The effects of rudeness, experience, and perspective-taking on challenging premature closure after pediatric ICU physicians receive hand-off with the wrong diagnosis: a randomized controlled simulation trial

Abstract

ObjectivesRudeness exposure has been shown to inhibit diagnostic performance. The effects of rudeness on challenging a handed-off diagnostic error has not been studied.MethodsThis was a randomized controlled study of attending, fellow, and resident physicians in a tertiary care pediatric ICU. Participants underwent a standardized simulation that started with the wrong diagnosis in hand-off. The hand-off was randomized to neutral vs. rude. Participants were not informed of the randomization nor diagnostic error prior to the simulation. Perspective taking questionnaires were administrated for each participant. Primary outcome was challenging diagnostic error post-simulation. Secondary outcomes included rate and frequency of diagnostic error challenge during simulation.ResultsAmong 41 simulations (16 residents, 14 fellows, and 11 attendings), the neutral group challenged the diagnostic error more than the rude group (neutral: 71%, rude: 55%, p=0.28). The magnitude of this trend was larger among resident physicians only, although not statistically significant (neutral: 50%, rude: 12.5%, p=0.11). Experience was associated with a higher percentage of challenging diagnostic error (residents: 31%, fellows: 86%, attendings: 82%, p=0.003). Experienced physicians were faster to challenge diagnostic error (p<0.0003), and experience was associated with a greater frequency of diagnostic error challenges (p<0.0001). High perspective taking scores were also associated with 1.63 times more diagnostic error challenges (p=0.007).ConclusionsExperience was strongly associated with likelihood to challenge diagnostic error. Rudeness may disproportionally hinder diagnostic performance among less experienced physicians. Perspective taking merits further research in possibly reducing diagnostic error momentum.

Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review

“…There were 4 qualitative studies, 22 survey-based studies, 3 mixed-methods studies, 1 retrospective cohort study, 1 prospective cohort study, 1 database study and 4 RCTs. Of the four RCTs, two were classroom based,18 20 one was an in situ simulation17 and one4 did not provide sufficient information for the setting to be determined. Twenty-one studies were conducted in North America, six in the Middle East, four in Europe, three in East Asia and two in Oceania.…”

“…All four RCTs were judged to have a significant risk of bias. Three4 17 20 scored low risk in at least three of the six categories, and either unclear or high risk in the remaining categories. The fourth18 scored high risk in two categories, unclear risk in two categories and low risk in two categories.…”

“…The four RCTs found in the search were all simulation based. HCWs were randomised to be exposed to unacceptable behaviour from a simulation lab manager,18 visiting expert,17 operating surgeon4 or surgeon handing over to intensive care unit (ICU) staff upon transfer 20. Riskin et al 17 found poorer diagnostic (p<0.00035) and procedural (p=0.0002) scores in those exposed to unacceptable behaviour.…”

“…In contrast, Johnson et al 18 found no significant difference in cardiopulmonary resuscitation, cognitive or teamwork performance post-exposure. In Avesar et al ,20 ICU doctors received a handover containing an incorrect diagnosis from a surgeon exhibiting either rude or neutral behaviour. The percentage of doctors that challenged the incorrect diagnosis was smaller in the group that received a rude handover (55%, 11 out of 20 doctors) compared with the group that received a neutral handover (71%, 15 out of 21 doctors), but this did not reach statistical significance (p=0.28).…”

“…Poorer technical (diagnostic, procedural) and non-technical (teamwork, communication) performance in two4 17 simulation-based RCTs. Two further negative trials with lower participant numbers20 and less robust methodology18…”