A mixed-methods examination of the nature and frequency of medical error among junior doctors.

PURPOSE OF THE STUDY: To examine junior doctors' experience and perceptions of medical errors in which they had been involved. STUDY DESIGN: A mixed-methods design, consisting of an error survey and critical incident technique (CIT) interviews, was used. The survey asked doctors in the first year of postgraduate training in Ireland whether they had made a medical error that had 'played on (their) mind', and if so, to identify factors that had contributed to the error. The participants in the CIT interviews were asked to describe a medical error in which they had been involved. RESULTS: A total of 201 out of 332 (60.5%) respondents to the survey reported making an error that 'played on their mind'. 'Individual factors' were the most commonly identified group of factors (188/201; 93.5%), with 'high workload' (145/201; 72.1%) the most commonly identified contributory factor. Of the 28 CIT interviews which met the criteria for analysis, 'situational factors' (team, staff, task characteristics, and service user factors) were the most commonly identified group of contributory factors (24/28; 85.7%). A total of eight of the interviews were judged by subject matter experts (n=8) to be of medium risk to patients, and 20 to be of high-risk to patients. A significantly larger proportion of high-risk scenarios were attributed to 'local working conditions' than the medium-risk scenarios. CONCLUSIONS: There is a need to prepare junior doctors to manage, and cope with, medical error and to ensure that healthcare professionals are adequately supported throughout their careers.

Disturbing and distressing: a mixed methods study on the psychological impact of end of life care on junior doctors.

BACKGROUND: The Irish Medical Council has identified gaps in knowledge and communications skills of new-entrant doctors in legal, ethical and practical aspects of end of life care. AIMS: To determine the frequency with which junior doctors deal with end of life care and patient death and to evaluate the impact this has on their psychological wellbeing. DESIGN: A questionnaire was distributed to junior doctors to determine the frequency with which the participants had managed a patient at end of life. An abbreviated Posttraumatic Stress Disorder Checklist-Civilian version was used to evaluate psychological distress. Critical incident technique interviews explored the challenges of caring for patients at end of life. SETTING/PARTICIPANTS: A total of 110 junior doctors in two teaching hospitals in Ireland completed the questionnaire: 39 (35.5%) interns and 71 (64.5%) senior house officers. In addition, 31 interviews were carried out with interns, senior house officers and registrars. RESULTS: The majority (81.8%) had pronounced a death with 39.4% of senior house officers doing so more than 10 times. Three quarters (75.5%) had discussed end of life with a patient's family. Of the 110 respondents that completed the posttraumatic stress disorder checklist, 11.8% screened positively for posttraumatic stress disorder. Challenges identified at interview included lack of knowledge and preparedness, difficulty communicating with family members, a lack of support and a feeling of failure. CONCLUSIONS: Junior doctors are regularly carrying out tasks related to end of life care, resulting in high levels of psychological distress. Further training and a change in culture are required.

Stress, coping, and psychological resilience among physicians.

BACKGROUND: Recent research has demonstrated that burnout is widespread among physicians, and impacts their wellbeing, and that of patients. Such data have prompted efforts to teach resilience among physicians, but efforts are hampered by a lack of understanding of how physicians experience resilience and stress. This study aimed to contribute to knowledge regarding how physicians define resilience, the challenges posed by workplace stressors, and strategies which enable physicians to cope with these stressors. METHODS: A qualitative approach was adopted, with 68 semi-structured interviews conducted with Irish physicians. Data were analysed using deductive content-analysis. RESULTS: Five themes emerged from the interviews. The first theme, 'The Nature of Resilience' captured participants' understanding of resilience. Many of the participants considered resilience to be "coping", rather than "thriving" in instances of adversity. The second theme was 'Challenges of the Profession', as participants described workplace stressors which threatened their wellbeing, including long shifts, lack of resources, and heavy workloads. The third theme, 'Job-related Gratification', captured aspects of the workplace that support resilience, such as gratification from medical efficacy. 'Resilience Strategies (Protective Practices)' summarised coping behaviours that participants considered to be beneficial to their wellbeing, including spending time with family and friends, and the final theme, 'Resilience Strategies (Attitudes)', captured attitudes which protected against stress and burnout. CONCLUSIONS: This study emphasised the need for further research the mechanisms of physician coping in the workplace and how we can capitalise on insights into physicians' experiences of coping with system-level stressors to develop interventions to improve resilience.

A mixed method, multiperspective evaluation of a near peer teaching programme.

PURPOSE OF STUDY: Peer teaching (PT) has become increasingly popular. PT may offer benefits for students, tutors and institutions. Although resistance to PT has been identified among faculty, research has typically focused on students' experiences and perceptions, rather than those of the peer tutors or senior doctors/medical faculty. The current study comprised of a comprehensive, multiperspective evaluation of a near PT programme delivered by interns to final-year medical students in the Republic of Ireland. STUDY DESIGN: This study employed a mixed methods design, using both interviews and questionnaires to assess students' (n=130), interns' (n=49) and medical faculty's or senior doctors' (n=29) perceptions of the programme. RESULTS: All three groups were emphatic about the programme's benefits, although senior doctors and faculty reported significantly more positive attitudes than the others. Mean ratings of the programme's value, out of 10, were 8.2 among students, 8.2 among interns and 9.1 among senior doctors and faculty. Challenges identified were largely organisational in nature. Perceived benefits for students included the informality of teaching sessions, increased opportunities in the clinical environment and improvements in exam preparedness. Perceived benefits for the interns included improvements in knowledge and teaching ability and experience as a role model. CONCLUSIONS: PT programmes have been posited as an 'easy fix' to growing numbers of students. However, it is apparent that PT has substantial value outside of this. Future research that conducts economic evaluations of such programmes and that collects objective data on teaching quality and student learning would be of much interest.

Diabetic retinopathy in pregnancy: a population-based study of women with pregestational diabetes.

The aim of this observational study was to evaluate screening and progression of diabetic retinopathy during pregnancy in women with pregestational diabetes attending five antenatal centres along the Irish Atlantic seaboard. An adequate frequency of screening was defined as at least two retinal evaluations in separate trimesters. Progression was defined as at least one stage of deterioration of diabetic retinopathy and/or development of diabetic macular edema on at least one eye. Women with pregestational diabetes who delivered after 22 gestational weeks (n = 307) were included. In total, 185 (60.3%) had an adequate number of retinal examinations. Attendance at prepregnancy care was associated with receiving adequate screening (odds ratio 6.23; CI 3.39-11.46 (P < 0.001)). Among those who received adequate evaluations (n = 185), 48 (25.9%) had retinopathy progression. Increasing booking systolic blood pressure (OR 1.03, CI 1.01-1.06, P = 0.02) and greater drop in HbA1c between first and third trimesters of pregnancy (OR 2.05, CI 1.09-3.87, P = 0.03) significantly increased the odds of progression. A significant proportion of women continue to demonstrate retinopathy progression during pregnancy. This study highlights the role of prepregnancy care and the importance of close monitoring during pregnancy and identifies those patients at the highest risk for retinopathy progression.