July is right around the corner, and the fear of the July Effect associated with being admitted to a teaching hospital in the month when a newly minted doctors are just starting residency is probably again running rampant. Not all teaching hospitals have an uptick in mortality rates; it depends on how vigilant our supervising practices are.
Our traditional teaching methods are still pretty much based on the master and apprentice model. In that hierarchy, trainees can be vulnerable to feeling intimidated and may be less likely to point out mistakes the attending might make. Attendings might be vulnerable to believing they are invulnerable.
My trainees include junior residents and medical students and I consider them my copilots. Last week I asked them for their ideas on how to manage a difficult patient issue and I told them I remembered hearing about some airplane disasters being caused by the reluctance of copilots to speak up to their pilots even when they became aware the pilots were making dangerous errors in judgment. Preventable medical errors are still an important cause of death to patients in hospitals.
The cockpit culture has changed quite a bit in recent years. The P.A.C.E. steps are part of a Crew Resource Management methodology on airplanes which are designed to promote safety for travelers:
Probing for a better understanding;
Alerting Captain of the anomalies;
Challenging suitability of present strategy;
Emergency Warning of critical and immediate dangers.
In a similar vein, The University of Iowa Hospitals and Clinics has a Stop the Line procedure for keeping patients safe:
The policy at our hospital is called “Protection of Patient Safety: Stop The Line” which is “the empowerment of all staff members to clarify or interrupt a process when a potential risk to patient safety is perceived.” This encourages all members of the healthcare team to speak up whenever something is perceived to be inconsistent with safe practices. This helps draw attention to the potential problem so that all stakeholders can acknowledge the concern and address it. There is even a funny acronym for it: C-U-S-S:
Concern: I need to communicate my concern
Understanding: “I don’t fully understand the process here”
Safety: “I believe patients’ safety might be placed at risk”
Stop: “Please stop and let’s review the process together.”
I suppose some trainees would like to cuss the boss at times. I guess that could work the other way around. It takes a bit of courage to challenge the leader’s authority and vestiges of the kind of subordinate culture discussed in the article about P.A.C.E. can be found in suggestions about how to approach the leader in a diplomatic way:
- Pick your spots. Use your credibility wisely. Play the naysayer too often, and you’ll be tuned out.
- Don’t embarrass your boss. If possible, speak privately. He or she may be less defensive about reversing direction if there isn’t an audience.
- Think twice about recruiting others to help deliver your message. Your boss might wonder what sort of trouble you’ve been stirring up behind his or her back.
But we don’t want to tiptoe around the grayheads when patients’ safety is at stake. July is just around the corner. Don’t be afraid to put in your two cents.