'More than words' - Interpersonal communication, cognitive bias and diagnostic errors

Why I Discourage "ED Course" in Oral Patient Presentations

Trainees frequently present data, including vital signs, laboratory test results, and imaging results, just after the history or presenting illness in a section labeled "ED Course." This practice distracts from the history and physical and decenters the patient as the most valuable source of diagnostic data. Reformatting presentations to appropriately present objective data after the complete history may improve diagnosis and refocuses attention on the patient.

Communication failures and racial disparities in inpatient maternity care: a qualitative content analysis of incident reports

BACKGROUND

Severe maternal morbidity (SMM) and mortality disproportionality affect Black women in the USA. Communication failures are a leading cause of poor maternal outcomes. We examined incident reports to identify communication failures within inpatient maternity care and racial disparities therein.

METHODS

We analysed de-identified incident reports submitted by hospital staff working on antepartum, labour and birth, and postpartum in an urban, academic hospital between 2019 and 2022. Reports were linked to electronic health records to capture race and SMM outcome. We conducted qualitative content analyses using a constant comparative method and an inductive and deductive approach. We explored communication failures by race/ethnicity and SMM outcome. In vivo themes included equity and positive communication.

RESULTS

We identified 541 communication failures within a random sample (n=1006) of incident reports across the study period. Black women represented 28% of births during this time, but 38% of the incident reports. Most of the communication failures occurred within the healthcare team rather than with patients. Communication failures were, broadly, contextual (eg, audience, who was present), conceptual (eg, lack of shared understanding) or sociotechnical (eg, computer-human interface). Of the incident reports coded as contextual failures, errors of omission were the most common. Most conceptual failures were a lack of shared understanding. Sociotechnical failures were predominantly workflow and communication and internal organisational features.

CONCLUSIONS

Our findings suggest that if we want to address communication failures as a root cause of maternal morbidity and mortality, we need to focus on the quality of communication within the healthcare team. These efforts should concentrate on decreasing omission and building shared understanding of responsibilities and processes, especially when teams are caring for Black women.

Typology of solutions addressing diagnostic disparities: gaps and opportunities

OBJECTIVES

Diagnostic disparities are preventable differences in diagnostic errors or opportunities to achieve diagnostic excellence. There is a need to summarize solutions with explicit considerations for addressing diagnostic disparities. We aimed to describe potential solutions to diagnostic disparities, organize them into an action-oriented typology with illustrative examples, and characterize these solutions to identify gaps for their further development.

METHODS

During four human-centered design workshops composed of diverse expertise, participants ideated and clarified potential solutions to diagnostic disparities and were supported by environmental literature scan inputs. Nineteen individual semi-structured interviews with workshop participants validated identified solution examples and solution type characterizations, refining the typology.

RESULTS

Our typology organizes 21 various types of potential diagnostic disparities solutions into four primary expertise categories needed for implementation: healthcare systems' internal expertise, educator-, multidisciplinary patient safety researcher-, and health IT-expertise. We provide descriptions of potential solution types ideated as focused on disparities and compare those to existing examples. Six types were characterized as having diagnostic-disparity-focused examples, five as having diagnostic-focused examples, and 10 as only having general healthcare examples. Only three solution types had widespread implementation. Twelve had implementation on limited scope, and six were mostly hypothetical. We describe gaps that inform the progress needed for each of the suggested solution types to specifically address diagnostic disparities and be suitable for the implementation in routine practice.

CONCLUSIONS

Numerous opportunities exist to tailor existing solutions and promote their implementation. Likely enablers include new perspectives, more evidence, multidisciplinary collaborations, system redesign, meaningful patient engagement, and action-oriented coalitions.

Implementation of Cultural Awareness and Cognitive Bias Training Within Graduate Nursing Programs

BACKGROUND

Cognitive bias negatively affects patient outcomes, resulting in medical errors, sentinel events, and legal claims. The brunt of bias-induced inequities and disparities has fallen on Black and Brown people, women, and the LGBTQ+ communities. Faculty training programs have rapidly increased in number, whereas student training has lagged.

METHOD

A three-part curricular series was developed for students seeking nurse practitioner (NP) training. The series addressed racial bias, microaggression, and gender bias using vignettes and guided pre- and debriefing.

RESULTS

The series was initially implemented to 70 students from four different specialty areas of study. Students resoundingly reported the content as valuable and challenging and the environment as a safe space to learn, be vulnerable, and be empathetic to the experiences of others.

CONCLUSION

This three-part series has been implemented across eight NP majors and has become a required component of the NP on-campus intensive experience. [J Nurs Educ. 2024;63(11):777-780.].

Using incident reports to diagnose communication challenges for precision intervention in learning health systems: A methods paper

Introduction

Poor communication is a leading root cause of preventable maternal mortality in the United States. Communication challenges are compounded with the presence of biases, including racism. Hospital administrators and clinicians are often aware that communication is a problem, but understanding where to intervene can be difficult to determine. While clinical leadership routinely reviews incident reports and acts on them to improve care, we hypothesized that reviewing incident reports in a systematic way might reveal thematic patterns, providing targeted opportunities to improve communication in direct interaction with patients and within the healthcare team itself.

Methods

We abstracted incident reports from the Women's Health service and linked them with patient charts to join patient's race/ethnicity, birth outcome, and presence of maternal morbidity and mortality to the incident report. We conducted a qualitative content analysis of incident reports using an inductive and deductive approach to categorizing communication challenges. We then described the intersection of different types of communication challenges with patient race/ethnicity and morbidity outcomes.

Results

The use of incident reports to conduct research on communication was new for the health system. Conversations with health system-level stakeholders were important to determine the best way to manage data. We developed a thematic codebook based on prior research in healthcare communication. We found that we needed to add codes that were equity focused, as this was missing from the existing codebook. We also found that clinical and contextual expertise was necessary for conducting the analysis-requiring more resources to conduct coding than initially estimated. We shared our findings back with leadership iteratively during the work.

Conclusions

Incident reports represent a promising source of health system data for rapid improvement to transform organizational practice around communication. There are barriers to conducting this work in a rapid manner, however, that require further iteration and innovation.

Refining a Framework to Enhance Communication in the Emergency Department During the Diagnostic Process: An eDelphi Approach

BACKGROUND

Emergency departments (EDs) are susceptible to diagnostic error. Suboptimal communication between the patient and the interdisciplinary care team increases risk to diagnostic safety. The role of communication remains underrepresented in existing diagnostic decision-making conceptual models.

METHODS

The authors used eDelphi methodology, whereby data are collected electronically, to achieve consensus among an expert panel of 18 clinicians, patients, family members, and other participants on a refined ED-based diagnostic decision-making framework that integrates several potential opportunities for communication to enhance diagnostic quality. This study examined the entire diagnostic process in the ED, from prehospital to discharge or transfer to inpatient care, and identified where communication breakdowns could occur. After four iterative rounds of the eDelphi process, including a final validation round by all participants, the project's a priori consensus threshold of 80% agreement was reached.

RESULTS

The authors developed a final framework that positions communication more prominently in the diagnostic process in the ED and enhances the original National Academies of Sciences, Engineering, and Medicine (NASEM) and ED-adapted NASEM frameworks. Specific points in the ED journey were identified where more attention to communication might be helpful. Two specific types of communication-information exchange and shared understanding-were identified as high priority for optimal outcomes. Ideas for communication-focused interventions to prevent diagnostic error in the ED fell into three categories: patient-facing, clinician-facing, and system-facing interventions.

CONCLUSION

This project's refinement of the NASEM framework adapted to the ED can be used to develop communications-focused interventions to reduce diagnostic error in this highly complex and error-prone setting.

Non-violent communication as a technology in interpersonal relationships in health work: a scoping review

BACKGROUND

Working in healthcare environments is highly stressful for most professionals and can trigger problems in interpersonal relationships that can result in horizontal violence. In order to prevent violence and improve the working environment, some strategies can be implemented to provide well-being for all those involved, whether directly or indirectly in health care, such as non-violent communication. The aim of this study was to map and synthesize the available scientific evidence on the use of Nonviolent Communication as a technology for a culture of peace in interpersonal relationships in healthcare.

METHODS

This is a scoping review carried out in the National Library of Medicine (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Excerpa Medica DataBASE (Embase), PsycINFO - APA/ PsycNET (American Psychological Association) and Latin American and Caribbean Health Sciences Literature (LILACS) databases between March and August 2023. The eligibility criteria used were studies that addressed the topic of NVC in the area of health, published in Portuguese, Spanish or English, with no time restrictions.

RESULTS

53 studies were found in the databases. Two additional studies were extracted from of primary research. In the first exclusion phase, 16 texts were removed due to being duplicated. 39 articles were potentially relevant, and full-texts were reviewed for eligibility along with the inclusion and exclusion criteria Thus, seven studies were included in this review, published in English (five) and Portuguese (two), two of which were carried out in Brazil, one in the United States of America, one in South Korea, one in France, one in Canada and one in Thailand. In terms of the type of study/publication, two studies were reflections, one was a review, one was a mixed study, one was an experience report and two were experimental. The studies were predominantly of high and moderate methodological quality (85.7%). The total number of participants in the studies was 185. The studies showed that NVC is a technology that has made it possible to improve interpersonal relationships between health professionals. Training programs or educational intervention projects on the subject are useful for familiarizing professionals with the subject and demonstrating situations in which the technique can be included.

CONCLUSION

The global scientific literature indicates that Nonviolent Communication is a significant resource for improving interpersonal relationships in healthcare work. This approach can be adopted as a strategy by managers and decision-makers, both to resolve conflicts and to prevent aggressive situations between health professionals, especially when it comes to moral or psychological aspects.

Understanding diagnostic conversations in clinical practice: A systematic review

OBJECTIVE

Summarize frameworks to understand diagnostic conversations and assessments of diagnostic conversations in practice.

METHODS

We systematically searched MEDLINE, Scopus, Cochrane, and other databases from inception to July 2022 for reports of diagnostic conversations. Two authors independently reviewed studies for eligibility, assessed methodological quality with the mixed methods appraisal tool and extracted information related to study characteristics, frameworks and components evaluated in assessments of diagnostic conversations and results.

RESULTS

Eight studies were included. One study reported an empiric framework of diagnostic conversations that included the following components: identifying the problem that requires diagnosis, obtaining information, and delivering the diagnosis and treatment plan. Thematic analyses highlighted communication between patients and clinicians as central in diagnostic conversations as it allows a) patient's presentation of their symptoms which guide subsequent diagnostic steps, b) negotiation of the significance of the patient's symptoms through conversation and c) introducing and resolving diagnostic uncertainty.

CONCLUSION

Despite the importance of diagnostic conversation only one empiric framework described its components. Additionally, limited available evidence suggests patients can have an important role in the diagnostic process that expands beyond patients as an information source.

PRACTICE IMPLICATIONS

Patients should be included as active partners in co-development of diagnostic plans of care.

How does work environment relate to diagnostic quality? A prospective, mixed methods study in primary care

OBJECTIVES

The quest to measure and improve diagnosis has proven challenging; new approaches are needed to better understand and measure key elements of the diagnostic process in clinical encounters. The aim of this study was to develop a tool assessing key elements of the diagnostic assessment process and apply it to a series of diagnostic encounters examining clinical notes and encounters' recorded transcripts. Additionally, we aimed to correlate and contextualise these findings with measures of encounter time and physician burnout.

DESIGN

We audio-recorded encounters, reviewed their transcripts and associated them with their clinical notes and findings were correlated with concurrent Mini Z Worklife measures and physician burnout.

SETTING

Three primary urgent-care settings.

PARTICIPANTS

We conducted in-depth evaluations of 28 clinical encounters delivered by seven physicians.

RESULTS

Comparing encounter transcripts with clinical notes, in 24 of 28 (86%) there was high note/transcript concordance for the diagnostic elements on our tool. Reliably included elements were red flags (92% of notes/encounters), aetiologies (88%), likelihood/uncertainties (71%) and follow-up contingencies (71%), whereas psychosocial/contextual information (35%) and mentioning common pitfalls (7%) were often missing. In 22% of encounters, follow-up contingencies were in the note, but absent from the recorded encounter. There was a trend for higher burnout scores being associated with physicians less likely to address key diagnosis items, such as psychosocial history/context.

CONCLUSIONS

A new tool shows promise as a means of assessing key elements of diagnostic quality in clinical encounters. Work conditions and physician reactions appear to correlate with diagnostic behaviours. Future research should continue to assess relationships between time pressure and diagnostic quality.

Communication of Diagnostic Uncertainty in Primary Care and Its Impact on Patient Experience: an Integrative Systematic Review

BACKGROUND

Diagnostic uncertainty is a pervasive issue in primary care where patients often present with non-specific symptoms early in the disease process. Knowledge about how clinicians communicate diagnostic uncertainty to patients is crucial to prevent associated diagnostic errors. Yet, in-depth research on the interpersonal communication of diagnostic uncertainty has been limited. We conducted an integrative systematic literature review (PROSPERO CRD42020197624, unfunded) to investigate how primary care doctors communicate diagnostic uncertainty in interactions with patients and how patients experience their care in the face of uncertainty.

METHODS

We searched MEDLINE, PsycINFO, and Linguistics and Language Behaviour Abstracts (LLBA) from inception to December 2021 for MeSH and keywords related to 'communication', 'diagnosis', 'uncertainty' and 'primary care' environments and stakeholders (patients and doctors), and conducted additional handsearching. We included empirical primary care studies published in English on spoken communication of diagnostic uncertainty by doctors to patients. We assessed risk of bias with the QATSDD quality assessment tool and conducted thematic and content analysis to synthesise the results.

RESULTS

Inclusion criteria were met for 19 out of 1281 studies. Doctors used two main communication strategies to manage diagnostic uncertainty: (1) patient-centred communication strategies (e.g. use of empathy), and (2) diagnostic reasoning strategies (e.g. excluding serious diagnoses). Linguistically, diagnostic uncertainty was either disclosed explicitly or implicitly through diverse lexical and syntactical constructions, or not communicated (omission). Patients' experiences of care in response to the diverse communicative and linguistic strategies were mixed. Patient-centred approaches were generally regarded positively by patients.

DISCUSSION

Despite a small number of included studies, this is the first review to systematically catalogue the diverse communication and linguistic strategies to express diagnostic uncertainty in primary care. Health professionals should be aware of the diverse strategies used to express diagnostic uncertainty in practice and the value of combining patient-centred approaches with diagnostic reasoning strategies.

Human centered design workshops as a meta-solution to diagnostic disparities

OBJECTIVES

Diagnostic errors - inaccurate or untimely diagnoses or failures to communicate diagnoses - are harmful and costly for patients and health systems. Diagnostic disparities occur when diagnostic errors are experienced at disproportionate rates by certain patient subgroups based, for example, on patients' age, sex/gender, or race/ethnicity. We aimed to develop and test the feasibility of a human centered design workshop series that engages diverse stakeholders to develop solutions for mitigating diagnostic disparities.

METHODS

We employed a series of human centered design workshops supplemented by semi-structured interviews and literature evidence scans. Co-creation sessions and rapid prototyping by patient, clinician, and researcher stakeholders were used to generate design challenges, solution concepts, and prototypes.

RESULTS

A series of four workshops attended by 25 unique participants was convened in 2019-2021. Workshops generated eight design challenges, envisioned 29 solutions, and formulated principles for developing solutions in an equitable, patient-centered manner. Workshops further resulted in the conceptualization of 37 solutions for addressing diagnostic disparities and prototypes for two of the solutions. Participants agreed that the workshop processes were replicable and could be implemented in other settings to allow stakeholders to generate context-specific solutions.

CONCLUSIONS

The incorporation of human centered design through a series of workshops promises to be a productive way of engaging patient-researcher stakeholders to mitigate and prevent further exacerbation of diagnostic disparities. Healthcare stakeholders can apply human centered design principles to guide thinking about improving diagnostic performance and to center diverse patients' needs and experiences when implementing quality and safety improvements.

Translating knowledge into practice for communication skills training for health care professionals

Despite the evidence that person-centred communication underpins all that we do in our interactions with patients, caregivers and team members, the knowledge about the implementation of systematic communication skills training is still in its infancy. This position paper describes some of the main contextual facilitators for translating knowledge about communication skills training for health care professionals (HCP) and recommends ways to guide practical implementation. Based on the literature that has been published over the last two decades, it seems evident that communication skills training programs should be underpinned by clinician self-reflection, be experiential, and focused on behaviour change and implementation of new skills into practice. The programs should be delivered by trainers possessing an understanding of communication micro skills, the skills and confidence to observe interactions, and coach learners through the rehearsal of alternative approaches. Communication skills programs should be flexible to adapt to individual learners, local needs, and circumstances. Interventions should not be limited to the empowerment of individual HCP but should be a part of the organisational quality assurance framework, e.g., by including communication skills in clinical audits. Implementation science frameworks may provide tools to align programs to the context and to address the determinants important for a sustained implementation process. Programs need to be embedded as 'core business', otherwise the culture change will be elusive and sustainability under threat if they are only dependent on provisional funding.

Cognitive Bias and Diagnostic Errors among Physicians in Japan: A Self-Reflection Survey

This cross-sectional study aimed to clarify how cognitive biases and situational factors related to diagnostic errors among physicians. A self-reflection questionnaire survey on physicians’ most memorable diagnostic error cases was conducted at seven conferences: one each in Okayama, Hiroshima, Matsue, Izumo City, and Osaka, and two in Tokyo. Among the 147 recruited participants, 130 completed and returned the questionnaires. We recruited primary care physicians working in various specialty areas and settings (e.g., clinics and hospitals). Results indicated that the emergency department was the most common setting (47.7%), and the highest frequency of errors occurred during night-time work. An average of 3.08 cognitive biases was attributed to each error. The participants reported anchoring bias (60.0%), premature closure (58.5%), availability bias (46.2%), and hassle bias (33.1%), with the first three being most frequent. Further, multivariate logistic regression analysis for cognitive bias showed that emergency room care can easily induce cognitive bias (adjusted odds ratio 3.96, 95% CI 1.16−13.6, p-value = 0.028). Although limited to a certain extent by its sample collection, due to the sensitive nature of information regarding physicians’ diagnostic errors, this study nonetheless shows correlations with environmental factors (emergency room care situations) that induce cognitive biases which, in turn, cause diagnostic errors.

Diagnostic statements: a linguistic analysis of how clinicians communicate diagnosis

OBJECTIVES

To investigate from a linguistic perspective how clinicians deliver diagnosis to patients, and how these statements relate to diagnostic accuracy.

METHODS

To identify temporal and discursive features in diagnostic statements, we analysed 16 video-recorded interactions collected during a practice high-stakes exam for internationally trained clinicians (25% female, n=4) to gain accreditation to practice in Australia. We recorded time spent on history-taking, examination, diagnosis and management. We extracted and deductively analysed types of diagnostic statements informed by literature.

RESULTS

Half of the participants arrived at the correct diagnosis, while the other half misdiagnosed the patient. On average, clinicians who made a diagnostic error took 30 s less in history-taking and 30 s more in providing diagnosis than clinicians with correct diagnosis. The majority of diagnostic statements were evidentialised (describing specific observations (n=24) or alluding to diagnostic processes (n=7)), personal knowledge or judgement (n=8), generalisations (n=6) and assertions (n=4). Clinicians who misdiagnosed provided more specific observations (n=14) than those who diagnosed correctly (n=9).

CONCLUSIONS

Interactions where there is a diagnostic error, had shorter history-taking periods, longer diagnostic statements and featured more evidence. Time spent on history-taking and diagnosis, and use of evidentialised diagnostic statements may be indicators for diagnostic accuracy.