Improving Resident Feedback on Diagnostic Reasoning after Handovers: The LOOP Project
Appropriate calibration of clinical reasoning is critical to becoming a competent physician. Lack of follow-up after transitions of care can present a barrier to calibration. This study aimed to implement structured feedback about clinical reasoning for residents performing overnight admissions, measure the frequency of diagnostic changes, and determine how feedback impacts learners’ self-efficacy. Trainees shared feedback via a structured form within their electronic health record’s secure messaging system. Forms were analyzed for diagnostic changes. Surveys evaluated comfort with sharing feedback, self-efficacy in identifying and mitigating cognitive biases’ negative effects, and perceived educational value of night admissions—all of which improved after implementation. Analysis of 544 forms revealed a 43.7% diagnostic change rate spanning the transition from night-shift to day-shift providers; of the changes made, 29% (12.7% of cases overall) were major changes. This study suggests that structured feedback on clinical reasoning for overnight admissions is a promising approach to improve residents’ diagnostic calibration, particularly given how often diagnostic changes occur.
© 2019 Society of Hospital Medicine
One of the most promising methods for improving medical decision-making is learning from the outcomes of one’s decisions and either maintaining or modifying future decision-making based on those outcomes.1-3 This process of iterative improvement over time based on feedback is called calibration and is one of the most important drivers of lifelong learning and improvement.1
Despite the importance of knowing the outcomes of one’s decisions, this seldom occurs in modern medical education.4 Learners do not often obtain specific feedback about the decisions they make within a short enough time frame to intentionally reflect upon and modify that decision-making process.3,5 In addition, almost every patient admitted to a teaching hospital will be cared for by multiple physicians over the course of a hospitalization. These care transitions may be seen as barriers to high-quality care and education, but we suggest a different paradigm: transitions of care present opportunities for trainees to be teammates in each other’s calibration. Peers can provide specific feedback about the diagnostic process and inform one another about patient outcomes. Transitions of care allow for built-in “second opinions,” and trainees can intentionally learn by comparing the clinical reasoning involved at different points in a patient’s course. The diagnostic process is dynamic and complex; it is fundamental that trainees have the opportunity to reflect on the process to identify how and why the diagnostic process evolved throughout a patient’s hospitalization. Most inpatient diagnoses are “working diagnoses” that are likely to change. Thus, identifying the twists and turns in a patient’s diagnostic journey provides invaluable learning for future practice.
Herein, we describe the implementation and impact of a multisite initiative to engage residents in delivering feedback to their peers about medical decisions around transitions of care.
METHODS
The LOOP Project is a prospective clinical educational study that aimed to engage resident physicians to deliver feedback and updates about their colleagues’ diagnostic decision-making around care transitions. This study was deemed exempt from review by the University of Minnesota Institutional Review Board and either approved or deemed exempt by the corresponding Institutional Review Boards at all participating institutions. The study was conducted by seven programs at six institutions and included Internal Medicine, Pediatrics, and Internal Medicine–Pediatrics (PGY 1-4) residents from February 2017 to June 2017. Residents rotating through participating clinical services during the study period were invited to participate and given further information by site leads via informational presentations, written handouts, and/or emails.
