By Victoria Stern

During a routine procedure, something goes awry. The patient is bleeding, but not at the surgical site. The OR team needs to act quickly to make a differential diagnosis and stabilize the patient.

Problem solving in a crisis situation like this one often comes down to how well the team communicates.

“Poor communication lies at the heart of so many medical errors,” said Daniel Katz, MD, an associate professor of anesthesiology and perioperative and pain medicine at the Icahn School of Medicine, Mount Sinai Hospital in New York City.

A 2015 report, for instance, identified almost 7,200 malpractice cases between 2009 and 2013 in which communication failures harmed patients, leading to almost 2,000 patient deaths and $1.7 billion in malpractice costs.

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“We wanted to know how incivility in the OR, in particular, impacts the team’s ability to communicate and deliver safe care in an emergency,” Dr. Katz said.

To address this issue, Dr. Katz and his colleagues examined the performance of anesthesiology residents in a standard simulated scenario of occult hemorrhage (BMJ Qual Saf 2019 May 31. [Epub ahead of print]). The researchers randomly assigned 76 anesthesiology residents to either a normal or “rude” simulated environment, and viewers graded several performance measures, including vigilance, diagnostic ability, communication and patient management. Residents also assessed their own performance.

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In the rudeness group, an actor portraying a surgeon behaved impatiently with the OR team but did not use inappropriate language, scream or become physically intimidating. In the control scenario, the actor surgeon was courteous. Participants rated the perceived realness of the scenario and surgeon in both cases to be high. To avoid bias, the study controlled for a variety of factors: The graders and participants did not know the study’s purpose; the simulation occurred at three hospitals in different states; and the video recording blurred the participants’ faces and adjusted the pitch of their voices so graders could not identify sex.

The results, Dr. Katz said, “were startling.”

Residents exposed to incivility scored lower on every performance metric than those in the control group. In the rudeness scenario, 63.6% performed at their expected level compared with 91.2% in the control group.

“In other words, more than one-third of residents in the intervention group failed their performance assessment,” Dr. Katz said. This group often did not administer IV fluids, call for more blood to the OR, or discuss the differential diagnosis with the surgeon.

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Dr. Katz found that incivility was the key factor that influenced performance. Rudeness, he explained, can create a “culture and cycle of being afraid to speak up and performing poorly, which is likely amplified in a crisis situation.”

Dr. Katz noted that the study is limited by the simulated environment and may oversimplify a team dynamic that “in real life is nuanced and complex,” but supports the existing body of evidence that “behavior in the workplace can affect the performance of those around them.”

Recently, for instance, Arieh Riskin, MD, MHA, and his colleagues published several studies that underscored this association between poor behavior and medical team performance. A 2015 study found that rude comments from an outside expert in a simulated environment had a negative impact on the performance of a neonatal ICU team, most notably in their ability to diagnose, work collaboratively and communicate (Pediatrics 2015;136[3]:487-495). A follow-up study, which evaluated how a parent’s rude comments affected physicians’ performance over a 24-hour period, found that the negative effects lasted throughout the day, which included four simulated scenarios (Pediatrics 2017;139[2]:e20162305).

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“The rude comments disrupted the medical team’s performance diagnostically and technically,” said Dr. Riskin, the director of the neonatal ICU at Bnai Zion Medical Center in Haifa, Israel.

Conversely, the researchers also found that patients’ expressions of gratitude to physicians significantly improved performance, although not to the same extent that negative behaviors harmed the team dynamic (Pediatrics 2019;143[4]:e20182043).

In terms of curbing the negative effects of rude behavior, Dr. Riskin believes that physicians need to look more closely at how they give feedback and interact with others in the medical world.

“Increasing awareness is the first step,” Dr. Riskin said. “It’s important to remember that we are not robots; we are human beings. If physicians, patients and families know that negative comments could endanger the patient, they may behave better.”

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Dr. Katz added that researchers don’t yet know the extent to which rude behaviors affect burnout and physician satisfaction at work, but health care providers should focus on developing better coping mechanisms to deal with pent-up stress, and medical schools and residency programs should teach physicians about appropriate behavior, especially during an emergency.

“It’s interesting that it takes a multicenter randomized controlled trial to demonstrate that we should be nice to each other,” Dr. Katz said. “The safety implications could mean life or death in the OR.”