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Team communication


Let's talk

Speaking up


  • All members of the team should have a voice.
  • Team members should speak up respectfully if they have a concern about the safety of the patient.

Case: A 16-year-old male with leukemia
Close up of male teenager's arm on intravenous

Background

During the last cycle of chemotherapy, the patient's oncologist is running behind schedule and asks a junior resident to administer three chemotherapeutic agents to the patient. The pharmacy had sent all three preloaded syringes in the same medication pouch.

The resident has had little orientation to the oncology service and asks the supervising oncologist to clarify his instructions. Instead, he is chided for not knowing how to do this.

Think about it

What is the best next step for this resident?

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Case: Questioning another clinician's assessment
Two physicians discussing an on-screen test result

Background

A 27-year-old health economist and active rower presents in the emergency department complaining of sudden headaches, weakness in his right arm and leg, slurred speech, nausea, vomiting, and mild aphasia.

A three-vessel arteriogram is ordered, and the staff interventional radiologist reads the films as normal. The radiology resident (who has been on this rotation for only two weeks) also reviews them, and notes that the left carotid artery looks narrower than the right. When the resident mentions her observation to the staff radiologist, he replies "that's how the left carotid artery appears in young people." The resident feels that some further review is probably indicated, but is not confident enough to pursue it further with a staff physician.

Outcome

Several days later, the patient is readmitted after developing partial paralysis. A repeat arteriogram reveals a left internal carotid artery dissection with emboli involving the middle cerebral and anterior cerebral arteries. Irreversible brain damage has occurred.

Think about it

How might the resident's concerns been asserted more effectively?
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Stylized side view of individual speaking into another's ear

There may be times when trainees or other healthcare providers find it difficult to speak up and share their opinions or concerns about an evolving clinical situation or impending patient safety incident. They may be afraid to do so because they are not encouraged to share their thoughts and opinions.

The hierarchies in medicine — differences in professional stature or seniority — can inhibit speaking up.

Effective assertiveness is:
  • respectful and polite (not aggressive) appropriately timed
  • constructive and focused on achieving clarification and a solution

Supervisors should welcome polite questions and concerns from their trainees. Trainees should recognize the clinical experience and wisdom of their supervisors.

Rather than relying on "hinting and hoping," some clinical units have adopted the use of critical language to get another team member's attention. Graded assertiveness is a communication approach adapted from the aerospace industry and the military to effectively raise concerns with another team member when one believes the other team member's judgment or decision may be incorrect.

Case: A question about dosage
Female resident taking notes

Background

As a resident you are speaking with the senior resident supervisor regarding an inpatient. The senior resident gives a verbal order for warfarin which you believe is double the appropriate dose for this patient.

Think about it

Using graded assertiveness, how might you discuss your concerns with the senior resident?
Levels of urgency

Suggestions

Level 1: That's higher than the dose I was expecting.
Level 2: Perhaps we should check the dose?
Level 3: Is there a reason for the higher dose in this patient?
Level 4: Dr. Jones, the dose you ordered is too high for this patient.

Your choice of level would depend on the urgency of the situation and on the response to lower levels.

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Other approaches include the following:

1. Two-challenge rule — A concern is stated at least two times to ensure it has been heard

2. CUS — to voice one's increasing concern

  • C - "I'm concerned"  
  • U - "I'm uncomfortable" or "This is unsafe"
  • S - "This is a safety issue" or "I am scared"

3. Let's chat! The MOREOB (Managing Obstetrical Risk Efficiently) program — teaches the use of CHAT, a communication tool for team members when wanting to voice a concern in a birthing centre. CHAT stands for:

  • C - Context
  • H - History
  • A - Assessment
  • T - Tentative plan

To learn more about the responsibilities of supervisors and trainees, see the section on Delegation and supervision.