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Sunday, March 17, 2013

Doctor please, not in front of the patient: interdisciplinary teamwork in healthcare

In today's New York Times, oncology nurse and author Theresa Brown highlights the sometimes fraught and always complicated relationship between physicians and nurses.  By drawing attention to the "hierarchical" interaction between these intertwined but very separate professions, she exposes some weighty issues.  These are matters with real consequences - both for those who provide, and those who consume contemporary, high-tech healthcare.  I want to talk about what she leaves out.

But first, here's what I think this accomplished nurse is saying that physicians have to hear. Medicine, if it was ever a solo act, isn't one anymore.  The hospital is a dangerous place.  We need to "expect" one another to make slips and errors - not so we can excuse ourselves, but so that we can see these events coming - before they harm a patient, and help one another by heading them off.  This is the essence of teamwork on behalf of patient safety.  

Changing the culture of an organization is hard work, but changing that of a whole profession is like steering an ocean liner.  Where do we come from, as physicians?  A longstanding "culture of accountability" means that doctors expect perfection of themselves and their colleagues.  That they, alone, must shoulder the burden of hard decisions.  That making a mistake is not merely a technical problem, but also a significant moral failure.  We are in many ways so different from our nursing colleagues that we have trouble understanding one another. Physicians focus on the mechanisms of disease and fixing what is broken.  Nurses respond to the patient who owns the disease, and that individual's overall needs.  Hospital leaders expect nurses, nowadays, to "stop the line" for safety.  They rightly complain that some of us physicians never go the memo.

On the other hand, many hospitals and Health Systems like ours have embraced team training.  We study and practice the language and techniques of highly effective teams...we call "huddles," we use checklists, and check backs and safe words that mean "I think we have to pause and figure this out because we're not on the same page." This is a framework adapted from aviation, nuclear power and the military, and applied in the Emergency Department, Labor Suite and Operating Room.  It is slow work, but there is reason to believe that it is stemming the tide of medical errors, a little at a time.
In her Times essay, “Healing the Hospital Hierarchy,” Brown describes an intimating encounter with a senior physician who “seethed” at her, eyeball to eyeball, when she proposed that a bone marrow procedure be delayed until her patient’s potentially serious heart problem could be evaluated.  She adds that “there is no established way for a nurse to resolve” such serious concerns. 

But here’s what Ms. Brown has left out.  First, escalation procedures in many hospitals absolutely encourage and protect the professional who speaks up.  In fact, they demand as much.  Second, intimidating behavior by any team member is verboten.  As a matter of fact, our Code of Conduct refers to it in great detail.  Physicians in our facility have been disciplined for it and privileges have been revoked. 

Finally, mutual understanding must be, well, mutual.  What I mean is that just as doctors need to understand the nurse’s role and hear her perspective, so nurses need to appreciate that most physicians, like most nurses, really ARE there for the patient and that they are committed to doing the right thing.  Therein lies the path to real teamwork – respect all around, and the patient at the center.        

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