have pathology of didactic value. The conversations between the physician and patient that were reflected in these survey results would not be expected to take place regularly in patients at the higher-severity end of the spectrum of illness. Although our sample size is relatively small, and a convenience sample due to the limited availability of study coordinators, we feel that it is representative of the patient population in our institution as a whole. What may be less representative of the various practice styles in academic EDs around the country is the way
Perceptions of Ultrasound Scans
our institution approaches educational BUS. Many facilities place greater restrictions on which patients may be scanned by residents, frequently requiring that any patient scanned for educational purposes must also have a confirmatory study, whether CT or ultrasound, performed either in the ED or within a certain timeframe (therefore including inpatient studies on admitted patients). This may help resolve the concerns for patients getting false reassurance from an educational BUS; however, it does not address patient understanding of the purpose of the educational scan. CONCLUSIONS The ED provides a unique environment rich with bedside educational opportunities. Moreover, it is the optimal showcase for patient-centered care and the performance of procedures such as ultrasound. Our study highlights how, frequently, physicians may not be communicating in a clear and transparent fashion with their patients. In summary, patients’ understanding of educational BUS is low when the bedside ultrasonographer does not use a specific informational introduction. BUS may therefore give patients a false sense of reassurance of a ‘‘clean bill of health.’’ This study demonstrates that the use of a scripted introduction regarding the purpose of educational BUS improves understanding of the objectives and limitations of such scans; however, there were still areas where the scripted introduction did not change patients’ perceptions of the educational BUS scan or may
5
have done some only in a limited fashion. A future case control study could focus on patients’ understanding of terminology, and the physicians’ word choices, as well as comprehension in different populations with different levels of health literacy.
REFERENCES 1. Santen S, Rotter TS, Hemphill RR. Patients do not know the level of training of their doctors because doctors do not tell them. J Gen Intern Med 2008;23:607–10. 2. Hemphill RR, Santen S, Rountree CB, et al. Patients’ understanding of the roles of interns, residents, and attending physicians in the emergency department. Acad Emerg Med 1999;6:339–44. 3. Aldeen AZ, Gisondi M. Bedside teaching in the emergency department. Acad Emerg Med 2006;13:860–6. 4. Janicik RW, Fletcher KE. Teaching at the bedside: a new model. Med Teach 2003;25:127–30. 5. Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J 1995;152:1423–33. 6. Toney v. Chester County Hospital, 36 A.3d 83 (2011). Supreme Court of the State of Pennsylvania, Decided December 22, 2011. 7. Lehmann LS, Brancati FL, Chen MC, et al. The effect of bedside case presentations on patients’ perceptions of their medical care. N Engl J Med 1997;336:1150–5. 8. Chesson R, McKenzie G, Mathers S. What do patients know about ultrasound, CT and MRI? Clin Radiol 2002;57:477–82. 9. Reynolds M. No news is bad news: patients’ views about communication in hospital. Br Med J 1978;1:1673–6. 10. Lloyd G, Skarratts D, Robinson N, et al. Communication skills training for emergency department senior house officers—a qualitative study. J Accid Emerg Med 2000;17:246–50. 11. Society for Academic Emergency Medicine. Emergency medicine milestones. Available at: https://www.abem.org/public/docs/defaultsource/migrated-documents-and-files/em-milestones.pdf?sfvrsn=4. Accessed November 15, 2012.
6
K. Goldflam et al.
ARTICLE SUMMARY 1. Why is this topic important? Ultrasound has increasing utility within the emergency department, and the education of residents and medical students on bedside ultrasound has become an essential part of medical teaching. Patients’ understanding of their health care encounters can be poor, especially in the context of medical training. 2. What does this study attempt to show? This study demonstrates that patients’ perceptions of educational ultrasound performed by trainees at the bedside can be altered by the use of a scripted introduction. 3. What are the key findings? Patients have a poor baseline understanding of the purpose of bedside educational ultrasound scans. This understanding was improved by the use of a scripted introduction. 4. How is patient care impacted? Patients may misinterpret the significance of bedside educational ultrasounds in the context of their medical care and their physician’s decision-making process. By using a scripted or other more comprehensive introduction, trainees practicing bedside ultrasounds can avoid leaving patients with an incorrect understanding of the educational scan.
