Gerald Hickson: Changing behaviour

IMAGINE a scenario where you are a cardiac surgical registrar assisting on a routine bypass. The surgeon you are assisting has a reputation for being brilliant but lately has been irritable and short-tempered.

Throughout the operation exchanges have been tense to the point where team members no longer make eye contact and communication has all but ceased. You find yourself thinking about whether you should mention your colleague’s behaviour to hospital management only to realise that you’re no longer concentrating on the task at hand.

This situation is an all too common example of how disruptive behaviours among doctors can affect patient safety. Disruptive behaviours, or behaviours that undermine a culture of patient safety, are usually thought of as overt acts such as throwing things, yelling and other aggressive behaviours.

However, passive and passive-aggressive behaviours such as the use of a condescending tone or publicly critical comments can be just as disruptive to patient care and teamwork. These behaviours distract other professionals from doing their jobs, which can lead to slips, concentration lapses and other cognitive effects that impair performance.

For the past 20 years, my team and I at Vanderbilt University in the US have been active in identifying physicians with a high medicolegal risk. Across institutions, we have consistently found that a small subset of physicians (around 4%) attract significantly more patient complaints than most, even when taking into account specialty and volume of service.

Recently published research suggests that this figure is similar in Australia with 3% of doctors found to attract 49% of claims over the past decade.

Patients make complaints against doctors for a variety of reasons but we wanted to understand why this small group attracted far more complaints than their peers. We wondered whether they also impaired the health care team from delivering the best possible outcomes for patients, and exposed themselves to greater risk of patient complaints, unexpected patient outcomes and malpractice claims.

We now have a good body of evidence* to suggest that it doesn’t have to be this way. We have found that many of these physicians are simply unaware of their impact on others.

We have learnt that once these professionals receive peer-comparative feedback about how their behaviour affects their team and their medicolegal risk, they are able to develop insight and adjust their practice behaviours.

In many cases, it just needs a well trained peer having a non-punitive, non-directive “awareness” conversation with the high-risk physician to share evidence-based data about the number and type of patient complaints they receive.

In the US, the Patient Advocacy Reporting System (PARS) — a peer-review system developed by my team at Vanderbilt — has been implemented in more than 40 institutions. So far, 910 high-risk physicians have received awareness intervention visits and of the 708 where follow-up data were available, 548 (77%) have substantially reduced patient complaints. That’s a very encouraging statistic.

The question is, can a system like PARS be applied in Australia?

I believe so. It must start with a commitment from an institution’s leadership and a set of clearly articulated goals. It is also essential to develop a process that will reliably identify high-risk physicians and a tiered intervention strategy to manage those physicians.

It requires resources to ensure staff are trained to execute the plan and that those physicians identified can receive the support they need.

At Vanderbilt, our success has been demonstrated through a reduction in patient complaints and litigation costs. However, its true success is measured by medical professionals providing kinder, safer and more reliable health care.

Professor Gerald Hickson is a professor of paediatrics and assistant vice chancellor for health affairs, senior vice president for quality, patient safety and risk prevention, associate dean for faculty affairs, and Joseph C Ross chair of medical education and administration at Vanderbilt University School of Medicine. He will be a guest at a series of free seminars for medical students and health care professionals hosted by Avant.

* Pichert JW, Karrass J, Moore IN, et al. Assessment of a peer-based model of interventions designed to promote professional accountability. Jt Comm J Qual Patient Saf 2013; in press.