Simulation-based mastery learning compared to standard education for discussing diagnostic uncertainty with patients in the emergency department: a randomized controlled trial

Danielle M McCarthy, Rhea E Powell, Kenzie A Cameron, David H Salzman, Dimitrios Papanagnou, Amanda Mb Doty, Benjamin E Leiby, Katherine Piserchia, Matthew R Klein, Xiao C Zhang, William C McGaghie, Kristin L Rising, Danielle M McCarthy, Rhea E Powell, Kenzie A Cameron, David H Salzman, Dimitrios Papanagnou, Amanda Mb Doty, Benjamin E Leiby, Katherine Piserchia, Matthew R Klein, Xiao C Zhang, William C McGaghie, Kristin L Rising

Abstract

Background: Diagnostic uncertainty occurs frequently in emergency medical care, with more than one-third of patients leaving the emergency department (ED) without a clear diagnosis. Despite this frequency, ED providers are not adequately trained on how to discuss diagnostic uncertainty with these patients, who often leave the ED confused and concerned. To address this training need, we developed the Uncertainty Communication Education Module (UCEM) to teach physicians how to discuss diagnostic uncertainty. The purpose of the study is to evaluate the effectiveness of the UCEM in improving physician communications.

Methods: The trial is a multicenter, two-arm randomized controlled trial designed to teach communication skills using simulation-based mastery learning (SBML). Resident emergency physicians from two training programs will be randomly assigned to immediate or delayed receipt of the two-part UCEM intervention after completing a baseline standardized patient encounter. The two UCEM components are: 1) a web-based interactive module, and 2) a smart-phone-based game. Both formats teach and reinforce communication skills for patient cases involving diagnostic uncertainty. Following baseline testing, participants in the immediate intervention arm will complete a remote deliberate practice session via a video platform and subsequently return for a second study visit to assess if they have achieved mastery. Participants in the delayed intervention arm will receive access to UCEM and remote deliberate practice after the second study visit. The primary outcome of interest is the proportion of residents in the immediate intervention arm who achieve mastery at the second study visit.

Discussion: Patients' understanding of the care they received has implications for care quality, safety, and patient satisfaction, especially when they are discharged without a definitive diagnosis. Developing a patient-centered diagnostic uncertainty communication strategy will improve safety of acute care discharges. Although use of SBML is a resource intensive educational approach, this trial has been deliberately designed to have a low-resource, scalable intervention that would allow for widespread dissemination and uptake.

Trial registration: The trial was registered at clinicaltrials.gov (NCT04021771). Registration date: July 16, 2019.

Keywords: Communication; Emergency department; Emergency medicine; Medical education; Simulation based mastery learning; Uncertainty.

Conflict of interest statement

Dimitrios Papanagnou is an Associate Editor of BMC Medical Education; all other authors have no conflicts of interest.

The study is funded as detailed below and the project proposal underwent grant study section review by AHRQ.

Figures

Fig. 1
Fig. 1
Participants flow through study
Fig. 2
Fig. 2
Screenshots from online educational module of UCEM
Fig. 3
Fig. 3
Screenshots from interactive smart-phone based game of UCEM
Fig. 4
Fig. 4
Sample of anticipated results demonstrating individual scores at each testing time point

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