Structured peer debriefing is a helpful component of empowering trainees in the health professions to respond to traumatic patient events and potentially address future causes of burnout.
Undergraduate Medical Education (UME) and Graduate Medical Education (GME) learners encounter many scenarios throughout their training in which they witness patient death. Physicians are emotionally impacted by distressing patient care events but are often ill-equipped to cope with these feelings despite their medical school and residency training. In one study of attending physicians’ and residents’ responses to patient death, 23% rated the deaths as “very disturbing” with no significant difference in emotional response based on level of training (Redinbaugh et al., 2003). In another survey where physicians were asked about their last memorable patient death, 84% of respondents recommended “talking with others” as a method of coping, and 57% supported additional education on this topic (Moores et al., 2007). A final study of pediatric residents regarding their experiences surrounding patient death named their peers as the most trusted support source (Yang et al., 2011). These studies highlight the need for education in structured peer debriefing after difficult patient events to improve trainee coping skills and self-care – which may lead to career longevity. Emergency medicine has previously demonstrated that the inability to cope with the grief and death of patients has been cited as one of the major reasons physicians ultimately leave the field (Knazik et al., 2003).
In addition to promoting trainee wellness, debriefing promotes learning. According to Kolb’s theory of experiential learning, the clinical encounter of tragedy may represent the “concrete experience,” whereas debriefing encompasses the next two steps – “reflective observation” and “abstract conceptualization,” in which the facilitator reviews and reflects on the previous experience and the trainee identifies new concepts to apply to future practice (Kolb, 1984). In this way, effective debriefing can also address all six of the core competencies developed by the ACGME and American Board of Medical Specialties as skills necessary for a practicing physician: patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The ability for debriefing to impact all core competencies also highlights a potential reason that debriefing has been shown to improve outcomes (such as improved CPR outcomes or better neonatal outcomes after emergent Caesarian sections) – the solidification of skills to apply to future practice as a physician (Weiner et al., 2014; Wolfe et al., 2014).
Finally, debriefing education directly addresses an emerging model of learning in medical education – adaptive expertise – which is intended to address the challenge of preparing learners for an unknown future (Mylopoulos et al., 2017). Adaptive expertise requires that learners develop both efficiency in order to reproduce effective performance, and innovation in order to learn new information and invent new strategies for learning as they go (Mylopoulos et al., 2018; Schwartz et al., 2005). As students are exposed to newly challenging or traumatic patient scenarios, effective debriefing education allows for improved preparation for future learning, as it is translatable and iterative. The act of debriefing one difficult patient encounter improves resiliency, as shown above, and allows for a more effective debriefing of the next encounter.
For these reasons, we adapted and evaluated a previously published structured peer debriefing tool for use among resident physicians, with the hope it would be implemented immediately following distressing patient care events (McDermott et al., 2017).
We delivered two interactive workshops, first to internal medicine resident physicians and later to a mixed interprofessional group of resident physicians from various specialties. The session included a lecture describing the burden of distress following patient tragedies and reviewing the risk of that burden on physician self-care, work performance, and eventual increase in burnout. We then reviewed a debriefing tool with the group, followed by participation in an interactive role-play where one learner volunteered to offer an example of a real-life difficult patient case and a workshop facilitator acted as the “peer debriefer,” utilizing the tool to model debriefing skills (Keene et al., 2010; McDermott et al., 2017). The debriefing tool which we adapted can be found in Appendix 1. During the role-play, the facilitator asked each question in the tool and allowed space for the learner to respond from personal experience caring for a patient, simulating an interaction taking place immediately following the encounter. Following this role-play, we split participants into groups of two and gave them time to both facilitate the debrief and play the role of the distressed trainee. Surveys were provided to all learners for assessment of efficacy and attitudes after the lecture.
Fifty-five trainees participated in one of the two workshop sessions. Of those who participated, 48 completed post-session surveys. Trainee demographics appear in Table 1. Following completion of the training workshop, participants had majority positive responses to the information shared and its likely impact on their clinical practice (Table 2). Ongoing barriers to effective debriefing that were identified included “feeling that someone more senior should lead the discussion,” their own “lack of experience,” and the balance of emotional support with “multiple other time-sensitive responsibilities.”
Through qualitative analysis of responses to the question “What aspects of this lecture will you take with you in your future clinical practice?”, several themes emerged including a sense of empowerment and credibility among medical students and earlier-year residents to ask for or conduct a debriefing session (“I have the power to debrief, even as a student”), the usefulness of a framework to remove discomfort with bringing up emotional topics while in a professional setting (“I can just follow the script and I know it will be helpful”), and the awareness that a short debrief can still be effective for a team (“it’s a short process to do it, and no emotion is too small.”).
In this way, both our quantitative and qualitative data indicated an overall satisfaction with the debriefing workshop among varied levels of learners, a majority of whom felt empowered to incorporate debriefing with their team members following a traumatic patient care experience in the future.
In conclusion, distressing patient care events are common in medical practice, and trainee physicians must learn skills to cope emotionally with these events to prevent burnout and increase retention in the field. As few UME/GME curricular models include a structure to discuss these traumatic experiences and facilitate debriefing, our debriefing workshop could be a helpful addition that is easily incorporated into existing didactic learning – in our pilot study, it was easy to execute, interactive, and well-received by learners of all levels. Future studies will be needed to follow the implementation of this model in the hospital setting among medical teams of various specialties in additional to internal medicine, such as general surgery, emergency medicine, pediatrics, and psychiatry, another practical extension of this work.
The authors would like to thank Drs. Ulemu Luhanga and Taryn Taylor for their support of this work and collaboration. This work has received no financial support, and neither author has a conflict of interest to report.
Appendix 1 – Debriefing Tool
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Emily Pinto Taylor, MD
Assistant Professor of Medicine in the Divisions of General Internal Medicine & Hospice and Palliative Medicine, Emory University School of Medicine, email@example.com
Theresa Vettese, MD
Associate Professor of Medicine in the Division of General Medicine and Geriatrics and a member of the Emory Palliative Care Center, Emory University School of Medicine