Thursday, March 30, 2017

Ultrasound Use Among Colombian Emergency Medicine Residents and Leveraging Behavioral Economics Insights

Alister Martin
Resident MGH/Brigham - Harvard Affiliated Emergency Medicine Residency
Ultrasound Use Among Colombian Emergency Medicine Residents and Leveraging Behavioral Economics Insights

I landed in Colombia intent on accomplishing three things: doing shifts in the emergency department at a local hospital here, executing our research project on the utilization of point of care ultrasound with the goal of investigating potential behavioral economics interventions to increase its use among emergency department residents, and taking full immersion Spanish classes. How was I going to fit all that into four short weeks? I had no idea. I jumped in and prioritized getting the study off the ground first. Our nationwide resident ultrasound survey project began in Cali, Colombia where a member of our team organized the residents of the emergency medicine program in that city. Our next city was Medellin, Colombia where I was based out of and that's where my story begins.

My first job in Medellin was to understand who the stakeholders were and what defined success for my time with regard to accomplishing the goals of our data collection process. Briefly, the question we were trying to answer was what was the current state of bedside ultrasound(BSUS) use among emergency medicine residents in Colombia and what, if any, were the current barriers to its use? This was a follow up from a study done in 2012 that found that while many residents had an interest in BSUS, and had been informally taught about its use, overall there was a limited use of ultrasound among emergency medicine residents. Since we already had the data from Cali, I was free to focus on organizing the data collection process in the Medellin based programs.

Prior to leaving I had predicted that there would be logistical challenges, I am a firm believer in Muphy’s Law after all. What I didn’t know was what the nature of those challenges would be. 48 hours into my trip I learned that my predictions were accurate, if not a bit underestimated. Those first few days were challenging. My Spanish was still pretty basic, I had only just begun my full immersion Spanish courses, and I experienced my fair share of the normal “we’re not in Kansas anymore” moments. I also came to find that I had overestimated my understanding of how the resident training process here worked and that I was operating from some critical misassumptions. I had initially thought that the administration that I would be working with to administer the study was the same as the hospital I was rotating at. After hearing from another member of the team who was also based out of Medellin, I came to learn that the administration of our ED rotation hospital had no idea that we intended to do a survey of the resident programs. It was here that I learned a crucial difference in the resident training process in Colombia as compared to the US. In Colombia, the residents are not at all affiliated with the hospital – they are only affiliated with the University they are part of. For example, they rotate at many of the hospitals in Medellin but are affiliated to one of the two universities in town. What this would look like in Boston would be a system where residents would either be from, say, Boston University or Harvard Medical School but would rotate at all the hospitals in Boston. For example, Boston University internal medicine residents would rotate at MGH, Brigham, Mount Auburn, BMC etc.
On the second night in Medellin I met up with a super helpful young attending who had rotated in Boston prior and had connections to my principal investigator back stateside. We met and he helped me revise my understanding of how things worked at the two programs here in Medellin; Universidad de Antioquia and CES. After this I began to draw a more accurate mental map of who the stakeholders were and how I would begin to rethink our approach. The residents of both programs had semi regular didactic conferences and these settings would prove to be the best for survey administration. 

It’s been a week since I’ve touched down now and after an initial hiccup with the Visa process, I started at the hospital mid-week last week. I was surprised by many things that first week in the hospital but three things jumped out at me immediately. The first was that there was a Sonosite ultrasound that belonged specifically to the Emergency Department here. Coming in I had guessed that maybe the ultrasound would be difficult to find or that, perhaps, it would belong to another department on some other floor in the hospital. Crucially, while the ultrasound was accessible, unlike our department where ultrasound is in sight providing a visual trigger, it was not easily visible here in this ED. Here it lives tucked away in a closet. This has consequences on behavioral change around ultrasound use and provides, perhaps, the first behavioral economics lever to investigate potential interventions. The concept of choice architecture, a term coined by Thaler and Sunstein, reflects the fact that there are many ways to present a choice to the decision-maker, and that what is chosen often depends upon how the choice is presented. Perhaps the current set up works against the use of BSUS, and increases the barrier to its use slightly, almost like out of sight out of mind. As my Spanish Professor likes to say, “Ya veremos(we’ll see). Second, was that I did not see any residents using the ultrasound on their own. I did however, see attendings use the ultrasound occasionally. The third was the most interesting finding. When I used the ultrasound to evaluate patients the residents who helped me translate and who were watching knew almost all of the most important images and structures. For example, I think the first patient I evaluated had SOB. The residents were easily able to identify B-lines, the pleural lines, and could identify lung sliding. They were also able to re-create images on their own when I passed them the probe. That pattern continued for most of the common uses of bedside ultrasound (evaluations of FAST, bedside echo, RUSH, gallbladder, renal US, etc). I was impressed and intrigued. If residents had access to the ultrasound, they were very knowledgeable on its use, and there were patients who could benefit from its use, why didn’t they use it? I had to learn more.

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