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Published 2/1/2019

Patient Safety Committee Discusses How Professionalism Can Limit Psychological Harm

Editor’s note: The AAOS Patient Safety Committee supports the development, validation, and dissemination of culture and processes that improve orthopaedic surgical safety and inform Academy policy regarding these issues. If you have questions related to the content presented in this roundtable discussion or patient safety in general, please email patientsafety@aaos.org.

Many medical errors and harms can be traced to ineffective communication and poor team dynamics, which are issues of professionalism. Recently, the definition of harm has expanded to include psychological harm, which also can occur with inadequate communication, etiquette, or virtue.

The AAOS Patient Safety Committee addressed the advantages and disadvantages of “professionalism” as a framework for emphasizing the importance of surgeons receiving training and practicing these essential skills in order to avoid psychological harm in the current high-paced practice environment.

This discussion occurred during a recent patient safety roundtable at the AAOS headquarters in Rosemont, Ill. David Ring, MD, PhD, chair of the Patient Safety Committee, served as the moderator. Other participants included Andrew W. Grose, MD; Dwight W. Burney III, MD; Michael Marks, MD, MBA; Michael S. Pinzur, MD; and Nina R. Lightdale-Miric, MD.

Dr. Ring: You could think you’re championing quality and safety by saying, “I’m a champion of professionalism,” yet you may be conveying, “I’m the champion of getting rid of bad apples or disciplining them.” It’s difficult to think of a new label for professionalism without the concepts of etiquette and virtue. As with all quality and safety endeavors, we benefit from expecting imperfect behavior and planning for room to learn and grow. There should be no shame and no surprise that we have room to learn, train, and improve our communication skills.

Dr. Grose: When we throw professionalism down, that can feel like walking into a blame culture. Labeling someone’s behavior as unprofessional may be the equivalent of saying, “You did something wrong.”

The biggest problem with the concept of professionalism is the implication that you’re going to be punished for your behavior. Safety is about a learning culture where the questions are, “Why did you come at it from that direction? Why did that make sense to you?” and “How did you, in the context of your world, get into that place?” When we say, “It’s a professionalism problem,” it’s often a euphemism for “that’s a bad apple.”

Dr. Burney: I’m not convinced of the value of framing a surgeon’s self-awareness, emotional intelligence, and interpersonal skills as a matter of professionalism. How can we draw needed attention to ethics and virtue?

Dr. Marks: It may be similar to when people say, “Well, he just needs to work on his bedside manner.” We could all improve our communication strategies, but this statement is typically not about a growth mindset and taking advantage of one’s opportunities. It seems more like a judgment about a person’s character.

Dr. Pinzur: Another way to think of professionalism is in the context of the morbidity and mortality conference. Where we used to look for someone to blame, we now look for system fixes. We need to get away from blame. Blame doesn’t lead to correction.

Dr. Ring: That may be particularly true for surgeons. By the nature of the work we do, we have a certain degree of stress immunity and low cognitive empathy, which help us run toward danger and take care of problems that the average person could not approach, such as an open fracture, severe infection, or traumatic amputation. The key is in understanding where our opportunities lie (conscious incompetence) and seeing the importance and value of working on them.

Dr. Lightdale-Miric: I have another thought about how surgeon nontechnical skills such as self-awareness, humility, emotional intelligence, and a growth mindset might improve quality, safety, and efficiency. What do you think it would take to get every surgeon to self‑report more of their own safety data?

Dr. Grose: Even pilots say they have no idea what happens with all the information they report or track.

We have a problem with reporting things that are meaningful, and we have a problem discerning signal from noise. We need to watch a process happen, learn what was good and bad about the process, and determine how the people involved in the process learn from it. If we collect meaningful data and use it in an impactful way, surgeons will participate in reporting and data collection.

Dr. Ring: Maybe that’s what professionalism looks like at the level of the institution. When the leadership reviews the quality data after there is a push for consistent reporting, they might say, “I don’t want to have a high error rate; get rid of that.” Or they might say, “Hey, when we’re honest and transparent, look at all the opportunities to learn that are identified.” Another way this might manifest is when somebody says, “You’re not professional enough,” they might be saying, “You’re screwing up my hospital’s score sheet again,” rather than saying, “Hey, that patient deserved more respect.”

Dr. Pinzur: Our institution initiated a medical optimization program that improved quality. We got people healthier prior to elective surgery. After administrators said, “It’s too expensive,” and cut it back, we saw our readmission and complication rates increase. When we showed them the data, they restored the program, and the metrics improved.

Dr. Ring: If institutions are expected to learn and grow, we should expect the same for individuals.

Dr. Grose: Most of the time, we do production, which is what we should be doing. Safety comes from knowing when to halt production. It can be disingenuous to say, “Safety first.” What we do is production as safely as we can.

Dr. Ring: That might be considered “drift” on an institutional or cultural level.

Dr. Grose: Exactly. We have to be honest about that and say, “How can we do this as safely as possible?” That’s where safety isn’t about compliance. Safety is about creativity and understanding where you are. That’s where checklists can be useful.

Dr. Ring: This exchange has been a useful discussion of surgeon nontechnical skills. It seems most of us feel there is a negative connotation to the word professionalism. We prefer a focus on etiquette (interpersonal skills) and virtue (humility, collaboration, self-awareness). The key seems to be a growth mindset. Adverse events and errors are expected, not evidence of flaws. And etiquette, virtue, and a growth mindset apply to groups and institutions as much as to individuals.