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Rude health: do ‘soft skills’ matter in medicine?

 

Surgeons are frequently hired on the basis of their knowledge, training, technical skill and professional reputation. But what of their ability to work in a team, to empathise with patients or to remain calm in a crisis? When it comes to life and death, the research suggests that soft skills matter.

By its very nature, the operating theatre is a highly charged working environment. The name itself – theatre – recalls a history where an audience of students and spectators watched skilled surgeons perform life-changing work under a spotlight. The stakes are high, and tensions often run high too. A 2010 British Medical Journal article1 by Dr Rhona Flin revealed that two thirds of healthcare workers in operating rooms have witnessed rude behaviour. Under pressure, it’s very easy to speak with haste or judge harshly.

 

Profound impact

Yet if rudeness is an occupational hazard for surgical teams, it’s certainly not a benign one. Far from being quickly forgotten, rude remarks have been found to have a profound impact both on diagnostic and procedural performance. This summer, researchers at Tel Aviv University published a study2 that they hope will encourage greater awareness of behavioural norms in medical contexts.

 

The study involved a simulation in which 24 Neonatal Intensive Care Units from hospitals around Israel were brought together to treat a premature infant with necrotizing enterocolitis. The teams were informed that a US expert on team reflexivity would observe the simulation by live video feed and occasionally comment over a two-way link. Half the teams were given a ‘rude’ expert, who glibly commented that he was ‘unimpressed by the quality of medicine in Israel’, while the other half had a ‘neutral’ expert. Independent judges then scored the teams’ performance, information-sharing and help-seeking.

 

The results showed that a rude comment decreased performance by more than 50%, even in this exercise involving a hypothetical life-or-death situation. This profound effect came as a surprise even to the authors. In an interview with NY Magazine, Professor Amir Erez of the University of Florida commented: “We found consistently and dramatically that rudeness isn’t something people can easily get over… [rudeness] damages your ability to think, manage information, and make decisions. You can be highly motivated to work, but if rudeness damages your cognitive system then you can't function appropriately in a complex situation. And that hurts patients.”

 

“A growing body of evidence suggests that a surgeon’s interpersonal skills directly impact patient outcomes.” 

Good behaviour gets results

The Tel Aviv University study3 is the latest in an increasingly compelling literature on how behaviour impacts medical performance. Writing in The Archives of Surgery in 20104, Dr Andrew S Klein, director of the Cedars-Sinai Comprehensive Transplant Center and the Esther and Mark Schulman Chair in Surgery and Transplantation Medicine, cited a study of more than 300 operations which showed the connection between civility in surgery and fewer postoperative deaths and complications. He wrote: "Often, surgeons get hired on the basis of their knowledge, training and technical accomplishments. But operating rooms are social environments where everyone must work together for the patient's benefit. When a surgeon, who is in the position of power, is rude and belittles the rest of the staff, it affects everything."

 

Focus on recruitment

With this in mind, is it time that the medical profession placed a stronger emphasis on interpersonal skills during the recruitment process? Recent developments suggest this evolution has already begun. In the UK, the NHS (the world’s fifth biggest employer, with 1.7 million employees) rates leadership and collaboration as key competencies in recruitment and performance measurement.

 

Meanwhile, the NHS and The Royal College of Surgeons of Edinburgh have for over a decade funded a multidisciplinary team of psychologists, surgeons and anaesthesiologists to create a Non-Technical Skills for Surgeons (NOTSS) framework5 – a behavioural rating system that assesses surgeons’ performance across four key non-technical skills: situation awareness, decision making, communication & teamwork, and leadership.

 

This skills taxonomy can be used to structure training and assessment, and it has already been adopted by the Royal Australasian College of Surgeons as part of their competence assessment and recommended by the ACGME (Accreditation Council for General Medical Education) for workplace assessment.

 

In the US, the Affordable Care Act, colloquially nicknamed Obamacare, made patient satisfaction a key measure of the quality rating of hospitals, resulting in a raft of new programmes designed to enhance EQ-related skills in medical teams. Writing on forbes.com6, Dr Thomas Chamorro-Premuzic, Professor of Psychology at UCL and Columbia University, highlights the example of the Centre for Creative Leadership – which has trained more than 400 healthcare institutions in collaboration and leadership – and the recruitment approach of leading centres such as the Mayo Clinic, NYU Langone Hospital for Joint Diseases, Rush University Medical Center, Thomas Jefferson, Cleveland Clinic and UCLA – all of which run personality assessments to help them to identify candidates who value team spirit and patient care.

 

As we witness this evolution in the working culture of the medical profession, it seems that empathy and civility will prove as important as scalpels and forceps in the surgical toolkit.

 

 

 

Recruitment focus:
do interpersonal skills matter?

While a growing body of evidence suggests that a surgeon’s interpersonal skills directly impact patient outcomes, is this reflected in recruitment priorities? We asked Roberto Chapa, Assistant Orthopedic Professor at the Hospital Christus Muguerza, Mexico, to share his perspective.

In addition to their medical knowledge and surgical technique, what interpersonal skills do you feel are necessary in the surgery profession?

Professional skills are important, yet it’s crucial that surgeons also acquire certain additional skills during medical school, residency and their first experiences of work. The first principal attainment is strong communication skills between your colleagues and with your patients. Surgeons also need to display leadership skills both in terms of how they position themselves within a group dynamic and how they demonstrate leadership in their skills and subject knowledge.

 

Considering workplace settings, there can be few more charged and high pressure environments than the operating theatre. Do you feel that this creates more opportunity for conflict?

Everyone experiences moments of stress, and medicine is a particularly stressful. Of course surgeons often find themselves in a situation where they have tried to achieve the best possible outcome for the patient and the whole medical team yet but the surgery does not go as well as you had hoped. A bad result can lead you to treat people with less care and that can lead to problems with colleagues and patients. That’s why it’s absolutely critical that surgeons work in as positive an environment as possible. Where we start as residents is so important because it sets the future for our career. If I have a good place to work I will feel comfortable and have good communication with my colleagues and patients that will reflect in my surgeries, my research and also in my personal life.

 

A Tel Aviv University study found that rudeness has a direct impact on patient care. Does that reflect your experience?

There’s no place for impoliteness in any kind of work, particularly medicine. Choosing the right words when communicating with patients and colleagues enables you to make an impact without resorting to being rude or impatient. Good communication is the most important thing in building relationships and impoliteness will only create a poor working environment, which of course will impact on patient care. I would say to any surgeon, if you have problems in your professional life or with your family or your kids you need to put them in a separate space in your mind. The patients aren’t responsible for your problems – they’re asking for your help.

 

In your experience are newly qualified doctors and surgeons entering the profession able to do that?

When you complete your residency it’s easy to think ‘yes, I have the abilities and the experience to do this job’ but no, that’s not the case. You need to take the time to build up experience in your carrier or speciality of the patients, of the good and bad surgeries and of life. You particularly need to find the right environment and build relationships with your team workers. That all takes time.

 

Do you think the education system does enough to help medical students to develop these skills?

It largely depends on where you study, since medical schools vary greatly in their teaching approach not only internationally but even within the same country. In Mexico we have more than 50 medical schools and you can see the difference, especially in national exams and when the candidates compete for residency program. It’s important that the education system not only teaches but allows future doctors the opportunity to experience their role and understand the importance of the relationships they will build.

 

As former Chairman of a spine unit, you have more than 15 years experience in recruitment. What do you look for in a surgeon?

The personal interview is the most important thing. Yes, you can review the CVs from every candidate, but generally they all have the required medical knowledge, finished their courses and received strong recommendations. The interview is a chance to get to know the person for yourself and to understand their experiences and relationships at medical school, as residents and even within their family. It’s all relevant to how they interact on a personal level and how they will contribute to your working environment. I ask them why they want to join this hospital and what their plans are for the future. Interpersonal skills are so important. Over several months a candidate can improve their technical abilities, but if you can identify a person who will work well with colleagues and bring new ideas and enthusiasm you have a good future surgeon in your team.

 

 

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Dr Roberto Chapa Sosa

 

Dr Roberto Chapa Sosa is Assistant Orthopedic Professor at the Hospital Christus Muguerza, Mexico, and AOSpine Latin America spokesperson.

 

 

 

 

References

 

  1.  Flin R. (2010) Rudeness at Work. http://www.bmj.com/content/340/bmj.c2480
  2.  https://english.tau.ac.il/news/rudeness_medical_staff
  3. Riskin A, Erez A,  Foulk T, Kugelman A,  Gover A, Shoris I,  Riskin K,  Bamberger P, (2015) The Impact of Rudeness on Medical Team Performance: A Randomized Trial. http://pediatrics.aappublications.org/content/136/3/487
  4.  Klein A (2010) http://consumer.healthday.com/general-health-information-16/doctor-news-206/rude-surgeons-hurt-patients-increase-costs-654991.html
  5.  www.rcsed.ac.uk/education/patient-safety-and-notss/notss.aspx
  6.  Chamorro-Premuzic T (2014) http://www.forbes.com/sites/tomaspremuzic/2014/10/26/social-skills-leadership-in-healthcare-the-case-for-boosting-doctors-eq/

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