The Importance of Emotional Intelligence in Human Factors Error Management in Medical Leadership.

As a former USAF fighter pilot and career airline captain my training was always focused on error avoidance and error management. In the aviation world, errors can kill us and others. The concepts of Human Factors and Error Management for aviation, transfer directly to the medical community.  While the aviation community has been addressing the issue of error mitigation/management for quite some time, it is relatively new to the operating room (Helmreich, 2000).  Studies indicate that as many as 100,000 patients die in the US each year from medical errors (Bohnen & Lingard, 2003; Helmreich, 2000). Recently, a Johns Hopkins Study places medical errors as the third leading cause of death in the US, topping 250,000 per year.  Emotional Intelligence (EI) is gaining importance as a major component for improvement in leadership and Human Factors (HF) integration.

The concept of EI is fairly new and is still the subject of debate.  For the purpose of this discussion let’s look at Daniel Golemen’s definition of Emotional Intelligence as cited by Wiley (2003).

The good news is that, according to Goleman, Emotional Intelligence can be learned. There are five dimensions to this, he says. These are:

  • Self-awareness: We seldom pay attention to what we feel. A stream of moods runs in parallel to our thoughts. This and previous emotional experiences provide a context for our decision-making.
  • Managing emotions: All effective leaders learn to manage their emotions, especially the big three: anger, anxiety, and sadness. This is a decisive life ski
  • Motivating others: The root meaning of motive is the same as the root of emotion: to move.
  • Showing empathy: The flip side of self-awareness is the ability to read emotions in others.
  • Staying connected: Emotions are contagious. There is an unseen transaction that passes between us in every interaction that makes us feel either a little better or a little worse. Goleman calls this a ‘secret economy’. It holds the key to motivating the people we work with. (Wiley, 2003)

EI has documented acceptance in the psychological and business communities.  This exploration is not contingent upon detailed variations in the concept of EI but in the gross application of the general concept as a skill. The need for improved EI is cross cultural as presented in the article, Doctors’ emotional intelligence and the patient-doctor relationship (Weng, Chen, H., Chen, H., Lu, & Hung 2008). This article begins by confirming that EI is an important component in the patient-doctor relationship. Weng et al. describe how EI is being assessed in some medical schools to screen applicants (p. 703). Most importantly for this discussion, they identify that their study is unique from previous studies because they did not rely on doctors’ self-ratings (p. 704). In comparing the relative EI score of the doctors, it was discovered that self-assessments did not correlate to EI scores garnered from external evaluators relative to the doctor patient relationship (p. 706). This particular point is developed in Helmreich’s article “On error management: Lessons from aviation.”(Helmreich, 2000)  Helmreich discusses the personality commonalities of pilots and doctors, how both groups suffer from inaccurate self-perceptions (p. 782). Epstein and Hundert further define this problem in their analysis (2002).  They claim that errors in medicine may be due to doctors believing in the infallibility of their judgment, especially during times of stress (Epstein & Hundert, 2002).  One can see how each article identifies the same problem using different terms based on their perspective.  The inability of doctors, like pilots, to accurately assess their emotional state and thereby misjudge their abilities and impact on other members of the team, is definitely a clear problem that can result in errors.

Identifying a problem and addressing it properly is not always easy.  It is important to drill down to the foundation and ensure that the causal factors involved are identified.  Of the referenced studies only one identified the base contributor.  The other authors failed to go deep enough.  Weng et al. identify that communication skills, the basal factor missed by the other authors, are based on EI (p 705).   Helmreich (2000 p. 783), Epstein and Hundert (2002 p. 227,) and Bohnen and Lingard (2003 p. 328) all identify the need for doctors to communicate better.    They clearly understand that better communication is needed to avoid errors, however, they do not describe how improved communication occurs and do not provide a basis for that improvement.  There are many scholarly articles written about EI, most agree that EI is developmental (Weng et al. 2008 p.704).

My training and background in communication led me to understand that one’s ability, or lack thereof, in exercising EI will dictate one’s interpersonal relationships through the communication expressed.  Our emotions are expressed in body language, facial expressions, tone, volume and tempo of our words, etc. and to the least amount, the words themselves.   Any attempt to improve communication with permanence will have to improve the awareness and management of the emotions behind the communication through improved emotional intelligence.

Bohnen and Lingard correctly identify the vector for change in the operating room.  First they identify the fact that there are few systems developed for error reduction, they then place the responsibility for improvement on the Surgeon/Leader. Mentoring, avoiding intimidation, improving communication, and reducing tension on the team are all improvement tactics recommended (2003, p. 328).  Managing one’s emotional state prior to communicating, through EI skills, or taking action, is foundational to most of the recommendations.  Helmreich discusses behavior countermeasures to combat errors (2000, p. 783).  He does not go beneath the data to evaluate how to change the causal factors that dictate the behavior in question.  He, like Bohnen and Lingard, places the primary responsibility for improvement on the team, therefore the leader in the operating room…the surgeon. Epstein and Hundert focused on assessing competence and also arrived at the need for mentoring (2002, p. 233). Mentoring can be done from various positions in a team environment, however, it is generally accomplished by the most experienced or knowledgeable individual.

Clearly, an effective way to mitigate the huge problem of medical/surgical error is through coaching physicians. If physicians understood the negative impact they have on others in their team through lack of EI skills, they will be motivated to participate.  Once the team leader (physician) is demonstrating improved skills the rest of the team will follow.  It is unrealistic to expect our healthcare system to be able to train every person who is involved in surgery on error reduction through improved communication by enhanced emotional intelligence. That would be costly and time consuming. However, if the medical community is seeded with skilled EI/HF practitioners who mentor those around them during every medical event, measureable improvement will occur with resultant error reduction, patient satisfaction and organizational prestige.

As a trained instructor/facilitator I have experience in improving error reduction through increased self-awareness and the resulting HF behavior modification.  I can now support this anecdotal experience with scholarly research in an attempt to further define Emotional Intelligence as an actionable skill more easily evaluated in the surgical theater.  The resources available that discuss surgical error reduction methods are few (Bohnen & Lingard, 2003 p. 328).  This research is just the beginning, although I believe it is representative of the current medical/surgical environment in many of our communities. By using Human Factors Error Management processes, the improvements described above can have an exponential impact on the organization, reducing HR costs, improving employee satisfaction and stability, and reducing risk management costs.

 

Captain Paul Westfield is available for group presentations and facilitated discussions.

Coachinghumanfactors.com                                                                           901-553-5894

References

Bohnen, J. M. A., & Lingard, L. (2003). Error and surgery: Can we do better? Canadian Journal of Surgery. Journal Canadien De Chirurgie, 46(5), 327-329.

Epstein, R. M., & Hundert, E. M. (2002). Defining and assessing professional competence. JAMA, 287(2), 226-35. Retrieved from http://search.proquest.com.library.capella.edu/docview/211381260?accountid=2796

Daniel Goleman, emotional intelligence, 1995. (2003). In The ultimate business library, Wiley. Retrieved from http://search.credoreference.com.library.capella.edu/content/entry/wileyultbuslib/daniel_goleman_emotional_intelligence_1995/0

Robert L Helmreich. (2000). On error management: Lessons from aviation. British Medical Journal, 320(7237), 781-785. www.bmj.com

Weng, H., Chen, H., Chen, H., Lu, K., & Hung, S. (2008). Doctors’ emotional intelligence and the patient-doctor relationship. Medical Education, 42(7), 703-711.

 

 

I signed up to be a Doctor! What’s with all this leadership stuff?

I’m a doctor”, you tell yourself, “I have earned the right to just do what I am trained to do. And on top of that, many of my patients don’t do what they are told and then blame me when they don’t see the recovery that they should! Someone should be leading them! They are the ones who don’t get it!”

Well……you are right, and you are right……. but where is the solution? The really great news is that the solution is literally within your grasp. It’s part of that leadership stuff! Many physicians are natural leaders, growing up as team captains, Boy Scout or Girl Scout leaders, class leaders, band leaders, science club leaders, and many other leadership roles. Many may never have had the urge, opportunity, or the personality to step into those roles, and that is ok too. By the time you were in medical school how many other activities could you lead anyway? You signed up to be a doctor, right? Yes, you did, but maybe there is more to that than what you were taught in school!

There were 661, 400 physicians and surgeons in the United States in 2008, according to the 2010 Statistical Abstract of the U.S. Census Bureau. This represents about 0.6% of all employed persons in the United States. As is the case with statistics, there is probably some variance. This number was probably close in 2010 however; it may have changed since then. The point of this is to show that you, Doctor, are actually part of a very exclusive club. Six tenths of one percent of anything is not very much. You achieved what you did through various levels of dedication, perseverance, focus, intelligence, and sacrifice. That is quite a list of characteristics, which are built on an additional list of values that you relied on to carry you forward. Was there any leadership involved? Yes! Absolutely there was, and that leader is still there for you to access. The traits that supported you through all your training are the traits of a leader.

For many years, leadership has been defined by looking at the effect leaders have on others. All the styles of leadership; autocratic, democratic, Laissez-faire, etc., address outward impact. Some claim there are four basic styles some six, it really doesn’t matter as long as we understand that leadership is dynamic and impactful. Let’s look at leadership from a different perspective. I have already given you a hint at where we are going……. self-leadership. All of you have all the basic skills of self-leadership or you would not have made it through your programs. At various times, I am quite sure, that you have motivated, cajoled, guided, mentored, acknowledged and rewarded yourselves! You created your own culture of excellence and held yourself to a high standard of performance. So, actually you know quite a bit about basic leadership.

Recent studies in leadership have shown some additional traits that make a truly successful leader. Empathy has proven to be a critical component that informs both self-awareness and relationships. Empathy is one of the competencies that Daniel Goleman lists under the domain of Social Awareness. It is part of his model of Emotional Intelligence, including three other domains, Self-awareness, Self-management, and Relationship management. He describes empathy as “sensing others’ emotions, understanding their perspective, and taking active interest in their concerns.” Why is this important to you? There have been several studies that now show that patients who feel they have been listened to, and have a relationship with their doctor, still rate the doctor very highly even with a problematic outcome. They trust that the doctor did the best he or she could and they are unwilling to place blame to blame on someone they trust and respect. The converse was also shown. Doctors with very high technical ratings and few errors get very poor patient ratings, even with good outcomes, if the patient felt the doctor was cold or aloof, didn’t communicate or establish a relationship. There are also studies, of which I am sure you are aware, that connect patient optimism with recovery. Where do you suppose that optimism comes from in many cases?

T he study of neuroscience has made great strides in the last 5 years in mapping and describing the brain and and oscillator neurons. As we interact with each other we cannot help but take in the nonverbal messages that are being transmitted. We tune ourselves to those around us. If we see someone smiling at us it is difficult not to smile back. Those are the mirror neurons engaging. When we match the movements or energy of those around us, the strength of a hand shake, hug, or open welcoming body language, oscillator neurons are at work. According to Daniel Siegel, for this rapport to develop, there must be full mutual attention. Ask yourself, “when was the last time I truly focused on my patient, accepted and understood their perspective of their condition, and made them feel heard?”. When it comes down to it, what people really want, is to be heard. If you hear them, they will trust you. If they trust you they will believe in you. If they believe in you they will follow you. Hmmm, sounds kind of like leadership doesn’t it?

T he tricky part is to really hear them, not just listen while you treat a condition. People are smart in unconscious ways. When your words and actions are not in sync it creates dissonance and that is recognized by your patient. So how do you train yourself to connect with your patients in a short period of time? Start by taking a moment before you open the door, do a few seconds of controlled breathing. This takes control of your reactionary brain, part of the limbic system, and pulls your awareness up to the thinking brain in the neo-cortex. Now you can choose how you spend that few minutes in the best way for you and your patient. You can choose to be curious about the patient, not just the condition. Ultimately this will lead to enrollment of the patient in their own care and improve compliance and recovery. The dynamic nature of medicine combined with the pressures of administration on providers continues to challenge the ability to establish trusting relationships with patients. Be creative; find other ways for developing better patient relationships. Improve the office environment and engage your staff in your vision. If needed you could hire a wellness coach who will spend the time with the patient, ensuring they feel heard, answering questions and providing follow up support. This is also a great tool to reinforce an optimistic attitude and compliance in recovery.

So, ask yourself another question, “Am I a leader that my patients and staff want to follow?” Do you set the example for your staff on how to lead? If you had to move, would your staff follow you, or are they just punching a t ime clock? Are you sharing all of you, not just the “MD”, with those around you? Are you burning out? Are you sacrificing your family? Have you any hobbies left that give you joy outside of your work?

Did you struggle with some of those questions? If so, you are not alone. That is why so many CEOs and business leaders have coaches. To truly see yourself you need a mirror, accurate and unbiased, non-judgmental. That is why athletes at the top of their game use coaches, to absolutely get the best performance they can, they need someone who only cares about what they care about. You have invested a lifetime in becoming a physician, are you where you want to be?

Captain Paul Westfield

Between stimulus and response there is a space… within that space we create opportunity!

Many may recognize part of that phrase as being credited to Austrian Psychologist Viktor.E. Frankl. While it turns out that he may never have said it, the truth in that first sentence is irrefutable. Within that space there is unlimited opportunity for positive changes in our lives.

Operational Human Factors Integration in healthcare embodies the concept of using our skills in communication, emotional intelligence, knowledge, and technical skills to reach optimal performance. Human Factors coaching is all about finding the opportunity in our response to stimulus. It’s greatest impact is in moments of great criticality, like surgery.

Remember a time when you were confronted by someone challenging your action or position. What feelings came up, defensiveness, insecurity perhaps, inferiority, anxiety, maybe even panic. Now imagine being open to the position of that person and being able to integrate their message, in a timely and positive way, into your plan for the task at hand. How different that would be for both of you! Your team will experience increased integration, motivation, cooperation, reduced errors, and in healthcare, dramatically improved patient outcomes. The opportunities that are created by our choices while we are in that “space” are truly life changing.Human Factors Integration

Surgeons operating using surgical equipment
Surgeons operating using surgical equipment

The Active Medical Monitor (AMM)© and Error Management

Active Medical Monitor (AMM)©

The role of the AMM is to maintain a watch for error producing behaviors. This is a person who has a good situational awareness and familiarity with all the roles and responsibilities in the room.  They of course will have their own duties; so how do we safely add more?

In aviation there is the Pilot Flying (PF) and the Pilot Monitoring (PM). The PM has responsibilities and tasks that need to be accomplished as the non-flying pilot yet their designated role as PM requires them to go outside their duties to maintain an awareness of the overall state of the flight.  The frequency and intensity of the monitoring is based on the phase of flight and the vulnerability to errors.  Takeoff and landing are very vulnerable areas so the frequency and intensity are very high.  Cruise on autopilot at altitude allows low frequency low intensity monitoring.

There are two distinct monitoring behaviors, active and passive.  We are all familiar with passive monitoring, we are just “along for the ride”.  We watch the things going on around us as a spectator and we react, after the fact, to what we have observed.  Active monitoring is very different.  We observe our environment and the actions occurring based on a plan of action. We compare what is occurring to what we expected to occur and evaluate any differences within the scope of standard practice and safe outcome.  We have all probably experienced active monitoring with poor execution and just didn’t realize it! Consider the “back seat driver”.  They are constantly driving the car from their seat and have no qualms about directing what should be done next.  The problem, is, they have their own standards and procedures which may not be safe, standard or appropriate. In addition, the guidance is usually delivered very poorly!   What they are doing, however, is thinking ahead of the car. What would they do, what would happen if this or that is done, what is the faster way, the shorter way, and so on.

What would that ride have been like had the driver explained the exact route and planned speeds and other details of the trip. First, the passenger would have had the opportunity to share their knowledge of short cuts, delays, or speed traps before ever departing. That in and of itself would reduce the volume of unwanted or unnecessary discourse during the trip. It also would have offered valuable information so the driver might alter their plans for a better outcome.  Now the passenger will be watching to be sure the driver does what they said they would do since there is a defined expectation.

That is the foundational essence of Monitoring, having a plan. If there is no plan, then the best observer is only a back seat driver reacting rather than evaluating.  Sharing the plan in advance creates what is called the “shared mental model”, everyone in the event has the same expectation of process and behavior.  This is commonality of expectation is critical because it allows for immediate identification of deviations from the plan.  In developing the plan, it is important to have the greatest input possible to insure the plan covers all possible requirements.  In aviation it is called gathering “untainted” input.  The Captain, will ask the crew what they see as the problem, or what options they think are appropriate, before offering his own plan.  The Captain will take all the best ideas from the crew and integrate them into his or her plan.  This is part of good Crew Resource Management (CRM).  Your team is a resource with vast experience and different perspectives. You must access that value to the greatest extent possible.

Before we go further it needs to be understood that what we are discussing is situational.  As we spoke earlier about phases of flight, so too, there are phases in any medical procedure.  The time available and criticality of response will dictate how much planning is available. So in a critical event, the basis for active monitoring is standardization and team continuity which will be addressed in another post.