Spotlight Case October 2007

1. Spotlight Case October 2007 Do Not Disturb!

2. Source and Credits • This presentation is based on the October 2007 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available online • Commentary by: F. Daniel Duffy, MD, University of Oklahoma, and Christine K. Cassel, MD, American Board of Internal Medicine • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Define professionalism • Discuss behaviors associated with lack of professionalism • Outline steps one should take if a significant breach of professionalism is witnessed

4. Case: Do Not Disturb! A 55-year-old obese woman with a history of hypertension and severe obstructive sleep apnea requiring CPAP is placed on morphine PCA (patient-controlled anesthesia) pump for pain control following cholecystectomy. At approximately 1:00 AM, 5 hours after starting the morphine, the patient’s respiratory rate decreased to 7 (while on CPAP). Physical examination revealed an oxygen saturation level of 98%, normal blood pressure, heart rate of 50, and pinpoint pupils.

5. Case: Do Not Disturb! (cont.) The patient was noted to be lethargic, opening her eyes and mumbling incoherently in response to vigorous shaking but quickly falling asleep when the stimulus ceased. Concerned, the RN called the attending physician. The physician seemed annoyed by the call, barking, “What would you expect when you wake up a patient in the middle of the night from deep sleep—an excellent level of consciousness? Naturally, she would be drowsy!” He followed with, “Wake me up only on life and death issues!”

6. Physician Competencies This case identifies intertwined failures in four physician competencies that affect patient safety: • Professionalism • Patient care • Communication and interpersonal skills • Systems-based practice

7. Professionalism As defined by ACGME: • Carrying out professional responsibilities, adhering to ethical principles, and showing respect, compassion, and integrity in clinical work with patients and members of clinical teams ACGME Outcomes Project Web site.

8. Professionalism and Sleep Deprivation • Sleep inertia • Confusion and dysfunction that occurs upon awakening during deep non-rapid eye movement (NREM) sleep • Disorientation may occur after 30 minutes of sleep and last from 10 minutes to 2 hours after arousal • Disorientation may include periods of amnesia • Initial response after awakening may be automatic, but with little reflection, may be refined Wertz AT, et al. JAMA. 2006;295:163-164.

9. Complex Causes of Sleep Interruption • Physicians may take on more patient responsibility than they can safely handle • There may be insufficient numbers of physicians to handle the patient care needs in the specialty • The system may fail to design call or duty schedules that assure accurate nighttime decision making and sufficient time for sleep and relaxation

10. Burnout and Professionalism • Burnout • Syndrome of depersonalization in relationships with coworkers and patients, emotional exhaustion, cynicism, and ineffectiveness • Associated with impaired job performance and poor health • May contribute to alcoholism and drug addiction • Causes • Providers under constant pressure • Little control over their schedules • Failure at self care Maslach C, et al. Annu Rev Psychol. 2001;52:397-422. Spickard A Jr, et al. JAMA. 2002;288:1447-1450.

11. Burnout and Residency • High rates of burnout among residents: • Self-reported unprofessional behavior in discharging patients early to make their work more manageable • Admitted to making medical errors, not fully discussing treatment options with patients, or not answering patients’ questions Shanafelt TD, et al. Ann Intern Med. 2002;136:358-367.

12. Professionalism in Practice • Professionalism includes responsibility for providing care throughout the course of a patient’s illness, including nights and weekends • Failing to assure that a competent physician is available in a timely manner is professional abandonment • Provider must be cognitively alert, emotionally attuned to respond, motivated to take appropriate action regardless of the hour or sleepiness

13. On-Duty and On-Call Systems • When demands for care are nearly constant • Limited “on-duty” shifts with mandatory time-off between shifts • When calls for service are infrequent • “On-call” or telephone contact from home with return to duty if needed • Intermediate patient needs • Longer “on-duty” shifts, during which naps of uninterrupted sleep can be anticipated

14. Professionalism and Teamwork • Team members share goal of quality care, have specific roles, perform independent tasks, and adapt to circumstances • Good teamwork mitigates risks of provider failures that disrupt team function and lead to unsafe outcomes • Physicians have ultimate responsibility for diagnosis and treatment decisions • Other team members also are responsible for performance monitoring, backup, adaptability, and clear communication Baker DP, et al. Jt Comm J Qual Patient Saf. 2005;31:185-202.

15. Systems and Teamwork • The physical and mental condition of every team member is important to a safe and patient-centered health care system • Physician altruism is generally insufficient to overcome survival instincts when humans exceed emotional or physical limits • Highly reliable health care systems must balance workload with time off to ensure physical and emotional well being of workers, including physicians

16. Challenges to Professionalism • Professionalism is challenged most when patient needs conflict with personal needs • Professionalism includes self-assessment of one’s own needs and self care that assures the physical and emotional well being of the health care team • Such self assessment and self-correcting behavior is central to competence in professionalism ABIM Foundation, et al. Ann Intern Med. 2002;136:243-246.

17. Predicting Problems with Professionalism • Difficulties with professionalism, communication, and interpersonal skills during training are related to problems later in life • Disciplinary action by medical boards strongly associated with irresponsibility and inability to improve behavior during medical school • Low ratings of professionalism during residency related to sanctions by medical licensing boards years later • Communication with patients that failed to express empathy was associated with increased malpractice claims See Notes for references.

18. Case: Do Not Disturb! (cont.) Unsatisfied with this response, the RN, who had already stopped the PCA, called the surgeon to express her concern. The surgeon ordered naloxone (Narcan). The patient immediately awoke, and the altered mental status and respiratory depression were reversed.

19. Reporting Breach of Professionalism • Should report the error in judgment and professionalism through the QI process • The report can document unprofessional behavior on several levels: • Failure to respect the judgment and concern of a team member • Failure at self-assessment of cognitive impairment induced by sleep or other problems • Failure to responsibly back up a fellow team member

20. Responding to Significant Breach of Professionalism • Approach issues of professionalism first as potential systems problems, which can be remediated with changes in the system • Education in professionalism often leads to the desired outcomes of safe, high quality care and collegial work relationships • Culture of “no blame” and system responsibility for safety issues can permit discussion of root causes of unprofessional behavior

21. Professionalism in Medical Education • ACGME requires that residency programs teach and evaluate professionalism • The American Medical Association Council on Ethical and Judicial Affairs considers physicians attending to their own health and wellness, as well as the health of their colleagues, an ethical imperative American Medical Association.

22. Changing Attitudes about Fatigue • Fatigue and physical or emotional exhaustion should be considered unacceptable risks to safe care, rather than signs of dedication • ACGME requires training programs to “educate faculty and residents…to recognize the signs of fatigue….and adopt and apply policies to prevent and counteract the potential negative effects” • Policies include duty-hour limitations of 80 hours per week, 30 hours of continuous duty without a break, and at least 1 day in 7 free of clinical duties Accreditation Council for Graduate Medical Education.

23. Professionalism in Medical Education • Some educators express concern that emphasizing physician self care and adopting a “shift-work mentality” may interfere with the physician-patient relationship and destroy medical professionalism • These concerns ignore the larger problem of fatigue-related burnout, depression, and emotional defensiveness expressed as cynicism or resentment resulting in detachment and a lack of compassion for patients

24. Assessing Professionalism Among Trainees • Important to identify and track incidents of unprofessional behavior • Obtain ratings of professional behavior from peers, nurses, telephone operators, and other team members • The National Board of Medical Examiners is testing a survey for use in medical schools • Professionalism Mini-CEX provides feedback to trainees about professional relationships observed during patient encounters See Notes for references.

25. Assessing Professionalism Among Trainees (cont.) • Objective Standardized Clinical Evaluations • Test communication and interpersonal skills • Teaching and formative evaluation of professionalism can be conducted at student or practicing team level through critical incident root cause analysis and reflection on action Cohen JJ. Med Educ. 2006;40:607-617. Epstein RM, Hundert EM. JAMA. 2002;287:226-235.

26. Professional Well Being • Internet resources • Physician’s Guide to the Internet: Physician’s Health and Well Being • The Center for Professional Well Being • The Vanderbilt Center for Professional Health

27. Take-Home Points • Professionalism is a core competency for all physicians • Prevention of and monitoring for burnout can improve professionalism among providers • Promoting physician well being must be a priority for health care systems and training programs