You’re in the operating room, with a resident beside you, and your clinical decisions are harming the patient. Does your resident have the wherewithal to stand up to you and intervene?
While the answer seems to be a resounding no, a study by a multicenter Canadian research team offers hope. The investigation showed that a short, targeted teaching intervention can prove both effective and clinically meaningful in significantly improving residents’ ability to challenge a wrong decision made by a superior. Incorporating similar interventions into residency curricula may help address this problem and improve teamwork during crisis management.
“The problem with professional hierarchy was first discovered in the aviation industry about 40 years ago,” said Zeev Friedman, MD, associate professor of anesthesia at the University of Toronto.
“A United Airlines flight [UA173] circled the airport for about two hours before crashing due to lack of fuel.” A subsequent investigation showed that junior crew members were unable to communicate the severity of the problem to the captain.
Blood for a Jehovah’s Witness
“So we decided to look at what’s happening within our own culture, which is probably as hierarchy-oriented as aviation,” Dr. Friedman said. “In our first study [Can J Anaesth 2015;62:576-586], we presented residents with staff who asked them to give blood to a Jehovah’s Witness. We found that 92% of them agreed to administer blood. We were obviously surprised with that result.”
Beyond questions of ethics, effective communication can have profound effects on patient outcomes, but never is this more obvious than in crisis situations. With that in mind, Dr. Friedman and his colleagues sought to assess whether a teaching intervention could change residents’ ability to effectively challenge an obvious clinical error made by a superior during a simulated life-threatening scenario.
Fifty second-year residents completed the trial. Half were randomly assigned to receive a teaching intervention that targeted the cognitive and interpersonal skills needed to monitor and challenge a superior’s decision. The teaching intervention was composed of four crisis-resource management tools:
the Five-Step Assertive Statement Process (address by title, state there is a problem, describe the problem, state an alternative course and seek approval to change course);
the Two-Challenge rule (in which staff challenge the directive in question not once but twice);
the Concerned-Uncomfortable-Safety communication tool (in which one states they are concerned about a situation, are uncomfortable with it and the safety of the patient may be at risk); and
a Describe-Explain-Share-Compromise conflict resolution and assertiveness script.
A control group received general instructions on crisis management.
Two weeks later, all of the residents participated in a simulated life-threatening “can’t intubate/can’t ventilate” crisis that was separate from the teaching sessions. During the crisis, the residents were presented with five distinct points at which they could challenge staff regarding a clearly wrong decision.
Deliberate deception was used during the simulation: Residents were told that staff/resident teamwork was being evaluated. Performances were recorded on video and later assessed and scored by two trained raters using the modified Advocacy-Inquiry Score.
“The results are clear,” Dr. Friedman said in reporting the study at the 2016 annual meeting of the Canadian Anesthesiologists’ Society (abstract 140763). “The control group did fairly poorly and was unable to effectively challenge the staff in a way that would change management.
The intervention group, on the other hand, used techniques that would most likely result in change of the management of the patient.”
Indeed, the median modified Advocacy-Inquiry Score result across all challenging opportunities was significantly higher in the intervention group (5.0; range, 4.50-5.62) than in the control group (3.5; range, 3.0-4.75). All trainees had comparable experience participating in simulations; the interrater reliability of the modified Advocacy-Inquiry Score was excellent.
Yet as Alain Deschamps, MD, PhD, pointed out, the intervention will only affect clinical practice if its effects endure. “You did the intervention and then you did the study two weeks later,” he said, who is chief of anesthesiology at the Montreal Heart Institute. “How do you think it would be if you performed the study six months or a year later?”
“I think the simulation itself branded a particular way of thinking into the residents,” Dr. Friedman replied. “I think they would be able to have the situational awareness, recognize that they need to intervene and have the tools to do so. And I would hope that we gave them those tools and they would be able to use them, no matter how much time had passed.”