Nontechnical skills, such as effective communication in the OR, can enhance patient safety.
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AAOS Now

Published 12/1/2014
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Dwight W. Burney, MD

The Missing Link in Safety and Quality

Recent reports in the orthopaedic and medical literature have cast orthopaedics in an unfavorable light. Consider the following examples:

  • A review of Medicare Patient Safety Monitoring System data showed no decrease in adverse events for patients who required surgery between 2005 and 2009; a significant portion of this study population was orthopaedic patients.
  • A recent article in The Journal of Bone and Joint Surgery suggested that 60 percent of adverse events in surgery were caused by technical errors.
  • Another study of perioperative deaths in orthopaedic surgery patients showed that deficient nontechnical skills (communication and teamwork, leadership, decision making, and situation awareness) were a factor in 44 percent of perioperative deaths.
  • A report on patient experience scores differentiated by specialty in a large multispecialty group showed orthopaedic surgeons with the lowest scores of any specialty on the “Physician Communication” domains (P < 0.001).
  • A systematic review of the literature on surgeon-patient communication found the greatest opportunities for improvement were in using empathy and exploring patients’ concerns and anxieties about their ability to successfully undergo surgery.

As orthopaedic surgeons, we know that patients want to be treated with respect. We also know that most of the information necessary to make an accurate diagnosis can be found in the patient’s history. Yet we continue to interrupt the patient’s “story” in our haste to arrive at a differential diagnosis.

Our failure to hear the patient out is seen as uncaring and disrespectful. Our failure to use empathic techniques keeps us from picking up on clues the patient gives us about his or her fears and anxieties. We often resort to using blocking behaviors such as premature reassurance, discounting pain/discomfort, inappropriate humor, or ignoring clues or deflecting them because we fear “opening the floodgates” and are uncomfortable dealing with emotional issues.

These defensive behaviors on our part interfere with patient-centered care and shared decision making. They also cast doubt on the adequacy of our surgical consent forms, particularly those used with people who have lower education levels or limited English proficiency.

In surgery, deficient nontechnical skills can erode performance by even the most technically gifted surgeon. Although surgeons are very accurate in assessing their technical skills, they consistently overestimate their nontechnical skills. Luckily, nontechnical skills can be assessed and successfully taught.

Addressing the problem
During the 2015 AAOS Annual Meeting in Las Vegas, the following CME courses addressing surgeon–patient communication and nontechnical skills are being offered:

  • Nontechnical Surgical Skills: What Are They, Why Do They Matter?—a 2-hour instructional course lecture (ICL) (Tuesday, March 24)
  • Shared Decision Making and Informed Consent: Understanding the Goals and Responsibilities of the Orthopaedic Surgeon—a 2-hour ICL focused on patient care and shared decision making (Tuesday, March 24)
  • TeamSTEPPS® Fundamentals—two programs, each 4 hours, designed to improve team performance and enhance patient safety through an evidence-based system of structured communication tools and strategies (Wednesday, March 25)
  • Clinician-Patient Communication—two 4-hour workshops presenting tips and tools to support patient-centered care and shared decision making (Wednesday and Thursday, March 25–26)
  • The Basics of Effective Surgeon-Patient Communication—a free 1-hour course as part of the faculty development sessions (Friday, March 27)
  • Residency Core Competencies and Surgical Tips and Tricks—a free symposium especially for residents (Friday, March 27)

If you have experienced frustration with your patient encounters (or patient experience scores), or if you wonder how you could make your operating room (OR) function more smoothly, consider attending one or more of these sessions. Communication and teamwork skills can be learned and improved. By improving your skills, you will have much greater satisfaction and a greater sense of control in your clinic and/or your OR as well as a safer, more satisfactory experience for your patients.

Dwight W. Burney, MD, is a member of the AAOS Patient Safety Committee; he can be reached at dwightburney119@gmail.com

References:

  1. Wang Y, Eldridge N, Metersky ML, Verzier NR, Meehan TP, Pandolfi MM, et al. National Trends in Patient Safety for Four Common Conditions, 2005-2011. N Engl J Med 2014; 370:341-351January 23, 2014DOI: 10.1056/NEJMsa1300991
  2. Westerlind B, Karam M, Anderson D, Yehyawi T, Kho J, Marsh JL. A Surgical Skills Training Curriculum for PGY-1 Residents. AAOS Exhibit Selection. J Bone Joint Surg Am. 2014;96:e140(1-6)
  3. Panesar SS, Carson-Stevens A, Mann BS, Bhandari M, Madhok R. Mortality as an indicator of patient safety in orthopaedics: Lessons from qualitative analysis of a database of medical errors. BMC Musculoskeletal Disorders 2012, 13:93. Accessed online.
  4. Quigley DD, Elliott MN, Farley DO, Burkhart Q, Skootsky SA, Hays RD. Specialties Differ in Which Aspects of Doctor Communication Predict Overall Physician Ratings. J Gen Intern Med 2014 Mar;29(3):447-54. doi: 10.1007/s11606-013-2663-2. Epub 2013 Oct 26.
  5. Levinson W, Hudak P, Tricco AC. A systematic review of surgeon–patient communication: Strengths and opportunities for improvement. Patient Educ Couns. 2013 Oct;93(1):3-17. doi: 10.1016/j.pec.2013.03.023. Epub 2013 Jul 16.
  6. Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ. Sep 28, 2002; 325(7366): 697–700.
  7. Ankuda C, Block SD, Cooper Z, Correll DJ, Hepner DL, Lasic M, et al. Measuring critical deficits in shared decision making before elective surgery. Patient Educ Couns. 2014 Mar;94(3):328-33. doi: 10.1016/j.pec.2013.11.013. Epub 2013 Dec 11.
  8. Siu J, Maran N, Paterson-Brown S. Observation of behavioural markers of non-technical skills in the operating room and their relationship to intra-operative incidents. Surgeon. 2014 Jul 9. pii: S1479-666X(14)00075-4. doi: 10.1016/j.surge.2014.06.005. [Epub ahead of print]
  9. Arora S, Miskovic D, Hull L, Moorthy K, Aggarwal R, Johannsson H, et al. Self vs expert assessment of technical and non-technical skills in high fidelity simulation. Am J Surg. 2011 Oct;202(4):500-6. doi: 10.1016/j.amjsurg.2011.01.024.
  10. McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care. 2009 Apr;18(2):109-15. doi: 10.1136/qshc.2008.032045.