During Medical Protection’s recent Ethics For All conference, Dr Julia Ambler, Paediatric Palliative Care Specialist, co-founder of Umduduzi – Hospice Care for Children, Board of PALPRAC, and Medical Protection Risk Prevention Faculty Presenter, presented on handling difficult interactions with colleagues. Here she outlines some of her advice.

With increasing subspecialisation and patient’s freedom to choose providers, there may be numerous healthcare practitioners involved in an individual’s care. The WHO has defined transitions of care as being “the various points where a patient moves to, or returns from, a particular physical location or makes contact with a health care professional for the purposes of receiving health care.”¹

With each transition of care there is a risk of communication failure and this may have significant impacts.

First and foremost is the impact on patient safety. For example, when referrals are lacking key medical information or there is an assumption that another provider will check and follow up abnormal results, diagnosis of serious disease may be delayed or completely missed. Further this kind of poor communication can lead to poor clinical outcomes, increased medical error, additional visits and increased costs and potential suffering for the patient.

Healthcare institutions can also be affected; undermined patient confidence, reputational damage, duplication of work and increased financial burden. 

As a healthcare practitioner one must acknowledge these impacts and reflect on the way in which we are personally affected. It is well understood that “poor teamwork, poorly defined roles, and hierarchical issues make medical care less efficient and increase frustration in the workplace.”² This in turn can lead to decreased morale and job satisfaction and ultimately even burnout.   

The threat of medico-legal action is a constant concern in today’s clinical environment and poor interprofessional communication raises this risk for each practitioner involved. 

Healthcare work places are full of strong personalities that may not always use respectful language when communicating with each other. Bradley and colleagues surveyed over 600 doctors of mixed career stage in the UK and their study identified that 31 percent of those surveyed experience rude or aggressive behaviour at least once a week and 40 percent of respondents felt that this behaviour was having a negative impact on their work.³

For an area of practice that is so very important in patient care and safety, it is alarming how frequently communication is poor. It is therefore imperative that we understand the many barriers to excellent and timely communication to be able to move past them. Time pressures are very real in the working environment and it can be difficult to access colleagues. Healthcare practitioners do not receive extra remuneration for the time it takes to communicate effectively, so must do so because it is the correct and safe way to practice. Organisational hierarchy is still common place with a blame and shame culture that inhibits speaking up. Healthcare practitioners may be reluctant to communicate with a colleague perceived to be difficult or where they have a history of a tricky relationship. 

To improve communication there are a few things to consider

Firstly, one has to make sure those involved are on the same page, using the same language. Strategies to do this include the use of standardised communication tools such as SBAR⁴ for handovers, checklists, protocols and templates.

One also needs to consider the people and setting. A highly stressed, tired and hungry clinician working in a noisy casualty is likely to have a difficult time concentrating on the message they are trying to receive. 

A further point is the mode of communication. Does the situation call for a face-to-face discussion, telephone call or will an email suffice? 

Lastly, ensuring that the message sent is actually the message that has been received is imperative; this can only be achieved by the message sender checking what the receiver has heard and understood. This may feel awkward to begin with, but as it becomes common practice, this approach can dramatically reduce communication failures.

Disagreements between healthcare practitioners are common, but in order to achieve the best result for the patient, these conflicts must be resolved respectfully. The first step is to raise one’s concerns, framing this conversation as being in the patient’s best interest, avoiding any language that can come across as accusatory or disrespectful.⁵ In particular, the importance of negotiating an agreed way forward that both parties are comfortable with should be highlighted. This could include options such as seeking a third opinion, presenting the case for a group discussion with peers, meeting together with the patient and/or their family or delaying non urgent treatment or investigation until a clearer clinical picture emerges (if this is appropriate). 

When one feels very strongly about a patient it can be all too easy to slip into using tone and language that are aggressive and rude. This is unlikely to result in a good outcome. Similarly, if one is not clear and assertive about their concern for the patient, it is possible that the response will be dismissive. Finding the balance between respect for one’s colleague and concern for the patient is key in achieving a satisfactory response.

If, after raising your concerns with a colleague you fail to find a way forward that you are both comfortable with and you are still of the opinion that the patient’s best interests are not being served, one should continue to take action until you are satisfied that the patient’s best is being served.

In summary, effective inter-professional interactions are essential to minimise risk for patients and healthcare practitioners. Healthcare practitioners are at risk if inter-professional communication is incomplete or not timely or if there is significant unresolved disagreement between themselves and a colleague. Standardised communication checklists and tools can be helpful. Poor interprofessional communication requires action.

Dr Julia Ambler’s presentation was delivered during the Healthcare Practitioner’s Conference at Medical Protection’s Ethics For All 2021.

Effective communications not only reduce the risk of possible adverse outcomes but help ensure the safe transition of care and documentation. Attend the 'Overcoming risky interactions with colleagues remotely' webinar by logging into Prism and signing up here. 

References

¹WHO, Transitions of Care, https://apps.who.int › handle › 9789241511599-eng (accessed 12/11/2021)

²Harolds, Jay A. MD Quality and Safety in Healthcare, Part LVII, Clinical Nuclear Medicine: April 2020 - Volume 45 - Issue 4 - p 299-300
doi: 10.1097/RLU.0000000000002728 (accessed 12/11/2021)

³Bradley V, Liddle S, Shaw R, Savage E, Rabbitts R, Trim C, Lasoye TA, Whitelaw BC. Sticks and stones: investigating rude, dismissive and aggressive communication between doctors. Clin Med (Lond). 2015 Dec;15(6):541-5. doi: 10.7861/clinmedicine.15-6-541. PMID: 26621942; PMCID: PMC4953255.

⁴Müller, M., Jürgens, J., Redaèlli, M., Klingberg, K., Hautz, W.E. and Stock, S., 2018. Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ open, 8(8), p.e022202.

⁵Gallagher, T,  Mello M,, Levinson W., Wynia, M.K., Sachdeva A., Sulmasy A.S., Truog R.D., Conway J., Mazor K, Lembitz A., Bell S.K and Sokol-Hessner L.; Talking with Patients about Other Clinicians' Errors; N Engl J Med 2013; 369:1752-1757, DOI: 10.1056/NEJMsb1303119