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Anesthesiology:
doi: 10.1097/01.anes.0000265145.40825.ac
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Communication and Teamwork: Essential to Learn but Difficult to Measure

Murray, David M.D.*; Enarson, Cam M.D., M.B.A.†

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TEAMWORK is recognized as an essential component of safe patient care. In obstetric practice, a multispecialty team is frequently challenged by the emergent requirement for operative delivery in a parturient who has an underlying serious medical condition or complication of pregnancy. When a crisis complicates patient care, teamwork among healthcare professionals is frequently strained, resulting in more frequent as well as more serious failures in managing critical events. A method to measure team performance is a first step in understanding the elements of successful teamwork. In this issue of Anesthesiology, Morgan et al.1 design four complicated obstetric emergencies and evaluate the teamwork skills of obstetric teams managing these simulated events.
In this study, teams managed simulated emergency operative deliveries complicated by events such as preeclampsia with pulmonary edema, abruptio placentae with massive hemorrhage, amniotic fluid embolism associated with cardiac arrest, and hypoxia associated with failed airway management. In the majority of high-acuity medical environments, teams of healthcare professionals perform specialized tasks and procedures in an interdependent manner. The interrelated team tasks, even in an emergency, usually occur in a logical, sequential, predictable manner, often with little reliance on communication, because the goals are understandable to all of the team members. When complications occur, shared communication and teamwork become essential because the immediate patient management goals may not be clear to all team members.
Morgan et al.1 evaluate team performances using two different scoring methods.1 The results indicate that raters are consistent when evaluating overall team performance using global ratings, but an in-depth itemized questionnaire (45 questions) that included factors such as confidence, leadership, teamwork, and information sharing could not be scored reliably. This indicates that many of the detailed characteristics of effective team performance remain elusive to measure. The promising study result is that experts consistently agreed about overall team performance. These consistent overall scores indicate that expert raters do agree on successful as well as problematic team management. The number of raters required (nine raters) to achieve a reliable score would preclude using this type of scoring system as a practical method to compare or rank-order team performances.
Teamwork and communication skills continue to be difficult to capture using traditional rating scales. The development of more effective methods to measure these skills will help to identify the attributes of superior teamwork as well as the root cause of team failures. Currently, team failures are the primary target of system-based patient safety interventions. These approaches that include mandated team checks may reduce some of the more egregious teamwork failures, but ultimately, research that identifies the most effective education and training strategies is needed to improve patient safety.2,3
A number of preliminary studies suggest that team members (surgeon, nurse, critical care physician, and anesthesiologist) may have differing perceptions of the quality of communication in their shared work environments.4–6 Studies involving interdisciplinary healthcare teams are needed to determine why these professionals differ in their view of teamwork. This study is one of the first attempts to develop a method to measure the skills of an interdisciplinary team of healthcare professionals in a high-fidelity training environment. The training curriculum used simulated events that challenge teamwork.
This work by Morgan et al.1 not only represents groundbreaking research in group interactions in complex medical emergencies, but also points the way to more effective medical education. Medical schools have recognized that prospective physicians require teamwork and communication training during medical school. A recent report entitled Educating Doctors to Provide High Quality Medical Care: A Vision for Medical Education in the United States (a report of the Ad Hoc Committee of Deans, Association of American Medical Colleges) called for changes in the system of medical education to assure that physicians can “listen and communicate effectively.”7 The Liaison Committee on Medical Education, jointly sponsored by the American Medical Association and the Association of American Medical Colleges, has also recognized the importance of communication skills and teamwork.6 Standard ED-19 notes that “there must be specific instruction in communication skills as they relate to professional responsibilities, including communication with patients, families, colleagues and other health professionals” (Liaison Committee on Medical Education).7 This committee reviews the content of a medical school’s curriculum in these areas as a component of the review of the educational program leading to the M.D. degree.
Medical school curricula have incorporated other methods to train and assess communication skills using more structured situations, such as the Objective Structured Clinical Exam. In addition, assessment of communication skills is now a component of the United States Medical Licensing Examination Step 2® (Philadelphia, PA) Clinical Skills Exam.6 It is intriguing to consider the use of simulation, as exemplified in the study by Morgan et al.,1 as another modality to teach communication skills.
Teamwork is also drawing increasing attention in medical schools as a component of patient safety and quality enhancement efforts. Students have the opportunity to participate in simulated clinical experiences and receive feedback on their performance as a team member. Increasingly, the importance of an early interdisciplinary approach has been recognized, and training has been implemented to ensure the development of interprofessional communication skills. Efforts are under way at a number of academic medical centers to develop courses in patient safety. At Creighton University, the Foundation in Patient Safety Course includes objectives that include interprofessional communication and a systems approach to understanding human performance fallibility. Similar examples of this curriculum emphasis exist at many medical schools.
The overall goal is to train physicians who will be well grounded in essential communication and teamwork skills. The medical student education program will provide a foundation for further skill development in residency training. The importance of this issue to our patients will mandate that interdisciplinary communication and teamwork skills will be considered prerequisite skills for professional training. Research such as the study in this issue of Anesthesiology will and must continue to identify more effective and efficient methods to assess these skills and provide feedback to facilitate improvement.1 Our patients will expect no less.
David Murray, M.D.,*
Cam Enarson, M.D., M.B.A.†
* Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri. murrayd@wustl.edu. † Department of Anesthesiology and Health Policy and Ethics, School of Medicine, Creighton University, Omaha, Nebraska.
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References

1. Morgan PJ, Pittini R, Regehr G, Marrs C, Haley MF: Evaluating teamwork in a simulated obstetric environment. Anesthesiology 2007; 106:907–15

2. Hayword RA, Hofer TP: Estimating hospital deaths due to medical errors: Preventability is in the eye of the reviewer. JAMA 2001; 286:415–20

3. Hofer TP, Hayword RA: Are bad outcomes from questionable clinical decisions preventable medical errors? A case of cascade iatrogenesis. Ann Intern Med 2002; 137:327–33

4. Thomas EJ, Sexton JB, Helmreich RL: Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med 2003; 31:956–9

5. Makary MA, Sexton JB, Freischlag JA, Holzmueller CG, Millman EA, Rowen L, Pronovost PJ: Operating room teamwork among physicians and nurses: Teamwork in the eye of the beholder. J Am Coll Surg 2006; 202:746–52

6. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Chicago, Liaison Committee on Medical Education, 2004, p 12

7. Report of the Ad Hoc Committee of Deans. Educating Doctors to Provide High Quality Medical Care: A Vision for Medical Education in the United States. Washington, DC, Association of American Medical Colleges, 2004, p 7

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