Transcript ppt - AAOS

INTER-PROFESSIONAL
RELATIONS and
COMMUNICATION
AAOS ETHICS COMMITTEE
S. Jay Jayasankar, MD.
1
Objectives
• Learn what ‘competent medical care’
(AMA)1 entails in the context of the
orthopaedic surgeon’s ‘primary
purpose of caring for the patient’
(AAOS)2
• Investigate the nuances in applying 3
of 6 physician core competencies
(ACGME, ABMS-MOC)3,4
o Patient Care
o Interpersonal and Communication Skills
o Professionalism
2
• Understand the essential elements of
effective communication and learn
communication’s key role in:
o Physician-patient and inter-professional
relationships (AAOS)1 (AMA)2
o Developing, utilizing expert teams (AAOS)1
o Using talents of other professionals
(AMA)2
• Learn what resources are available
from the AAOS for improving
communication skills5,6
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Ethical Guidance
AAOS Code of Ethics, V.A.2
“Good relationships among physicians, nurses,
and other health care professionals are
essential for good patient care. The orthopaedic
surgeon should promote the development and
utilization of an expert health care team that
will work together harmoniously to provide optimal
patient care.”
AMA Principles of Medical Ethics. V.1
A physician shall …use the talents of other health
professionals when indicated.
4
Case
Mr. Boudreau is a 45-year-old male
with a left knee patellar tendon
rupture from a
basketball injury.
Yesterday the
emergency room
physician instructed
Mr. Boudreau to
return to see
Dr. Winter, the on call orthopaedic
surgeon.
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iStockphoto/Thinkstock
Dr. Winter structures the evaluation
around the hospital “H&P Short
Form” for day surgery
patients. Dr. Winter
completes the form
while Mr. Boudreau
answers his questions.
The notes indicate
previous surgery on the right knee
and hernia repair. Dr. Winter obtains
informed consent and arranges for
outpatient surgery that same day.
iStockphoto/Thinkstock
6
“Bleeding/Clotting” is checked in the
nurse’s notes, and clotting is circled.
The nurse also notes
that the patient had
hernia repair at age
16 and a history of
deep venous
thrombosis (DVT)
following anterior
cruciate ligament (ACL), medial
collateral ligament (MCL) repair and
full reconstruction of the right knee
six years earlier.
Ingram Publishing/Thinkstock
7
The nurse anesthetist also noted
DVT related to a prior ACL surgery.
Dr. Winter repairs
the tendon under
general
anesthesia and
discharges
Mr. Boudreau
on oral oxycodone.
Fuse/Thinkstock
8
Do Dr. Winter’s evaluation and management
constitute:
A. Competency (AMA- I.)1 and
B. Effective communication for good
patient-physician relationship (AAOSI.A.)?2
What actions of Dr. Winter lead you to your
conclusion?
Do the nurse’s notes provide good
communication necessary to deliver
competent medical care?
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Dr. Winter did not read the nurse’s
notes and thus was unaware of Mr.
Boudreau’s history of DVT.
In addition, he did not ask
Mr. Boudreau about the
outcome of prior surgeries, or
whether any complications or medical
issues arose afterwards.
In Dr. Winter’s experience
a patient will volunteer this
information, so customarily he does
not ask.
iStockphoto/Thinkstock
10
Does Mr. Boudreau have a
responsibility to inform Dr. Winter of
his DVT?
What physician skills are necessary
to elicit relevant history?
Does Dr. Winter have a responsibility
to read the nurses’ notes?
Do the nurses have a responsibility
to personally inform Dr. Winter of
Mr. Boudreau’s DVT history?
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Two weeks post op, Mr. Boudreau
returns to Dr. Winter’s office for
suture removal.
In the office visit
questionnaire that
Mr. Boudreau
completes, he
reveals that
there is a family
history of blood clotting disorders.
iStockphoto/Thinkstock
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Dr. Winter remembers having
reviewed the form briefly with the
patient and recalls
asking about this
and learning that
the patient’s brother
had sustained a
stroke. Dr. Winter
does not ask
Mr. Boudreau about his personal
history of clotting disorder.
iStockphoto/Thinkstock
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Dr. Winter’s notes at this visit
indicate that Mr. Boudreau is doing
well with intact neurovascular
status of the leg. There was no
notation re: examination for signs
of DVT. He is advised to stay in an
immobilizer for an additional 3½
weeks and a follow-up appointment
is scheduled.
14
Do Dr. Winter’s evaluation and
management at this visit
constitute competency?
What actions of Dr. Winter lead
you to this conclusion?
15
The orthopaedist who performed
the ACL reconstruction on the
opposite knee six years earlier is a
colleague of Dr. Winter in the same
practice. The office records
indicated that 6½ weeks after the
previous ACL surgery, Mr. Boudreau
had non-tender but substantial
swelling in his right calf.
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An ultrasound revealed “a very
large, deep clot up to
the femoral region.”
Mr. Boudreau was
hospitalized, treated
with heparin, and
discharged four days
later on Coumadin which he took
for about six months. There was no
indication in Dr. Winter’s post op
visit notes that he had read these
notes from the earlier treatment.
Oleg Shipov/iStock/Thinkstock
17
Were any ethical norms
transgressed by Dr. Winter
by not reading the notes of
his colleague from the
previous treatment?
If so, which of the ones
referred to in this module?
18
Two days after the post op visit, the
patient was found dead in his home
due to a massive pulmonary
embolism.
Dr. Winter acknowledged that had he
known of Mr. Boudreau’s prior DVT,
he would have investigated it, and,
there being no contraindications
for anticoagulation therapy, would
have prescribed it.
19
Dr. Winter did not anticoagulate as he
indicated he would have. Which core
competencies (ACGME, ABMS- MOC)3,4
are involved?
•Patient Care
•Medical Knowledge
•Interpersonal and Communication Skills
•Professionalism
•System-based Practice
•Practice-based Learning and Improvement
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Summary
Mr. Boudreau had a past history
of DVT which was well
documented. Dr. Winter did not
obtain nor read the nurse’s
notes, nor did he read, at Mr.
Boudreau’s postop office visit,
the office notes of his practice
colleague who had done the prior
surgery and treated the DVT
episode.
21
There is no unanimity of evidence/
consensus-based best practice for
prophylaxis against postop DVT,
even for a person with a prior
history.14 Dr. Winter stated that had
he known of Mr. Boudreau’s DVT
history, he would have
prophylactically anti-coagulated the
patient because of the high risk.
Unfortunately Mr. Boudreau died of
pulmonary embolism two days after
the postop office visit.
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What role did each of the following
have in the events that led to
Mr. Boudreau’s death?
• Inter-professional Relations
• Communication
• Teamwork
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Recommendations Related to
Inter-professional Relations
and Communication
Knowledge and surgical skills are
important, but in addition:
• Be mindful and aware of self and
environment
• Practice ‘active listening’ to patients and
team members
• Utilize the talents of other team members
• Elicit, seek, organize, and transmit
information
• Acknowledge/appreciate communication
• Encourage non-hierarchical interaction
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References:
1. American Medical Association. Principles of Medical
Ethics. http://www.ama-assn.org/ama/pub/physicianresources/medical-ethics/code-medicalethics/principles-medical-ethics.page
2. American Academy of Orthopaedic Surgeons. Code of
Ethics and Professionalism for Orthopaedic Surgeons,
I.A., II.A., V.A. Accessed on Sept. 26.2013 at
http://www.aaos.org/about/papers/ethics/code.asp
3. Common Program Requirements: General
Competencies. Approved by the ACGME Board February
13, 2007. http://www.cme.hsc.usf.edu/latestdocs/05ACGME%20COMPETENCIES.pdf
4. American Board of Medical Specialties. MOC
Competencies and Criteria.
http://www.abms.org/Maintenance_of_Certification/M
OC_competencies.aspx
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5. American Academy of Orthopaedic Surgeons
Communication Skills Mentorship Program.
http://www3.aaos.org/education/csmp/about.cfm
6. Gebhardt MC: Communication matters. AAOS Now, May
2011.
http://www.aaos.org/news/aaosnow/may11/managing5.asp
7. American Academy of Orthopaedic Surgeons
TeamStepps Program.
http://www.aaos.org/education/TeamSTEPPS/teamhome.asp
8. Mevis H: AAOS begins second year of TeamSTEPPS
project. AAOS Now, April 2013.
http://www.aaos.org/news/aaosnow/april13/clinical6.asp
9. Beckman HB, Frankel RM: The Effect of Physician
Behavior on the Collection of Data. Ann Intern Med.
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10. Leape LI, Brennan TA, Laird N, Lawthers AG, Localio AR,
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11. American Academy of Orthopaedic Surgeons: Shared
physician-patient responsibilities. Position Statement
1182. Adopted Decemer 2011.
http://www.aaos.org/about/papers/position/1182.asp
12. AAOS Standards of Professionalism, Professional
Relationships, Mandatory Standard 4. Adopted April
18, 2005.
http://www3.aaos.org/member/profcomp/profrelation.pdf
13. Perneger TV. The Swiss cheese model of safety
incidents: Are there holes in the metaphor? BMC
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14. Reason J: Human error: models and management. BMJ
2000;320:768–70.
15. Kelly L. Listening to patients: a lifetime perspective
from Ian McWhinney. CJRM 1998;3:168–9.
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16. American Academy of orthopaedic Surgeons:
Preventing venous thromboembolic disease in patients
undergoing elective hip and knee arthroplasty.
Evidence-based guideline and evidence report, 2011.
http://www.aaos.org/Research/guidelines/VTE/VTE_
full_guideline.pdf
17. Jayasankar SJ: What does it take to make our practices
safe? AAOS Now, May 2011.
http://www.aaos.org/news/aaosnow/may11/managing6.asp
18. Epstein RM: Mindful practice. JAMA, 1999;282(9):833839.
19. Quote from Knight S. in: Robertson K. Active listening.
Australian Family Physician, 2005;34:1053-1055
20. Crew Resource Management: An Introductory
Handbook. US Department of Transportation, Federal
Aviation Administration. August 1992. ADA257441
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21. The Joint Commission Sentinel Alert on Preventing
Unintended Retention of Foreign Objects.
http://www.jointcommission.org/sea_issue_51/
22. Institute for Healthcare Improvement: SBAR
Technique for Communication: A Situational Briefing
Model. Accessed on October 3, 2013 at:
http://www.ihi.org/knowledge/Pages/Tools/SBARTechniqu
eforCommunicationASituationalBriefingModel.aspx
23. Graham KC, Cvach M: Monitor Alarm Fatigue:
Standardizing Use of Physiological Monitors and
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2010;19:28-34.
24. Makary MA, Sexton JB, Freischlag JA, Holzmuller CG,
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25. Harden SW: Surgeons and teamwork. AAOS Now,
March 2011.
http://www.aaos.org/news/aaosnow/mar11/managing3.asp
26. American Academy of Orthopaedic Surgeons: PatientPhysician Communication. Information Statement
1017. Adopted December 2000. Revised 2005 and
2011.
http://www.aaos.org/about/papers/advistmt/1017.asp
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