Parents' Perspective on Trainees Performing Invasive Procedures: A Qualitative Evaluation.

OBJECTIVES: When obtaining informed permission from parents for invasive procedures, trainees and supervisors often do not disclose information about the trainee's level of experience. The objectives of this study were 3-fold: (1) to assess parents' understanding of both academic medical training and the role of the trainee and the supervisor, (2) to explore parents' preferences about transparency related to a trainee's experience, and (3) to examine parents' willingness to allow trainees to perform invasive procedures. METHODS: This qualitative study involved 23 one-on-one interviews with parents of infants younger than 30 days who had undergone a lumbar puncture. In line with grounded theory, researchers independently coded transcripts and then collectively refined codes and created themes. Data collection and analysis continued until thematic saturation was achieved. In addition, to triangulate the findings, a focus group was conducted with Yale School of Medicine's Community Bioethics Forum. RESULTS: Our analysis revealed 4 primary themes: (1) the invasive nature of a lumbar puncture and the vulnerability of the newborn creates fear in parents, which may be mitigated by improved communication; (2) parents have varying degrees of awareness of the medical training system; (3) most parents expect transparency about provider experience level and trust that a qualified provider will be performing the procedure; and (4) parents prefer an experienced provider to perform a procedure, but supervisor presence may be a qualifying factor for inexperienced providers. CONCLUSIONS: Physicians must find a way to improve transparency when caring for pediatric patients while still developing critical procedural skills.

The Association Between Physician Empathy and Variation in Imaging Use.

BACKGROUND: Variation in emergency physician computed tomography (CT) imaging utilization is well described, but little is known about what drives it. Physician empathy has been proposed as a potential characteristic affecting CT utilization. OBJECTIVES: The objective was to describe empathy in a cohort of emergency physicians and evaluate its association with CT utilization. We also sought to compare emergency physician performance on an empathy psychometric test with performance on other psychometric tests previously proposed as predictors of CT utilization. METHODS: This cross-sectional study included two parts: 1) a secondary analysis of emergency department (ED) CT imaging utilization data in a large health system from July 2013 to June 2014 and 2) a survey study of the cohort of physicians responsible for this imaging using four psychometric scales: the Jefferson Scale of Empathy (JSE), a risk-taking subset of the Jackson Personality Index (RTS), the Stress from Uncertainty Scale (SUS), and the Malpractice Fear Scale (MFS). The study included data and physicians from four EDs: one urban, academic ED, two community, and one free-standing. A hierarchical, mixed-effects regression model was used to evaluate the association between emergency physician performance on the four scales and risk-adjusted CT imaging utilization. The model incorporated physician-specific CT utilization rates adjusted for propensity scores that were calculated using over 500 patient-level variables via random forest methods, physician demographics, and a random provider effect to account for the clustering of observations. RESULTS: CT variation analysis included 113,517 patients seen during the study period by the 74 eligible emergency physician survey respondents; 20,972 (18.5%) of these patients had at least one CT. The survey response rate was 74 of 82 (90.2%). Correlation coefficients between JSE and the other scales were not statistically significant. In subset analysis, there was a trend toward a physician's number of years in practice and RTS score contributing to CT utilization for traumatic head CT. There were no significant associations between performance on any of the psychometric scales and CT utilization. CONCLUSIONS: Performance on the JSE, RTS, SUS, or MFS was not predictive of risk-adjusted CT utilization in the ED. The underlying physician-based factors that mediate interphysician variation remain to be clearly identified.