By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer
“When the pressure is on, we don’t rise to the occasion, we fall to the highest level of preparation.”
– Chris Voss, Author and Former FBI Negotiator
At the end of residency training, what knowledge do clinicians retain, and what tends to fade quickly over time?
Knowledge is often retained when clinicians experience a high-stakes clinical syndrome firsthand – watching it unfold, making difficult decisions, and later second-guessing whether those decisions were correct. In contrast, information is often forgotten quickly when it comes to reading about a topic they have never personally encountered.
Memories are stronger when the neuronal connections associated with that memory are more myelinated and have redundant pathways. Memories become stronger with repetition, when memories are attached to emotion, if the memory involves multiple learning modalities (listening, reading, watching, and doing), if the information is repeated over time, and if it is associated with other memories.
Some clinical scenarios are rare, but the consequences of decisions are particularly impactful. Some examples include unexpectedly being a clinician responsible for the care of a person with cardiopulmonary arrest, major trauma, status epilepticus, or obstetrical emergency.
Being relatively calm and effective in these cases depends on the level of preparation and knowledge one has gained before being confronted with an emergency. The more automatic our actions are, the faster and more accurate they will be.
Simulations and case studies are two helpful resources to help prepare for high-stakes situations. If the scenario requires a manual skill, watching a video or practicing the actual skill with some repetition is essential (simulation). If the scenario involves high-stakes decision making, a deeper and more considered thought process is helpful (case studies). Watching attentively as one of our peers struggles with the manual skills or cognitive processes of an emergency also reinforces the neural pathway; so, learning as a team is better than learning alone.
What sort of emergencies might you encounter in an outpatient practice? One of the most common is a patient who unexpectedly loses consciousness or nearly loses consciousness. First, we must quickly assess the situation to determine the underlying severity of the situation. Is it a vasovagal reaction, a hypoglycemic episode, or a cardiopulmonary arrest? Subsequently, or sometimes simultaneously, promptly initiating treatments that will help or resolve the situation is key.
Training together as a team offers other major benefits, such as: deepening trust with teammates, developing shared mental models so that the actions of others can be anticipated, and strengthening communication to be as efficient as possible in an emergency situation. In the past several months, Partnership has been sponsoring trainings in obstetrical emergencies for hospital teams and found that the enhanced team effectiveness was a major unexpected benefit highlighted by the hospitals afterwards.
Unfortunately, as our health care delivery system has moved to the convenience of online training for Advanced Cardiovascular Life Support (ACLS), Basic Life Support (BLS), etc., this becomes a missed opportunity to develop our team effectiveness, particularly with new staff. We might consider alternating or augmenting our online training with in-person scenarios to help the material resonate better and build team effectiveness. Another best practice could be to combine an in-person BLS training with clinic-specific customizations, such as treatment of vasovagal reactions, seizures, and hypoglycemia.
One final best practice is what our outgoing Physician Advisory Committee chairman, Dr. Steve Gwiazdowski, calls “high frequency, low fidelity” practice. Finding ways to do quick refreshers on key scenarios or skills every three months or so, has been proven to keep this knowledge fresh. The Banner Hospital system, with small rural hospitals throughout the rural western states, has institutionalized such quarterly re-trainings for their nursing staff and found that this approach improves both outcomes and teamwork. To better prepare for emergencies, please consider ways to incorporate these types of quick refreshers into your clinical setting.