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|2013 YP Award Essay 1|
2013 Winner - Essay 1
The Doctors Company Foundation Young Physicians Patient Safety Award
We were in the OR about to start an operation to remove a massive tumor from our patient’s abdomen. The patient was an older woman with a significant cardiac history. Were it not for the sheer magnitude of this tumor and the risk it posed for her health, she would never been a surgical candidate because of her severe cardiovascular disease.
Before the operation began, the attending surgeon asked the anesthesiologists to place a central line because the tumor had been compressing her abdominal vasculature for several years, and resection would remove this compression, rapidly increasing blood flow to her heart which could overload her cardiac capacity. The surgeon wanted a central line to prepare for the worst. The anesthesiologist appeared frustrated and told the surgeon that she could place a central line as needed if the patient deteriorated. The anesthesiologist had just placed two peripheral lines, both of which required ultrasound guidance. These were not large bore IVs but the anesthesiologist thought them sufficient in size for the operation.
The conversation between the surgeon and anesthesiologist was strained and I felt uncomfortable with their communication. The surgeon seemed aggressive in her manner of asking for the central line, and the anesthesiologist seemed defensive and appeared to take offense at the surgeon’s tone. The surgeon was not satisfied with the peripheral IVs, but deferred to the anesthesiologist and began the case. We removed a 44-pound tumor from our patient’s abdomen.
Just as the surgeon had predicted, the patient began having changes on her EKG consistent with myocardial infarction when her vasculature was decompressed. The anesthesiologist stopped our operation while they tried to stabilize the patient. Our patient had a massive heart attack on the table. The anesthesiology team placed a central line to quickly administer medications and fluids, which took several minutes. The surgeon scoffed and rolled her eyes when anesthesia was struggling to place the line. Although we were able to remove the tumor, we were unable to perform the rest of the operation due to the patient’s unstable condition.
The ineffective communication between the two doctors led to a poor outcome for the patient. The surgeon came off as bossy and like she was telling the anesthesiologist how to do her job. The anesthesiologist did not seem to hear what the surgeon was asking for, but solely responded to her tone, and did so in a defensive manner. The rest of the team in the OR felt uncomfortable with the conversation and no one intervened on behalf of the patient. I felt awkward because it seemed reasonable to have a central line placed, and yet the conversation was so strained that this suggestion was never really addressed. It was more about who was right and who had control over the situation. What could have been a relatively straightforward discussion about what was best for the patient was elevated to a power struggle between two physicians. It is hard for me to know why this adversarial relationship develops when both professionals are well educated and are both caring for the same patient. I do believe that the style of communication one uses definitely affects how others respond and, in the case of medical professionals, patient safety. Unfortunately, in this case I do think the poor communication between the caregiving teams led to a worse outcome for the patient.
This extremely vivid incident made me think about how communication with other professionals impacts patient safety. There is a significant body of literature about health professional communication and health care outcomes, from medical errors to patient satisfaction. One meta-analysis of studies of OR communication found three publications documenting the relationship between communication and patient outcome. These studies demonstrated a link between how the team communicates in the OR (how frequently, what type of info, type of environment) and patient morbidity and mortality(1). The less frequent the communication and the more hostile the environment, the worse the outcome for the patient. Another study measured communication in the OR and found that of 421 conversations observed in the OR, 129 were classified as failures. Failure in this study meant the communication event was marred by poor timing, inaccurate information, issue not resolved, or exclusion of key team members from the conversation. Of these failures, almost 40% resulted in “visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error”(2). Furthermore, another study provided a communication intervention between anesthesiologists and surgeons in the OR, where the weaknesses were pointed out and training was provided to improve relations. Initially, the surgeons rated communication between the teams as good, nurses rated the same scenarios as adequate and anesthesiologists thought the communication was poor, demonstrating a major disconnect in perception and teamwork. They clearly were not on the same page. The intervention showed significant improvement from baseline observations in quality and safety of the patient care, and the perceptions of communication were more unified throughout the team members(3).
My experience thus far in my third year has taught me a great deal about navigating personalities and fitting in with teams in different settings. Part of fitting in well requires observing the team and their interactions with others. Outside of the OR, I have certainly seen instances of less than ideal communication. From my limited experience, it seems that these failures of communication stem from a lack of perspective, incorrect assumptions about each other, or the need to be right and feel in control. I think successful teamwork in health care necessitates putting the patient first and leaving egos out of the picture. The hierarchical nature of the medical profession sets us up for these power struggles, however. It is natural to be resentful of those at the top of the hierarchy, making communication that much more difficult. This experience in the OR reminded me of how crucial communication is to patient safety, and, in my career, I plan to address this by prioritizing patient care over my own agenda, and reminding all members of the health care team of our duty to the patient.
*Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.