Admission case review occurs daily at teaching hospitals around the world. During these reviews, the medical team gathers, and the attending physician listens to a case presentation by a junior team member (a first-year resident or senior medical student), asks questions, and then provides guidance and teaching to the team.
Admission case review serves two, at times, competing functions—teaching and patient care.1 According to Irby, during case review, attending physicians iteratively diagnose the patient, diagnose the learner, and teach.2 As this process occurs in real time regarding a patient who is usually unfamiliar to the attending physician, the teaching and patient care discussions require a significant amount of improvisation.2 Attendings must strike a balance between teaching their teams and addressing the necessary patient issues. From a patient care standpoint, case review provides the team with an opportunity to receive guidance on how to further assess and manage their patients, who often suffer from a number of problems other than the main reason for their hospitalization.3,4 Failing to address a patient’s full set of problems can lead to medical errors and hospital readmission.4–6
Many previous studies of case reviews have focused on the teaching and learning aspects of the team’s morning presentation to the attending. This research established general principles of good teaching and the characteristics of good clinical teachers.7,8 These characteristics include actively involving learners, modeling clinical thinking, focusing teaching around the case, and providing explicit direction and feedback.7,8 Researchers also have characterized patterns of dialogue during case reviews and identified variables that can alter the division of talk time. They found that the presenter (junior team member) does most of the speaking during the first half of the case review, whereas the supervisor (attending physician) dominates the final quarter.1 From the attending’s perspective, variables that can alter the ratio of talk time and the discussion topics include the quality of the presentation, the complexity of the case, and the number and type of issues that trigger particular teaching scripts.1,2 From the junior team member’s perspective, other variables include hierarchical differences, conflicting roles, role ambiguity, and interpersonal conflict.9
The morning case review is only one in a complex series of oral and written episodes that also includes the junior team member’s admission note and overnight review with the senior resident. The patient care assessment and plan that the team develops through these conversations and documents in the clinical notes serves as the organizing framework around which all subsequent care takes place during the patient’s hospital stay.10 Many previous studies of case reviews have focused on the teaching and learning aspects of single episodes of communication and have not reflected the complex, intersecting nature of communication in a hospital setting, limiting our understanding of how case review interacts with the whole set of communication practices to shape patient care plans.
Rhetorical genre theory provides a useful lens for understanding how recurring communication practices, or genres, produce social action. Case review discussions and clinical documentation are genres because they recur predictably, involve distinct participant roles and common expectations with regard to structure and purpose(s), and serve to shape both current and future actions.11,12 These genres influence the work the team does together; they make possible certain actions and constrain others.12 Additionally, the concept of genre sets—which are combinations of interrelated genres,11 such as admission notes, case review discussions, etc.—affords a way to analyze how what happens in one genre influences and informs other genres in the set.
As part of a larger study on the impact of case review and documentation practices on patient care, the purpose of this study was to explore case review discussions and examine their influence on the comprehensiveness of case review.
This study is part of a multiple-instrumental-case study. The methodology facilitated our exploration of complex, real-world phenomena.13 The study was conducted with approval from the University of Western Ontario research ethics board for health sciences research involving human subjects.
Setting and participants
We conducted our study through the internal medicine teaching unit at London Health Sciences Centre, University Hospital in Ontario, Canada. Here, the majority of patients are admitted overnight by the on-call team. This team consists of a senior resident and one junior team member (senior medical student or first-year resident) from each of the three teams at the site. The on-call senior resident performs the overnight case reviews. The attending physician supervises case reviews during morning rounds. The majority of presentations are given by the postcall junior team member (senior medical student or first-year resident).
We recruited participants for our study from the team members on service at the time of our data collection and included 10 attending physicians, 13 senior residents, 19 junior residents, and 14 medical students. To minimize observer effect, we did not disclose the specifics of the study to the participants.14
We collected data throughout the admission process through direct observation, audio-recording, and chart extraction. We audio-recorded, transcribed, and anonymized both the overnight and morning case review discussions. We also observed the morning case review discussions in person and collected field notes. For each case review discussion, we copied the admission notes from the patient’s record and deidentified all data.
We collected data across two 8-week periods (winter and summer of 2010). Our data sampling was purposeful to include factors that may influence case review practices, such as the team to which the patient was admitted, the attending physician, weekday versus weekend admission, level of training of the admitting junior team member (senior medical student versus first-year resident), and team pairings between the senior resident and the admitting junior team member (same versus different teams). The patient cases themselves were a convenience sample—We included all cases admitted during periods when we had consent from the on-call junior and senior residents as well as the team attending.
Our data collection yielded 19 patient cases each consisting of three sources: (1) the note written by the admitting junior team member at the time of admission and subsequent follow-up notes, (2) the overnight oral case review discussion with the senior resident on call, and (3) the morning case review discussion with the attending physician and team.
We coded the case review discussion transcripts using a constant comparative analytic method informed by sensitizing concepts including theories of supervisory practice and genre sets.15,16 Our analysis explored (1) the characterization of the interactions between team members and (2) an assessment of how these interactions affected the details of the case discussed and the sequence of the case discussion. We next analyzed interactions between team members for recurring patterns. Two of us (M.G., L.L.) reviewed a subset of the transcripts and developed preliminary codes. The other of us (N.A.) then applied those codes to a portion of the transcripts and consulted with the others to further develop, revise, and refine the codes. We repeated this iterative process of coding and recoding four times until we had accounted for all key interaction patterns. We then applied the final codes to our full data set using NVivo version 9 (Sydney, Australia) qualitative data analysis software.17 Lastly, one of us (M.G.) reviewed a portion of the final coding to ensure consistency. We resolved discrepancies by returning to excerpt instances in the transcripts and clarifying code language.
We analyzed the impact of team interaction on the comprehensiveness of the case review discussions using both within- and across-case analyses.15 We examined case details such as medical history, physical exam findings, and details of the assessment and plan. Our across-case analysis explored commonalities and variations in the case review discussion genre. Our within-case analysis described interaction types and explored their consequences as seen through differences in source content (admission note and on-call case review transcripts versus next-morning case review transcripts).
To ensure rigor and increase authenticity in our methodology, we used two kinds of triangulation—investigator triangulation and data triangulation.18,19 We sought analytical rigor using an audit trail and multiple coders; our coding team included an experienced clinician (M.G.) as well as a nonclinician with expertise in medical communication and team dynamics (L.L.).
Our analysis of the case review discussion genre demonstrated that junior team members were expected to present in a standard sequence that largely followed a textbook documentation format (see List 1).20 Still, deviations from this sequence were common; sometimes presenters spontaneously introduced these deviations themselves, but often supervisors prompted them by interrupting the presentation. When a presenter introduced the deviation, the supervisor typically redirected the presenter back to the standard sequence.
In all 19 cases that we analyzed, supervisors created opportunities for teaching and patient care via their “interruptions.” We identified five interruption types: (1) probing for further data, (2) prompting for expected sequence, (3) teaching around the case, (4) thinking out loud, and (5) providing direction (see Table 1). Several interruption types served both goals of the case review discussions—teaching and patient care. For example, when thinking out loud, supervisors reasoned through problems and taught the team: “So that’s the big question, did she have a mechanical fall, or did she have a medicine-related fall?” (Case 2). Supervisors prompted for expected sequence, preventing presenters from skipping over information while simultaneously allowing the supervisor to instruct the team on presentation style: “So now you can tell me what the rest of his test results are because I haven’t heard those” (Case 16).
Although interruptions were an important form of supervisor–presenter interaction, we can best see the effect of these interruptions on the comprehensiveness of the case review discussion by examining their ability to cause “detours.” We conceptualized detours to include both purposeful and unintentional deviations from the usual case review discussion presentation sequence. We focus the remainder of our report on these detours.
We found detours in all 19 cases (average: 18.3/case). We identified five detour types: (1) pausing the presentation, (2) referring to a section later in the presentation, (3) presenting sections out of sequence, (4) skipping a section or section element, and (5) truncating the presentation (see Table 2). As shown in Table 2, pausing the presentation was the most common detour type (311 instances; average: 16/case) and the only type that appeared always to be intentional.
We found detours to be triggered by all interruption types, as well as a number of other causes (see Tables 1–2). Supervisors’ interruptions played a major role in initiating pausing (261 of 311 instances) and truncating the presentation (7 of 7 instances). As presenters used their admission note to guide their presentation, disorganization of this note, as identified by our within-case analysis of the admission note, was another detour trigger. At times, presenters also signaled this in their case review presentation: “I think I missed my investigations because I wrote my note funny” (Case 7).
We found alternative focus to be another contributor to detours. For example, a supervisor’s viewing of the electronic patient record while listening to the case review presentation contributed to detours. In Case 13, field notes indicated that when the supervisor interrupted the presentation of the physical to ask about ordering a particular test, she was reviewing lab values. Her interruption led to the team skipping the remainder of the physical findings and moving the discussion to the results of other investigations. Other sources of alternative focus, such as the junior or senior resident writing orders during the presentation or being paged, appeared less likely to cause detours.
The main differences between pausing the presentation and the other detour types were detour length and subsequent communication. After longer, pausing-type detours, supervisors often used prompting or summarizing to bring the presenter back to the right place in the presentation: “Okay, what are you doing about her diabetes?” (Case 11). Similarly, presenters would use transitional or regrouping statements to get back on track: “Okay, just let me make sure, what else did I have to say about him?” (Case 13). We also found that a well-organized admission note with a clear assessment and plan seemed to help the presenter get back on track.
The following representative case summary provides an example of how detours can arise and their consequences:
The patient, a female in her 80s, is admitted overnight for foot cellulitis. She is seen by a junior resident on the team who identifies five issues: (1) cellulitis, (2) edema, (3) diarrhea, (4) diabetes, and (5) hyponatremia. The junior resident documents a plan for each issue in the admission note. During the overnight case presentation, the team discusses each of these issues.
During the morning case review discussion, the attending interrupts when the presenter mentions diabetes to teach the team about diabetes management. This discussion continues for some time and engages many of the team members. The attending then gives instructions for the team to investigate the patient’s newly identified atrial fibrillation before concluding the discussion. The team does not discuss the patient’s hyponatremia. (Case 10)
This example illustrates two kinds of detours—pausing and truncating the presentation. The initial pause, triggered by teaching around the case, allowed the attending to teach the team about diabetes management and address the issue of atrial fibrillation. However, as a result of the pause, the presentation is truncated and the patient’s hyponatremia is not presented or discussed. This instance is representative in that most detours have both potential positive and negative consequences with regard to the team completing a comprehensive review. This example also demonstrates the insight afforded by our collection and analysis of multiple, interrelated, communication episodes—only through analyses across the genre set do potential omissions become visible.
We defined “omissions” as instances in which relevant information from the admission note and/or the overnight case review discussion was not included in the morning case review discussion. Omissions included skipping medical problems, not reporting patient data (e.g., results of laboratory investigations), and not discussing plans for some of the patient’s medical problems. Detour types varied in their likelihood to cause omissions. Pausing the presentation did not result in any omissions in our data set. Referring to a section later in the presentation resulted only in a few omissions because the team generally repeated these details in the appropriate section. Although both presenting sections out of sequence and skipping a section or section element did cause omissions, their impact on information sharing was difficult to gauge because they involved omissions of unknown significance, such as omitting the social history. In comparison, truncating the presentation could lead to the team omitting from the discussion one or more of the patient’s active medical problems. These detours typically occurred at the impression and plan stage of the case review presentation if the supervisor took control of the discussion. We found truncating the presentation to be the result of an interruption by an attending rather than a senior resident in six of seven instances. Some instances of truncating the presentation evolved from other detour types. For example, pausing the presentation for teaching could lead to truncating the presentation when the supervisor remained in control of the discussion.
Our study builds on prior research, including explorations of attendings’ teaching scripts during case review discussions, studies of supervisor interruptions and questioning strategies, and analyses of the oral case presentation genre.1,2,7,8,21–23 The innovation in our study arises from the theoretical lens of genre sets that we used, which afforded us the opportunity to analyze how communication episodes intersect and the impact of particular patterns of supervisors’ practices on the comprehensiveness of case review discussions. The five interruption types that we identified are consistent with prior research describing features of supervisors’ interruptions, such as frequency,21 types of utterances,22 and the role of supervisors’ questions in assessing competence.23 Additionally, many of the supervisors’ interruptions in our study exhibited a “dual focus on the patient and the learner.”2 However, we also found that interruptions can lead to detours, which can have both positive and negative effects on the comprehensiveness of the case review.
We found detours to be a pervasive and essential element of case review discussions—They provided the supervisor an opportunity to interrupt the case review presentation to teach, gather more information on the patient, and guide the team. However, detours also caused the presenter to omit details. Even those detours that included established features of good teaching, such as being anchored in the case and actively involving learners,7,8 could result in omissions.
Questions critical to interpreting our results include the following: Are supervisors in control of the case review genre? Are they aware that detours can lead to omissions? Are omissions purposeful and deliberate? During case review discussions, supervisors must balance being detail-oriented, working efficiently, and finding time for teaching.24 With the exception of pausing the presentation, we found no explicit evidence that supervisors recognized or intended to omit details as the result of a detour. We expect that some of the omissions that we observed were likely remedied by the supervisors outside the case review discussion. According to Kennedy and colleagues, not all work done by attending physicians is front-stage; they also employ “back stage” oversight strategies to ensure patient safety while giving trainees an experience of independence.25 We did not capture these backstage strategies in our study because we did not observe supervisors outside of case review discussions. The supervisors in our study may indeed have attended to the details omitted in case review discussions by reviewing the patient’s chart in advance or addressing them at a later time.
However, recent attention in the literature to the issue of “team competence” leads us to question the teams’ reliance on the “attending-with-a-master-plan” approach to comprehensive patient care.26,27 Case review is an important time for the whole team to develop and document a shared understanding of the patient’s problems.10 The well-documented problems with handoffs, continuity of care, and clinical documentation further highlight the importance of case review as a time for building this shared understanding.9,28–30 Although supervisors might choose to focus a particular case review on teaching rather than on a comprehensive discussion of the complete patient problem list, we did not observe any supervisors explicitly indicating this strategy, nor did we observe a team discussion of their expectations regarding omitted items. Therefore, we concluded that junior team members were left to interpret omissions, should they notice them at all, in a variety of ways—as essentially unimportant patient details, as unimportant right now in the care trajectory, or as low priority for discussing in the case review but high priority for capturing at another time, such as in the progress note. Past research suggests that these novice interpretations of such tacit issues may have unintended consequences.31
Our study has several limitations. It was conducted at a single institution and focused on the two admission case review discussions (overnight and morning); other departments and institutions may have different review practices, triggers, and strategies for handling detours, so our results may not apply outside our institution. Broadening the observational scope of our study to include shadowing attendings throughout the day and various handoff conversations would allow us to expand the genre set included in our study, providing more insight into how team members strategically use the whole genre set to balance effective teaching and appropriate patient care planning.
Recommendations for improving future case review discussions
We cannot establish the full impact of omitting patient details from case review discussion on actual patient care from our findings alone. However, in a larger study, of which this study is a part, we identified that the details not discussed during case review can lead to medical error and decreased quality of care, especially if those details are also not accurately documented.10 Because patients with multiple medical problems appear to be at a higher risk for omissions and subsequent errors in their care,4 supervisors should pay special attention to these cases. To mitigate the risk of omissions arising from detours, supervisors should avoid interruptions in the middle of the presentation of the assessment and plan or develop strategies for returning to the presentation when such interruptions are deemed necessary. Although prior research has noted that clinical supervisors tend to dominate this later stage of the case presentation,1 we found that this shift of control is accompanied by the potential omission of salient patient problems during case review. Reflecting on this finding, we propose adding a fourth step to the iterative set outlined by Irby2 for supervising physicians—diagnose the patient, diagnose the learner, teach, and monitor the case review presentation genre to ensure that relevant details and problems are not omitted. As part of this step, supervisors should use strategies such as prompting and summarizing to reorient the presenter after an interruption. Although we observed some junior team members also playing a role in this monitoring, prior research has shown that hierarchical differences, conflicting roles, and role ambiguity influence who will take charge of such strategies within the team.9 We therefore advocate that the supervisor should take responsibility for this extra step. We hope that this monitoring will support supervisors in ensuring that their case reviews provide comprehensive guidance to the team and avoid unintentional omissions.
Acknowledgments: The authors thank Dr. David Irby for his useful commentaries on an earlier draft of this research report.
Funding/Support: Summer Research Training Program, University of Western Ontario, Schulich School of Medicine and Dentistry, and the Academic Medical Organization of Southwestern Ontario.
Other disclosures: None.
Ethical approval: Granted by the University of Western Ontario research ethics board for health sciences research involving human subjects.
Previous presentations: The abstract of an earlier version of this research report was presented at the Centre for Education Research and Innovation 2011 Annual Research Symposium, October 2011, London, Ontario, Canada, and at the Canadian Conference on Medical Education, April 2012, Banff, Alberta, Canada.
1. Spafford MM, Schryer CF, Mian M, Lingard L. Look who’s talking: Teaching and learning using the genre of medical case presentations. J Bus Tech Commun. 2006;20:121–158
2. Irby DM. How attending physicians make instructional decisions when conducting teaching rounds. Acad Med. 1992;67:630–638
3. Vogeli C, Shields AE, Lee TA, et al. Multiple chronic conditions: Prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med. 2007;22(suppl 3):391–395
4. Hayward RA, Asch SM, Hogan MM, Hofer TP, Kerr EA. Sins of omission: Getting too little medical care may be the greatest threat to patient safety. J Gen Intern Med. 2005;20:686–691
5. Singh H, Thomas EJ, Petersen LA, Studdert DM. Medical errors involving trainees: A study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007;167:2030–2036
6. Dunlay SM, Redfield MM, Weston SA, et al. Hospitalizations after heart failure diagnosis: A community perspective. J Am Coll Cardiol. 2009;54:1695–1702
7. Irby DM, Ramsey PG, Gillmore GM, Schaad D. Characteristics of effective clinical teachers of ambulatory care medicine. Acad Med. 1991;66:54–55
8. Irby DM. Three exemplary models of case-based teaching. Acad Med. 1994;69:947–953
9. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: An insidious contributor to medical mishaps. Acad Med. 2004;79:186–194
10. Goldszmidt M, Dornan T, Lingard L. Fragmented communication: Understanding a common threat to quality patient care on medical teaching units. Manuscript currently in preparation.
11. Devitt AJ Writing Genres. 2004 Carbondale, Ill Southern Illinois University Press
12. Miller CR. Genre as social action. Q J Speech. 1984;70:151–167
13. Stake RE The Art of Case Study Research. 1995 Thousand Oaks, Calif Sage Publications
14. Hammersley M, Atkinson P Ethnography: Principles in Practice. 20073rd ed Milton Park, Abingdon, Oxford, UK Routledge
15. Eisenhardt KM. Building theories from case study reasearch. Acad Manage Rev. 1989;14:532–550
16. Bowen G. Grounded theory and sensitizing concepts. Int J Qual Methods. 2006;5:12–22
17. Bringer JD, Johnston LH, Brackenridge CH. Using computer-assisted qualitative data analysis software to develop a grounded theory project. Field Methods. 2006;18:245–266
18. Thurmond VA. The point of triangulation. J Nurs Scholarsh. 2001;33:253–258
19. Denzin NK The Research Act: A Theoretical Introduction to Sociological Methods. 2009 New Brunswick, NJ Aldine Transaction
20. Bickley LS, Szilagyi PG, Bates B Bates’ Guide to Physical Examination and History-Taking. 20079th ed Philidelphia, Pa Lippincott Williams & Wilkins
21. Yang G, Chin R. Assessment of teacher interruptions on learners during oral case presentations. Acad Emerg Med. 2007;14:521–525
22. Jackson JL, O’Malley PG, Salerno SM, Kroenke K. The teacher and learner interactive assessment system (TeLIAS): A new tool to assess teaching behaviors in the ambulatory setting. Teach Learn Med. 2002;14:249–256
23. Kennedy TJ, Lingard LA. Questioning competence: A discourse analysis of attending physicians’ use of questions to assess trainee competence. Acad Med. 2007;82(10 suppl):S12–S15
24. Lingard L, Schryer C, Garwood K, Spafford M. ‘Talking the talk’: School and workplace genre tension in clerkship case presentations. Med Educ. 2003;37:612–620
25. Kennedy TJ, Lingard L, Baker GR, Kitchen L, Regehr G. Clinical oversight: Conceptualizing the relationship between supervision and safety. J Gen Intern Med. 2007;22:1080–1085
26. Lingard L. What we see and don’t see when we look at ‘competence’: Notes on a god term. Adv Health Sci Educ Theory Pract. 2009;14:625–628
27. Lingard LHodges B, Lingard L. In: Rethinking Competence in the Context of Teamwork. The Question of Competence. 2012 Ithaca, NY Cornell
28. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: A critical incident analysis. Qual Saf Health Care. 2005;14:401–407
29. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121:866–872
30. Kaplan DM. Perspective: Whither the problem list? Organ-based documentation and deficient synthesis by medical trainees. Acad Med. 2010;85:1578–1582
31. Lingard LA, Haber RJ. What do we mean by “relevance”? A clinical and rhetorical definition with implications for teaching and learning the case-presentation format. Acad Med. 1999;74(10 suppl):S124–S127