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Teamwork: In medicine, more than ever, patient safety demands it

Image for Teamwork: In medicine, more than ever, patient safety demands it In 2009, The Joint Commission (TJC) called attention to the “disruptive physician” and required hospitals
to develop a process for identifying and dealing with doctors who seemed to have problems working with others.

As usual, TJC did not dictate how hospitals should do this. Rather, TJC simply required hospitals to create procedures to deal with the problem. As a result, licensees and others contacted the NCMB to ask it to issue a formal position on “disruptive physicians.” In response, the Board published the osition entitled, “Collaborative care within the health care team” on January 1, 2010.

The position statement outlines the Board’s expectation for licensee conduct (among physicians and others such as PAs) in the context of working with others to provide patient care. We purposefully avoided the term “disruptive physician” in the title, choosing to emphasize the most important part of our professional lives—care of the patient—by everyone involved. We did define disruptive behavior, noted that the behavior may result from other underlying causes, and indicated that such behavior may be grounds for discipline.

Almost always, it is physicians who are singled out as “disruptive” and it’s not terribly difficult to understand why. In medicine, physicians have traditionally been at the top of the power structure and, consequently, have the greatest potential to impact those around them, including patients and other members of the health care team. This phenomenon is commonly referred to as “power distance.” Defined simply, power distance occurs when individuals in positions of less power are reluctant to challenge those with greater authority. In some environments, such as the battlefield, there are very good reasons for strict adherence to the established power structure. But in other environments, power distance may actually result in harm.

The aviation industry is rife with examples that tragically demonstrate this. If the captain intimidates crew members or the culture of the airline allows the captain an absolute authority, crew members may not speak up appropriately. Examples of this include the 1977 KLM crash in Tenerife, in which hundreds of people lost their lives essentially because the flight crew did not contest a poor decision made by the captain. Similarly, the crash of Korean Air Flight 801 in 1997 was attributed primarily to the rigidly hierarchical power structure in the cockpit, which prevented crew from speaking up until it was too late
to avoid catastrophe.

Similarly hierarchical cultures exist in medicine, and the implications are clear. If a physician or surgeon (the captain) intimidates or disrespects others who help care for the patient (the crew), bad or even fatal outcomes may occur. In an airplane crash, however, the captain and flight crew often perish with the passengers. In the context of health care, only the patient suffers the consequences.

Just as in the aviation industry, health care organizations such as TJC and the Accreditation Council for Graduate Medical Education have started to understand the effects of poor team performance. Still, not everyone agrees that personal behavior can impact care.

During a confidential interview at the NCMB that I helped conduct, an attorney for a physician argued that his client was an excellent physician and that his behavior had no effect on the quality of care he provided. I felt compelled to explain that physician behavior can have a very large impact on quality. If a nurse has been verbally abused by a physician, that nurse will be understandably reluctant to call the physician when concerns arise. Who would, knowing that the likely result would be a rude, belittling response? So in ambiguous circumstances, a nurse might wait until a patient’s condition has worsened further before alerting the physician, potentially increasing the risk of complications. It was a simple but compelling example that I hope helped the attorney understand that medicine is more than just technical knowledge.

In 2003, the Institute for Safe Medication Practices surveyed 1,565 nurses and 354 pharmacists about their experiences with physicians. Eighty-eight percent of respondents reported that a physician had spoken to them with condescending language or tone; 87 percent reported that physicians had been impatient with questions; and 79 percent said physicians had demonstrated reluctance to, or had
refused to, answer questions or phone calls. In other words, a significant majority of nurses and pharmacists had experienced this treatment. Nearly half of those surveyed—48 percent—said they had experienced strong verbal abuse from a physician; and 42 percent reported they had experienced threatening body language. Aside from the potential for patient harm, how many of us would want our sons, daughters or other family members to be treated in such a fashion?

We’ve all heard the same excuses to explain poor behavior by physicians, but in reality, there are no excuses. Treating people poorly is never right, especially if there is even a chance that our patients might suffer as a result. While physicians have certainly seen a substantial change in their roles over the last several years, they remain the leaders of the team. As such, the physician must set the example and welcome the engagement of the other team members.

How do physicians successfully lead the team? Most physicians can probably appreciate the value of a calm, professional, deliberate atmosphere. But many of us don’t remember that we play a huge part in setting that tone. As team leaders, physicians should encourage communication from all members of the team, regardless of level of training or role. Many of my surgical colleagues have questioned the
part of the surgical checklist that requires team members to introduce themselves. It might seem unnecessary, since many of us have worked with the same nurses, techs and nurse anesthetists for years, but the action of actually speaking up empowers people to continue speaking if concerns arise. Physicians should encourage members of the team to express concerns without fear of retribution, sarcasm or bullying. It sounds pretty fundamental, but we’ve all seen those behaviors from our colleagues. Some of us may even have participated in them. By engaging everyone on the team, we support each other and make errors much less likely.

At a session presented by the health care safety consulting firm HPI, the speaker quoted data published in 2004 about perceptions of teamwork. In a survey of operating room personnel about teamwork, 75 percent of surgeons rated teamwork as “high” (e.g. surgeons felt the team worked well together.) You may be reading this thinking, ‘I’ve seen bad behavior in others but I’m one of the good ones—my team works like a well-oiled machine.’ Just remember that we are not always the best and most accurate judges of how we are perceived by others. The responses of other team members to the same survey question are telling. Thirty-nine percent of anesthesiologists surveyed reported that teamwork was “high.” Just 28 percent of surgical nurses rated teamwork as “high” and nurse anesthetists came in at a slightly less enthusiastic 25 percent. Surgical residents were the toughest critics, with just 10 percent of residents describing the level of teamwork as “high.”

The same study gives some hints as to what might influence team members’ perceptions of the team. The survey found that 50 percent of surgeons felt junior team members should not question senior physicians (though, as a surgeon, it pains me to share this finding.) That attitude probably reflects the failure of physicians to understand that working as part of a team doesn’t mean rule by committee. No one suggests that surgery should be done by consensus after discussion by all members of the team. Teamwork does require mutual trust and respect and a shared expectation that any member of the team has an obligation to speak up if he or she believes an error is imminent or sees some potential for patient harm. It should be clear to all that good communication is not a challenge to anyone’s authority.

While I hope I’ve argued persuasively that physicians play a critical role in nurturing true collaboration, I also want to be clear that I think it’s time to move beyond simplistic and pejorative terms such as “disruptive physician.” Anyone can disrupt the smooth functioning of the team and potentially harm the patient, and anyone disrupting good care should be held accountable. No individual has all the knowledge required to take care of patients in an exceedingly complex medical care environment. Rather than resenting suggestions about care or questions that clarify issues, we should all welcome support from our teammates and offer such support in kind.
Collaborative care within the health care team
Created: January 1, 2010

The North Carolina Medical Board (“the Board”) recognizes that the manner in which its licensees interact with others can significantly impact patient care.

The Board strongly urges its licensees to fulfill their obligations to maximize the safety of patient care by behaving in a manner that promotes both professional practice and a work environment that ensures high standards of care. The Accreditation Council for Graduate Medical Education highlights the importance of interpersonal/communication skills and professionalism as two of the six core competencies required for graduation from residency. Licensees should consider it their ethical duty to foster respect among all health care professionals as a means of ensuring good patient care.

Disruptive behavior is a style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care. Behaviors such as foul language; rude, loud or offensive comments; and intimidation of staff, patients and family members are commonly recognized as detrimental to patient care. Furthermore, it has become apparent that disruptive behavior is often a marker for concerns that can range from a lack of interpersonal skills to deeper problems, such as depression or substance abuse. As a result, disruptive behavior may reach a threshold such that it constitutes grounds for further inquiry by the Board into the potential underlying causes of such behavior.
Behavior by a licensee that is disruptive could be grounds for Board discipline.

The Board distinguishes disruptive behavior from constructive criticism that is offered in a professional manner with the aim of improving patient care. The Board also reminds its licensees of their responsibility not only to patients, but also to themselves. Symptoms of stress, such as exhaustion and depression, can negatively affect a licensee’s health and performance. Licensees suffering such symptoms are encouraged to seek the support needed to help them regain their equilibrium.

Finally, licensees, in their role as patient and peer advocates, are obligated to take appropriate action when observing disruptive behavior on the part of other licensees. The Board urges its licensees to support their hospital, practice, or other health care organization in their efforts to identify and manage disruptive behavior, by taking a role in this process when appropriate.