By Wendy Anson, Ph.D.
These are some of the perceptions of nurses and physicians who responded to a 2005 survey regarding disruptive behavior and clinical outcomes.
“Adverse event related to med error because MD would not listen to the RN.”
“RN did not call MD about change in patient condition because he had a history of being abusive when called. Patient suffered because of this.”
“Cardiologist upset by phone calls and refused to come in. RN told it was not her job to think, just to follow orders. Rx delayed. MI extended.”
“Difficult endoscopy. Physician angry, frustrated, abusive to patient and technician. Patient safety compromised.”
“Communication between OB and delivery RN was hampered because of MD behavior. Resulted in poor outcome in newborn.”
“MD yelled at RN for calling at night, patient condition not addressed, resulting in a negative patient outcome.”
“RN called MD multiple times re: deteriorating patient condition. MD upset with RN calling. Patient eventually had to be intubated.”
“RNs did not want to call MD after IV ran out. No antibiotic therapy for four days. RN afraid to call MD. Patient expired.”
“Poor communication postop because of disruptive reputation resulted in delayed treatment, aspiration, and eventual demise.”
“It’s not surprising given what we know about communication processes, that faulty messaging would be a key contributor to medical errors,” said Dr. Bill Riley, director of the National Institutes of Health Office of Behavioral and Social Sciences Research (OBSSR), about recent headlines cropping up in medical journals and the popular press alike.
“Those communication complexities are typically under-appreciated by medical health professionals and everyone else,” Riley said.
Johns Hopkins University’s clinician–researchers reported in May that medical errors were the third leading cause of death in the United States; more than 250,000 Americans die each year for this reason. According to the researchers, the rate of death from medical errors ranks just below heart disease and cancer on the Centers for Disease Control and Prevention (CDC) leading causes of death.
A study conducted by Milliman, Inc. researchers and funded by the Society for Actuaries in 2010 claimed that the economic impact of these preventable deaths ranges from $735 to $980 billion. Meanwhile, Andel and colleagues estimated that when quality-adjusted life years are applied to those that die expenditures soar to nearly $1 trillion annually.
“My pager has gone off five times in the past 15 minutes, while I’ve been trying to take Mr. Jones’s history. I can't keep his complicated history straight.”
“I just got called by the nurse about Ms. Davis, who is hypotensive. All I know about her from the sign-out information is that she is an 82-year-old woman with a urinary tract infection who is scheduled to go home tomorrow. The information does not indicate her code status.”
“I was on call yesterday, and I can't keep up with all the details on our team’s new patients. Other caregivers are doing things for our patients that we didn’t know about. The two interns I supervise duplicate work and neglect important issues.”
“The nurse couldn’t read my writing and gave the patient 10 mg of morphine instead of 1 mg. Now Mr. Smith is over sedated and needs naloxone stat.”
Volpp, K. G, Grande, D. M.D. Residents’ Suggestions for Reducing Errors in Teaching Hospitals. N Engl J Med 2003; 348:851-855
A medical mistake can mean everything from stomach operation complications that go unnoticed, to giving a patient her roommate’s medicine instead of her own, to removing the wrong foot during an operation. As the Institute of Medicine would have it, an error in the medical setting is the “failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning).”
Misinterpretation of information, unclear orders over the telephone, or even a colleague’s reputation for verbal abuse can all lead to medical errors. In their research, Rosenstein and O’Daniel documented an instance where a physician’s reputation for aggressive interactions was seen as delaying patient-related questions to the doctor, leading to a patient’s preventable demise.
“The other day, we had an arrest and we had been talking at the handover only 2 hours before, ‛Is this patient blue-spotted?’, and she [nurse giving the handover] said I don't know, we ought to find out. And just as the arrest was taking place, nobody knew (p. 254).”
Davey, B. Do-not-resuscitate decisions: Too many, too few, too late? Mortality, 6 (2001), pp. 247–264
The OBSSR is the unit at the NIH specifically charged to lead research efforts looking into and behind the kind of behavioral and social processes underlying societal health mechanisms, including the way medical care is ordered up and then delivered.
“‘Behavioral,’” Riley explains, “refers to overt actions; to underlying psychological processes such as cognition, emotion, temperament, and motivation; and to bio-behavioral interactions. The term ‘social’ encompasses a range of interactions, including sociocultural, socioeconomic, and sociodemographic. It includes small groups and complex cultural and societal levels of influence.”
How does the OBSSR address these types of communication failures which have such dire consequences?
“In one recent effort, we got teachers and program directors from key medical schools across the country to come and demonstrate how ten years of NIH-funded research contributed to working curriculum models,” said Riley. “These teaching innovations integrated key behavioral and social skills, including communication, for the most effective on-the-ground doctor-patient practice.”
The Behavioral and Social Science Consortium for Medical Education convened the workshop, “Integrating Behavioral and Social Sciences (BSS) into Health Education” last April.
Organizer of the event and American Association for the Advancement of Science (AAAS) Science and Technology Policy Fellow Lauren Fordyce explained that physicians should be well acquainted with theories and methods of behavioral change in order to improve their patients’ health outcomes. “Two of the areas we focused on were reflective awareness and practice innovations in physician-patient communication.”
As a matter of fact, the medical education establishment has itself taken heed of the value of a doctor’s biopsychosocial skills. The Institute of Medicine mandated that medical students should “… be provided with an integrated curriculum in the behavioral and social sciences throughout the four years of medical school.”
“He [the medical resident] filled only the first dose and told the evening nurse: “make sure the next shift knows about this.” But that communication never happened, either on the physician’s side or the nurse’s side. The problem was not discovered until the patient had a toxic reaction; she spent three to four days in a severely toxic state.”
Chassin, M. “Joint Commission Touts Research on Reducing Handoff Failures.” In: Clark C, editor. Chassin M. HealthLeaders Media; 2010.
The workshop’s panelists shared research results and disseminated best practices and successes from over ten years’ worth of OBSSR-funded studies from medical schools coast-to-coast. Researchers and researcher-clinicians arrived from schools including Stanford, University of California San Francisco, Columbia, Einstein, University of Texas, Harvard, University of North Carolina. Program directors described how they successfully embedded behavioral and social sciences curricula into medical students’ and residents’ education and training and taught research-based techniques in shared decision-making, obtaining patient consent, and effective intra-hospital and interdisciplinary teamwork skills.
At Columbia Medical School’s Narrative Medicine Program, innovator, psychiatrist and literature scholar Dr. Rita Charon concentrates on the “special, intimate encounter between a health provider and someone who is ailing.” She inspires her students to “listen, recognize, absorb, interpret and be moved to action by the stories of illness.” The experience is “always relational, always inter-subjective.” The two people in the room (patient, doctor) “together co-construct that which is thought to be the problem” and “the practice is always committed to social justice in that everyone deserves this kind of fully focused care,” Charon said.
Einstein College of Medicine introduced the evidence-based Choosing Wisely curriculum in which students practiced effective communication skills with patients. Program directors pointed out that death can be an uncomfortable topic with doctors, leading to important missed opportunities with their patients. At University of North Carolina and Wake Forest schools of medicine, medical students write their own “illness metaphors,” focus on critical reflection, and explore the question, “to whom does death belong?”
The Economics of Health Care Quality and Medical Errors. Journal of Health Care Finance, Vol. 39, No. 1, Fall 2012, Wolters Kluwer Law & Business
Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula. Institute of Medicine (US) Committee on Behavioral and Social Sciences in Medical School Curricula; Cuff PA, Vanselow NA, editors. Washington (DC): National Academies Press (US); 2004.
Medical Error—The Third Leading Cause of Death in the US
Making Health Communications Programs Work
NIBIB, Enhancing Nurse Decision-Making via Augmented Communication Tools (ACT), Grant # 5R01EB020395- 03, PI Jane Carrington, University of Arizona, Fiscal Year 2013
NINR, Conversational Agents to Improve Quality of Life in Palliative Care,
Grant, #R01 NR016131-01, PI Michael Paasche-Orlow, Boston Medical Center, FY 2016–2010
NCI, Advancing Health Communication Research through the KCHC-DCHC Conference Series, Grant # 5R13CA168316-05, PI Nancy Grant Harrington, University of Kentucky, FY 2014–2016
Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.
Doctor–Patient Communication About Drugs: The Evidence for Shared Decision Making
Rosenstein A, O’Daniel M. Disruptive Behavior and Clinical Outcomes: Perceptions of Nurses and Physicians. Am J Nurs. 2005 Jan;105(1):54–64.
