Background: Feedback on clinical management and diagnostic accuracy may enhance physicians’ learning and reduce diagnostic error. Residents on night admitting rotations rarely receive feedback on their clinical management and seldom have the opportunity to reflect on their patients’ clinical courses. Barriers include the lack of a structured approach to feedback and reflection, discontinuous training environments, and time constraints.

Purpose: To develop an educational intervention for internal medicine residents on night admitting rotations that promotes learning through chart review, reflection and feedback.

Description: We first developed a worksheet outlining a process for structured chart review and reflection. Internal medicine residents on their night admitting rotation were asked to maintain a list of all patients they admitted during the month and complete reflection worksheets for 4 of those patients. They were also instructed to solicit feedback on their diagnosis or clinical management from 2 attending physicians and 2 residents on ward teams via secure email (Figure 1).
Between January-August 2017, 68 of 82 eligible residents (83%) completed 248 structured reflections worksheets, and 78% of residents solicited feedback. We analyzed the reflection worksheets to assess the content of reflections. Several themes emerged from our analysis. Residents recognized discrepancies in initial and final diagnoses. They also identified changes they might make in their future clinical practice and heuristics that affected their diagnostic reasoning (Table 1). 28% of residents reported seeking feedback “most of the time” or “always” from the receiving day team before the intervention. After the intervention, 58% of residents reported intending to seek feedback. 70% of the residents surveyed found the intervention valuable for their professional development.

Conclusions: A structured program of patient follow-up, reflection, and feedback on night admitting rotations may provide an opportunity for residents to identify areas for improvement in their own practice. Future iterations include providing residents training on critical reflection and delivering peer feedback.

IMAGE 1: Figure 1

IMAGE 2: Table 1