Tuesday, March 29, 2016

SPEAKING UP: Are we enabling our trainees or hindering them?

Anyone familiar with Malcolm Gladwell’s Outliers or the 1990 crash of Columbia Avianca Flight 052’s has read about mitigated speech. For those who have not:
1.    Mitigated speech is where we downplay or sugar coat what we say to avoid being deferential to authority or we are embarrassed.
2.    The Jan 1990 crash of the 707 Avianca flight 052, involved a Columbian plane that circled the northeast for 90 minutes while they were rapidly running out of fuel and the copilot revealed their dire situation to ground control by stating: “That right to one-eight-zero on the heading and… ah… we’ll try once again… We’re running out of fuel…”

A recent paper from the Surgery Department at the University of Chicago reminded me of this today. I won’t go into detail but clearly the residents expressed the following:
1.    A deep sense of overall responsibility for the outcomes of their patients when they are provided direct involvement via delegative or consultative leadership expression by the attending surgeons.
2.    The importance of being able to speak up when they have a concern.
3.    The dwindling sense of responsibility for the patient when they have concerns that are not heeded in some and self-blame in others if they did not go further to express their concerns.
4.    Situational/environmental factors- knowing that the preoperative conference out of the operating room and away from the patient would be the most appropriate place to raise a concern, residents are reluctant to do so when they are in the operating room or at the “bedside”.

I have been known to put this to the test:
Resident: “Dr. Lipshy, the patient we have on the schedule to start the day, had diverticulitis 6 weeks ago and his pain and nausea are back and he feels today like he did back then, what do you want to do?”
Me: “I want to do the scope anyway”
Resident: “ok”
Me: “why did you say 'ok' when you knew that was the wrong decision?”
Resident: “well….. its your patient so….”
Me: “how do you know I even heard what you said or was even listening? You did not ask me to repeat back to you and this is a clear change in the situation and likely dangerous to proceed, Right?”
Resident: “yes”
Me: “so if you have concerns and I clearly did not repeat back what you said don’t assume I was listening and if it is clear I heard what you said but am proceeding down a wrong pathway, ask me why I am moving forwards if it does not make sense to you”.

So from this study we see two contradictions: Residents have a deep sense of obligation to the patient and if we appear to be doing harm and they don’t attempt to understand fully why we are making that decision or they really did not try very hard to assure we are totally comprehending the potential danger, they have much angst when things go wrong.

Kenneth A. Lipshy, MD, FACS


Sur MD, Schindler N, Singh P, Angelos P, Langerman A. Young Surgeons on speaking up: when and how surgical trainees voice concerns about supervisors’ clinical decisions. Am Jnl Surg. 2016;211(2):437-444.

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