Research Snapshot Theater: Quality & Patient Safety XXI
Learning Objectives: Exposing resident teams to rude behavior worsens diagnostic accuracy by inhibiting collaborative processes. The effect of rude behavior on diagnostic cognition is less studied at the individual code-team leader level and among experienced providers. We hypothesize that a rude physician-to-physician hand-off will inhibit Pediatric Critical Care Medicine (PCCM) physicians from overcoming diagnostic error, compared to a hand-off in a neutral, professional environment.
Methods: This was a simulation-based randomized control study among physicians in a tertiary care pediatric ICU. Pediatric resident, PCCM fellow, and PCCM attending physicians participated in one high-fidelity simulation where all clinical information was standardized using progressive reveal by confederate ancillary staff. The scenario was a post-operative cardiac tamponade that began with a hand-off by an operative team member who included an incorrect diagnosis of sepsis. The hand-off was randomized to neutral vs rude (condescending tone with dismissive non-medical commentary). Primary outcome was whether or not the hand-off diagnostic error was challenged; secondary question was whether or not experience level affected this relationship. Data were analyzed using Fisher’s Exact Test.
Results: In total, there were 35 simulations (13 resident, 12 fellow, and 10 attending). Among residents, 6 of 7 (86%) did not challenge the diagnostic error in the rude group compared to 4 of 6 (67%) in the neutral group. Among fellows, 1 of 6 (17%) did not challenge the diagnostic error in either group. Among attendings, 1 of 4 (25%) did not challenge the diagnostic error in the rude group compared to 1 of 6 (17%) in the neutral group. Overall, 47% of physicians with a rude hand-off did not challenge the diagnosis compared to 33% with a neutral hand-off (p = 0.4). Level of experience was associated with challenging diagnosis; 23% of residents, 83% of fellows, and 80% of attendings challenged regardless of their exposure to rudeness (p = 0.003).
Conclusions: Experience level had a far more significant effect than exposure to rudeness on whether or not PCCM physicians challenged diagnostic error. Unlike resident team focused studies, we did not find an effect of rudeness on diagnosis. This could be because novice trainees are more vulnerable to rudeness, or perhaps because rudeness has more of an effect on teams than individuals. More research should explore how experienced providers challenge diagnostic error.