Sandefur, Benjamin J.

AbstractBackgroundIn 2013 the Accreditation Council for Graduate Medical Education (ACGME) introduced “Milestones” designed to nationally standardize the assessment of resident physicians. Previous studies compare resident self‐assessment on milestones to faculty assessment, with varying degrees of agreement, but integration of self‐assessment into the formative feedback process has not yet been directly studied. This study uses a conceptual framework of self‐determination theory, integrated with concepts from adult learning theory, to compare the perception of the feedback quality given in semiannual reviews before and after the incorporation of resident self‐assessment into the feedback process.MethodsThis was an interventional study conducted in a single emergency medicine residency program at a major academic hospital over 1 calendar year. Residents first engaged in a semiannual review without self‐assessment. At subsequent semiannual reviews, residents completed a Milestone‐based self‐assessment that was provided to the faculty member assigned to conduct their semiannual review. Residents and faculty completed surveys rating perception of feedback quality. Two‐sided Wilcoxon signed‐rank tests were used in comparison analysis.ResultsOne resident did not self‐assess prior to the semiannual review and was excluded leaving 25 paired surveys for analysis. Residents found feedback after the self‐assessment more actionable (p = 0.013), insightful (p = 0.010), and better overall (p = 0.025). Similarly, faculty felt the feedback they provided was more actionable (p < 0.001), more insightful (p < 0.001), and better communicated (p < 0.001); led to improved resident understanding of milestones (p < 0.001); and were overall more satisfied (p < 0.001). Free‐text comments explore pre‐ and postintervention perceptions of feedback.ConclusionsIntegration of self‐assessment into semiannual reviews improves perception of feedback given to residents as perceived by both residents and faculty. Although limited by sample size, the results are promising for a simple, evidence‐based intervention to improve feedback during an existing mandated feedback opportunity.

AbstractObjectivesMany guidelines for septic olecranon bursitis recommend aspiration of the bursa prior to initiation of antimicrobial therapy despite the absence of robust clinical data to support this practice and known risk of aspiration complications. Our objective was to describe outcomes associated with empiric antibiotic therapy without bursal aspiration among emergency department (ED) patients with suspected septic olecranon bursitis.MethodsWe conducted a retrospective observational cohort study of patients presenting to an academic ED from January 1, 2011, to December 31, 2018, with olecranon bursitis. The health record was reviewed to assess patient characteristics and outcomes within 6 months of the ED visit. Olecranon bursitis was considered “suspected septic” if the patient was treated with antibiotics. The primary outcome of interest was complicated versus uncomplicated bursitis resolution. Uncomplicated resolution was defined as bursitis resolution without subsequent bursal aspiration, surgery, or hospitalization.ResultsDuring the study period, 264 ED patients were evaluated for 266 cases of olecranon bursitis. The median age was 57 years and 85% were men. Four (1.5%) patients had bursal aspiration during their ED visit, 39 (14.7%) were admitted to the hospital, 76 (28.6%) were dismissed without antibiotic therapy, and 147 (55.3%) were dismissed with empiric antibiotic therapy for suspected septic olecranon bursitis. Among these 147 patients, 134 had follow‐up available including 118 (88.1%, 95% confidence interval [CI] = 81.1%–92.8%) with an uncomplicated resolution, eight (6.0%, 95% CI = 2.8%–11.8%) who underwent subsequent bursal aspiration, and nine (6.7%, 95% CI = 3.3%–12.7%) who were subsequently admitted for inpatient antibiotics.ConclusionsEighty‐eight percent of ED patients with suspected septic olecranon bursitis treated with empiric antibiotics without aspiration had resolution without need for subsequent bursal aspiration, hospitalization, or surgery. Our findings suggest that empiric antibiotics without bursal aspiration may be a reasonable initial approach to ED management of select patients with suspected septic olecranon bursitis.

We present four medicolegal cases involving medication errors, which led to patient harm and subsequent settlements or jury awards to patients. These cases each involved scenarios in which a medication was inappropriately prescribed and/or inappropriately dispensed. In such cases, it is often not obvious whether the physician or pharmacist is at fault. These cases highlight the importance of understanding the roles and responsibilities of the physician and pharmacist in medication prescription and dispensation.