SGEM#227: A Message to you Rudy – About Rudeness - The Skeptics Guide to Emergency Medicine

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Date: August 22nd, 2018

Reference: Riskin A, Erez A, Foulk TA, et al. Rudeness and Medical Team Performance. Pediatrics. February 2017

Guest Skeptic: Dr. Simon McCormick is an Emergency Medicine Consultant from Northern Ireland who works in Rotherham Hospital in Yorkshire, England. He is currently redeployed in Medical Education on “Burnout Sabbatical” but is hopeful of returning to the shop floor in the near future. He writes a blog called Broken Toy covering topics such as his experience with burnout, medical education and looking after each other.

Case: You are working in the emergency department (ED) and have just been involved in a difficult case in the resuscitation room. During the resuscitation, a relative of the patient you have been treating named Rudy makes a derogatory/rude comment about Emergency Medicine (EM) staff.

Background: Unfortunately, rudeness is a problem that is rife in medicine. It does not just come from patients and/or their relatives, as in this case, but can also come from the medical team. Specialties make fun of each other using unflattering stereotypes, seniors are unpleasant to juniors and physicians can say derogatory things to nurses.

This internal rudeness has traditionally been seen as just “part of medicine”, a way to “build a tribe” or just part of the black humour and banter needed to survive in a tough environment.

More recently, however, this has been questioned and people are now more inclined to think of the worst of this as a form of bullying and harassment and other, milder rudeness, as detrimental to the development of staff and harmful to a collaborative culture within medicine.

Perhaps even more worryingly, is the concern that rudeness has an impact on staff performance, actually putting patients at risk. That said, it is unlikely that we can eradicate rudeness completely from our working lives. However, is it perhaps possible to reduce the impact rudeness may haveon staff, either with some form of pre-emptive education or a post event debriefing whether the rudeness comes from the team or those patients and families we are trying to help.

Rudeness does not need to be part of medicine. A better option is to try kindness as outlined in the excellent book by Dr. Brian Goldman. We discussed Brian’s book on the SGEM Xtra called Don’t Give Up – The Power of Kindness.

Being rude might make us feel better sometimes but that is always at the expense of who we are being rude to. Whilst it might take a little effort, taking the time to try to understand why someone is behaving as they are, showing some empathy, can have real benefits. As we start to understand the issues behind their actions and reactions, we are given the opportunity to reach out and show some kindness which not only helps them, it also helps us by reconnecting with that basic human desire to be helpful. Instead of the win/lose of rudeness we get a win/win with kindness!

Clinical Questions:

1) Does rudeness affect the performance of a clinical team?

2) If it does, can we mitigate the effects of rudeness?

Reference: Riskin A, Erez A, Foulk TA, et al. Rudeness and Medical Team Performance. Pediatrics. February 2017

Population: Neonatal Intensive Care Unit (NICU) staff, both physicians and nurses, working in a number of NICUs in Israel.
Intervention: Staff were exposed to a controlled rude event by a relative during the first of a series of five resuscitation simulations. Staff were given either a pre-intervention Cognitive Bias Modification(CBM) or a post-intervention therapeutic narrative intervention.
- CBM: This is also known as cognitive behavior therapy or CBT is a therapy that tries to change behaviors by identifying maladaptive behaviors and finding ways, often using talk therapy, to change those behaviors.
  - The CBM intervention involved brief, computerized cognitive training modules designed to alter threat-oriented biases in interpretation, by promoting a more positive or benign response rather than a threat-based interpretation of ambiguous information or stimuli.
- Narrative Intervention: This was having the participants writing down the events post-experience to help process the event. This has been shown to improve health and general well-being. [i]
Comparison: A neutral comment was made by the relative with no pre or post rudeness intervention given.
Outcomes: Nine parameters separated into two broad aspects of team performance rated on a 5-point Likert scale (1 = failed; 5 = excellent) as well as a rudeness manipulation check (this was not listed or described in the methods section)
- Medical and Therapeutic Performance
  1. Diagnostic performance
  2. Quality of therapy plan
  3. Intervention
  4. Overall general assessment of medical therapy
- Teamwork or Relational Cooperative Performance
  1. Information sharing
  2. Workload sharing
  3. Helping among team members
  4. Communication between team members
  5. Overall general assessment of teamwork
- Rudeness Manipulation Check

Authors’ Conclusions: “Rudeness has robust, deleterious effects on the performance of medical teams. Moreover, exposure to rudeness debilitated the very collaborative mechanisms recognised as essential for patient care and safety. Interventions focusing on teaching medical professionals to implicitly avoid cognitive distraction such as CBM may offer a means to mitigate the adverse consequences of behaviours that, unfortunately, cannot be prevented.”

Quality Checklist for Randomized Clinical Trials:

The study population included or focused on those in the emergency department. No
The teams were adequately randomized. Yes
The randomization process was concealed. Yes
The teams were analyzed in the groups to which they were randomized. Yes
The study teams were recruited consecutively (i.e. no selection bias). Unsure
The teams in both groups were similar with respect to prognostic factors. Unsure
All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No
All groups were treated equally except for the intervention. Yes
Follow-up was complete (i.e. at least 80% for both groups). Yes
All (team) patient-important outcomes were considered. No
The treatment effect was large enough and precise enough to be clinically significant. Unsure

Key Results: They recruited 39 NICU teams consisting of two physicians and two nurses split across the four groups:

Neutral control group
Rudeness exposure with no intervention
Rudeness exposure with prior CBM
Rudeness exposure with post event narrative intervention

Rudeness negatively impacted medical and therapeutic performance as well as teamwork or relational cooperation. Pre-exposure CBM seemed to mitigate the impact of rudeness while post-exposure narrative intervention did not.

Compared to the control group, those exposed to the rudeness had statistically significant reduction in seven of the nine scores measured including the mean therapeutic and mean teamworking scores.

Those who were exposed to rudeness but had received pre-exposure CBM did not have a statistically significant drop in any scores compared to the controls. This suggests a degree of protection with CBM from the impact of rudeness.

Those who had the post-exposure narrative intervention showed a similar drop in medical and therapeutic performance as well as teamwork or relational cooperation scores compared to the controls. This suggests a lack of protection with post-exposure narrative intervention from the impact of rudeness.

1) External Validity: The population in this study was not ED staff but rather NICU teams. The clinical scenarios they faced were pretty extreme, pushing their teamwork to the limit. It is reasonable to think rudeness would have a similar impact on the function of the ED staff and that CBM could mitigate the negative effect. However, the intellectually honest answer is we are unsure if these results can be generalised to ED until it is studied in that specific environment.

This is not because we in the ED are any better than those in the NICU, but because our working experiences are different. Whilst it is clear that staff on a NICU will experience rudeness at work, most people would agree that the ED is a place where tensions run high more often, and interpersonal conflict is unfortunately too frequent an occurrence. Having been in EM for nearly twenty years, I found the rude statement used in this study quite benign compared to what I’ve faced on a semi regular basis in the ED. It is therefore possible, given the successful intervention was a type of desensitisation therapy, that ED staff have already become immune to this level of rudeness.

And whilst talking about the level of rudeness, I wonder what the impact of the study’s rude statement would have in different countries? How might the ‘famously’ or is it infamously polite British and Canadians react compared to our stereotypically more robust colleagues from the US, South Africa and Australia?

2) Recruitment and Prognostic Factors: They do not specifically mention that teams were recruited consecutively. This could have introduced some selection bias. It is unclear if this would have impacted the results.

Another important issue is prognostic factors. The teams being studied were randomly assigned to each group but there is a very limited assessment of their baseline characteristics. The only characteristic recorded was of “cumulative experience”and this was found to be “distributed equally” across the groups.

While it may be impossible to control for all life experiences that might impact upon a psychological study such as this, it would have been good to know if the groups were matched for age, sex, individual clinical experience or seniority of position, to name a few.

In this study a team of four staff, each with five years of experience, is deemed equal to a team with three staff who have one year of experience and one who has seventeen. It might be argued that this was a study designed to look at teams not individuals, hence the use of cumulative experience, but we cannot ignore the fact that teams are composed of individuals, each of whom can have a huge impact upon how that team functions as a whole.

3) Interventions: There are two intervention points described in this study. The rudeness intervention was delivered during the first simulation by the actor playing the mother and was the statement “I know we should have gone to a better hospital where they don’t practice Third world medicine!” However, how do we know whether this was considered rude by the study participants? The investigators did do manipulation checks at two points later in the day to see if the team members had picked up on this rudeness, which they had.

The second intervention was the attempt to “treat” the rudeness, either proactively or retrospectively. The proactive treatment was a Cognitive Bias Modification (CBM) which is described in detail in the paper. In short it appeared to be a computer-based task where team members looked at faces in different stages of happiness or anger and rated what they thought the emotion displayed was. After establishing where their “threshold to threat” was, the computer program gave feedback to try to raise that threshold, effectively immunising against minor threats.

The retrospective treatment was a narrative intervention where, after the first simulation, team members were asked to write a couple of paragraphs about how the mother might have felt during the resuscitation. We are probably much more familiar with this approaches to rudeness with reflective practice an increasing part of our development as clinicians.

However, whilst this reflective process appeared to make team members feel the mother was less rude by the end of the day (from the previously mentioned manipulation checks), it didn’t seem to help protect them from the effect of the rudeness. On the other hand, the CBM appeared to increase the perception of the mother’s rudeness but did seem to prevent that rudeness adversely affecting performance.

While this CBM intervention looks like it might be useful we are unsure as to the duration of effect, as no measurements were carried out beyond the day of training. This means the practical application of such an intervention is currently pretty low as having all staff spend 20 minutes on a computer program pre-shift is unrealistic!

However, if it is consistently shown to make a significant, persistent difference one could easily imagine an app-based version being created that staff could access at an evidence-based interval to raise their threshold of threat.

4) Multiple Measurements and Comparisons: This study had nine different outcomes measured on a five-point Likert scale. They never did identify what their primary outcome was and what the secondary outcomes would be.

They also compared CBM vs. control and narrative intervention vs. control. This lead to multiple measurements and multiple comparisons. The concern with this approach is that eventually one or two will have a statistically significant difference by chance.

However, given that all the measurements in this study seem to move in a similar direction for each group and consistent with the interventions, it is probably okay but we do need to watch out for this type of thing.

Whilst on this subject of measurements, the one they used in the trial does not appear to have been validated anywhere. They were similar to those used in the authors’ previous paper on rudeness looking at individuals but tweaked slightly to reflect team skills rather than those of individuals. On a positive note, the two-person team doing the assessments were blinded, had good training and their inter-rater reliability was reported as moderate to high.

5) Outcomes: The mean difference between the rudeness and control groups for general teamwork and general therapeutic performance were 0.37 and 0.57 respectively on a 5-point Likert scale. This was statistically significant difference, but we do not know if this would be clinically significant.

More importantly we have no knowledge on whether the rudeness negatively effecting the team work and therapeutic performance has any impact on any patient-oriented outcomes.

Even if CBM mitigates the negative impact of rudeness on those measurements does it result in a net patient-oriented benefit? These are important questions that still remain, and we would encourage the authors to consider exploring these additional important questions.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with their conclusions, although we might ask the authors nicely if they would tone the certainty in their language down a bit given the limitations of the study design and results that we have discussed.

SGEM Bottom Line: Rudeness can have an impact upon how medical teams function and there may be a way to mitigate staff against this negative influence.

Case Resolution: Whilst waiting for further information about practical use of CBM, you decide to try and reduce the amount of rudeness in your department by setting a good example to others. You also have a private conversation with Rudy later about his derogatory comment about the EM staff and politely discuss it could be perceived and negatively impact the team performance during resuscitations. In addition, you use this event as a teaching opportunity for your staff to explore the topic of rudeness, explain the impact it can have on team performance and encourage them to try and always be kind to patients and each other.

Dr. Simon McCormick

Clinical Application: We are unsure how to apply this information clinically. It does appear that rudeness can have an impact on team performance. What we do not know is if it has a negative impact on patient-oriented outcomes in the ED. In addition, would CBM mitigate the effect of rudeness in this clinical setting?

What Do I Tell the Team? Sometimes patients and relatives can be rude to us, but we can also be very rude to each other. It is a practice of tribalism that has gone on for too long in medicine. This can have a negative influence on our team performance and could impact patient care and safety. Let’s try to be kind to each other and always remember that we are all working for the best interest of the patients.

Keener Kontest: Last weeks’ winner was Noel Blanco from El Paso, Texas. He knew 22,000 Canadians are estimated to die each year due to adverse drug reactions?

Listen to the SGEM podcast on iTunes to hear this the new keener question. If you know the answer send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

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