1. The “Emory Case Method” for Professional and Interpersonal Competency Training in Neurosurgery
Jordan Amadio, M.D., M.B.A.
Nelson Oyesiku, M.D., Ph.D.
Emory University, Department of Neurological Surgery
Senior Society Meeting, Atlanta, May 2012

2. Outline ACGME Competencies: Concept of the Case Method
Professionalism
Interpersonal and Communication Skills
Concept of the Case Method
Adaptation to Neurosurgery: the Emory experience
Case examples
Conclusion and Future Directions

3. ACGME Core Competencies
Source: ACGME

4. Professionalism
“Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.” Source: American College of Graduate Medical Education

5. Interpersonal and Communication Skills
“Interpersonal and Communication Skills that result in effective information exchange and learning with patients, their families, and other health professionals.”
- Source: American College of Graduate Medical Education

6. Challenges of Neurosurgery Residency
High stakes decisions / high emotional valence
Families, patients, & other health professionals in crisis mode
Personal stressors for residents: emotion, intellect, stamina
“Drinking from a fire hose”
Diverse population with views and beliefs that may diverge from the resident’s
Pressure for constant vigilance

7. Emotional Intelligence
The ability to identify, assess, and control the emotions of oneself, of others, and of groups.
Perceiving emotions
Using emotions
Understanding emotions
Managing emotions
Mayer, J.D., Salovey, P., Caruso, D.L., & Sitarenios, G. (2001). Emotional intelligence as a standard intelligence. Emotion, 1,

8. Inspiration: Harvard Business School (HBS) Case Method
Method Developed: 1908
“There are no simple solutions; yet through the dynamic process [….] students become adept at analyzing issues, exercising judgment, and making difficult decisions — the hallmarks of skillful leadership.”
Source:

9. Blueprint of the HBS Case Method
An Individual’s Dilemma
(in media res)
Background
(Context)
The Extended Situation
(Key players, Key factor analysis)
The Choice at Hand
(Returning to the dilemma)
Copyright HBS Press. For illustration only.

10. Case Method as Adapted to Neurosurgery Training
Context:
Cases of detailed, real-life scenarios facing residents
Group of peers
Method:
Free and open discussion, without fear of criticism
Encourage creative, out-of-box analysis
Preceptor merely curates discussion = Socratic, NOT didactic
Goal:
Identifying areas for improvement in future action
Build professional and interpersonal skills via “exercise”

11. Advantages Solicit perspectives equally from PGY1-7 + faculty
Unique opportunity to temporarily suspend hierarchy in the name of wisdom-seeking
Realistic scenarios
Builds skills by exercising them, not by top-down lectures
Skills become integrated into behavior, rather than compartmentalized as mere didactic knowledge

12. Disadvantages Time-consuming
Residents and faculty must be committed to idea
Dependent on whether relevant cases provided
Requirement of having 100% free, confidential discussion
Gaps in curriculum coverage due to non-didactic method

13. The Emory Case Method
Real scenarios collected yearlong by PD, from all residency years
Kickoff was Grand Rounds activity in July 2011
Residents proctoring case examples of difficult interpersonal situations from previous year  group analysis
Case method-based sessions performed periodically throughout year
Now actively developing written case formats
Incorporating into PGY-1 orientation, charting outcomes

14. Case Example 1
Excerpt of complaint letter from a patient’s wife: “One doctor in particular, Dr. A, told [my husband], when he said he had some questions after surgery, that he didn’t have time because he had some other patients he had to see. Excuse me, is he not a patient also? What made the other patients more important? Another doctor said he would return after completing a procedure, but never did.”

15. Case Example 1: Discussion
Overall, the patient had a frustrating hospital experience. How did the resident’s words make the wife and patient feel?
Dr. A is normally a conscientious resident. Why might he have communicated this way?
What did the wife understand as the reason for the resident’s behavior?
Within the constraints of a busy service, how could the resident have improved this simple interaction?

16. Case 1 Takeaways “What you say” vs. “what is heard”
Power of nonverbal communication
How to communicate meaning
Body language
Intonation
Facial expression
Word content (a small fraction)

17. Case Example 2 Setting: A Non-Operative ER Consult
“The daughter of was dissatisfied with the professionalism displayed by our Emory physicians during their time in our ED.  The daughter, who works for an OR, was unhappy with the 2 consulting neurosurgeons’ behavior of talking and texting on their cell phones in the midst of the patient assessment…”
Source: Brandon Miller, M.D.

18. Case Example 2: Discussion
Dr. M’s Perception of Reality: “I was texting Dr. [Attending] about a critical patient we had in the pediatric ER across the street. I acknowledged this, apologized to the patient, and stepped away when texting.”
What accounted for the differences in how Dr. M and the patient’s daughter perceived the situation?
How could Dr. M have acted to improve his interpersonal outcome?

19. Case 2 Takeaways Different perceptions, one reality
Parable of the six blind men
When dealing with stressful encounters, the effective resident must integrate each stakeholder’s perception in order to frame the situation

20. Future Directions Archiving of written cases in standard format
Publication of complete HBS-style case studies for use by Emory and other neurosurgical training programs
Incorporate method into PGY-1 orientation training
Chart outcomes, impact on formal measures of interpersonal and professional competencies
Standardized longitudinal questionnaires
Quantitative data on patient- & staff-generated incident reports

21. Conclusions
The rigors of neurosurgical training demand strong professional and interpersonal competencies.
These 2 core competencies are crucial, but nebulous and difficult to teach.
The case-based training method, adapted from Harvard Business School, is ideally suited for this purpose.
The Emory Case Method has shown excellent results at Emory as a formal component of resident training, and would likely prove successful if widely adopted.