Background

Iatrogenesis is an adverse patient condition directly resulting from medical treatment or error, occurring in nearly 4% of hospitalizations with 50% being preventable and 14% resulting in death (Berwick 1999, Brennan 2000).  What is even more concerning is that studies have suggested that this rate is higher in pediatric patients. Research has focused primarily on patient-related factors like age and weight, though it has been suggested that stressors on practitioners can also increase the risk of iatrogenesis.

One study (Suresh 2004) speculated that subtle contextual stressors are linked to iatrogenic events by directly affecting cognitive processing at the level of the individual and communication at the team level. No study, though, has provided empiric evidence to support this. Psychology professionals classify rudeness into three main types: hierarchical rudeness via an authority figure, peer rudeness via other members of the medical team, and client rudeness via patients or their family members. Psychology research, however, shows that the source of the incivility is moot, as they all can cause iatrogenesis.

Clinical Question

What is the effect of practitioner rudeness on rates of iatrogenesis during patient care?

Population

Seventy two NICU professionals were organized into twenty four teams consisting of one physician and two nurses from the same unit from four Israeli hospitals, randomly assigned to teams at the same time and shift of the day as their usual shift and randomly assigned to the control versus incivility conditions.

Intervention

See "other issues" section for details on study

Control

See "other issues" section for details on study

Outcomes

The participant’s individual performance along 4 parameters: diagnostic performance, procedural performance, information sharing and help seeking, on a scale of one to five

Design

Prospective, randomized, double blind trial

Primary Results

  • Rudeness explains 12% of the variance in overall medical performance.
  • Diagnostic and procedural performances are negatively affected by rudeness
  • Rudeness reduced information sharing amongst the physician and nurses, which, in turn, negatively affected their diagnostic performance.
  • Rudeness also reduced help seeking amongst the team members, explaining the reduction in their procedural performance.
  • Overall, rudeness explained 52% of the variance in diagnostic performance and 43% of the variance in procedural performance

Strengths

  • Double blinded study
  • Uses actual clinical teams to best simulate reality
  • Represents the optimal way to assess this factor given that attempting to do this in a real clinical scenario would be unethical
  • Provides empiric data on a previously under-researched topic

Limitations

  • Difficult to know if these results can be applied to actual clinical situations
  • The study only includes four hospitals in one county, questioning its generalizability to the population as a whole
  • Given this study only looks at authoritarian-based rudeness, how would the data correlate  with peer or client rudeness?

Other Issues

Study Details

Participants were enrolled in a one hour simulation session using a NICU mannequin followed by a workshop where members would review their work and develop ideas for performance improvement, led by a NICU attending who stated that he was working with a visiting head of a US based NICU expert in the field. They were then showed a video where the expert explained team reflexivity and how it may be used to enhance team performance. The team was informed that the expert would be watching their interactions via webcam and that the expert wanted to greet them. The experimenter then played a prerecorded message to the participants where he stated that he had observed other groups from different hospitals in Israel and that “he was not impressed with the quality of medicine in Israel”. They then proceeded to the simulation. After ten minutes in the simulation, the expert stated that the staff observed in Israel “wouldn’t last a week” in his department and that “I hope I don’t get sick while in Israel”. They were then given 10-15 minutes to continue their simulation, including the treatment for the patient based off their diagnosis. The physicians were asked to submit their written diagnosis and course of treatment. For the control group, the expert solely stated during the second communication that he hoped that they learned from their experiences. The simulation itself consisted of a case surrounding  a 28-week pre-term infant who at 23 days of life developed rapidly progressing necrotizing enterocolitis. They were asked in phase 1 to identify  (1) the acute deterioration of the patient, presenting as multiple episodes of apnea and bradycardia, (2) to identify the infant’s respiratory failure and shock and respond with ventilation, IV fluids and IV antibiotics, and (3) to diagnose sepsis and/or NEC.  In phase 2, the patient continued to deteriorate due to tamponade from a leaking central line, facing the diagnostic challenge as well as resuscitation and pericardiocentesis.

Author's Conclusions

“Rudeness had adverse consequences on the diagnostic and procedural performance of the NICU team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.”

Our Conclusions

This study, while not without its limitations, is one of the first pieces of literature that provides empiric evidence endorsing a negative effect of rudeness on practitioners and its link to iatrogenesis. The authors provide data that would otherwise be unable to be obtained without the simulation setting. Rudeness appears to have a direct negative impact on information sharing (and thus diagnostic performance) as well as help seeking (and subsequent procedural performance). More research is needed to gain an insight into the different causes of rudeness in the work place and the most efficacious methods for decreasing these situations.

Potential Impact To Current Practice

This study helps solidify the idea that a collaborative workplace where information sharing and help seeking are valued leads to less medical errors

Bottom Line

Rudeness has a direct negative impact on team performance and may lead to iatrogenic harm to patients.

Read More

Read More

Science of Us: Rudeness in Medical Settings could Kill Patients

References

Berwick DM, Leape LL. Reducing errors in medicine. BMJ 1999; 319(7203):136-7. PMID: 10406730

Brennan TA. The Institute of Medicine report on medical errors–could it do harm? NEJM 2000;342(15):1123-5. PMID: 10760315

Riskin A et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics 2015;136(3):487-95. PMID: 26260718

Suresh G et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics 2004; 113(6):1609-18. PMID: 15173481