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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_422"
                     title="Nurses Often Silent About Workplace Violence (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/HospitalBasedMedicine/WorkForce/tb/18335?impressionId=1265797487650"
                     
      The physical and verbal abuse nurses face on the job often goes unreported, according to an Australian survey.&lt;br&gt;
&lt;br&gt;Over the prior year, 52% of nurses in one community hospital said they had been physically assaulted and 69% reported being threatened with violence, according to Rose Chapman, PhD, of the University of Western Australia in Perth, and colleagues.&lt;br&gt;
&lt;br&gt;Verbal abuse was almost universal, being reported by 92% of respondents, the researchers wrote in the February issue of the &lt;em&gt;Journal of Clinical Nursing&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;However, only half mentioned the incidents to senior staff or co-workers, and just 16% filed an official report.&lt;br&gt;
&lt;br&gt;&quot;The reasons for not reporting are many and may include lack of time and management support and the belief that being attacked is &apos;just part of the job,&apos;&quot; they wrote.&lt;br&gt;
&lt;br&gt;The same is true in the U.S., where assaults and under-reporting appear just as common as suggested in the Australian survey, commented Kathleen M. McPhaul, PhD, RN, MPH, of the University of Maryland School of Nursing in Baltimore, who has been involved in such research in the U.S.&lt;br&gt;
&lt;br&gt;A culture change would likely be needed to make a real difference for nurses, Chapman&apos;s group suggested.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;Hospitals would have to ensure that nurses have necessary support, education, encouragement, and time to complete official reports. Nurses who report abuse should get positive feedback from all levels of nursing, they said.&lt;/p&gt;
&lt;p&gt;&quot;If administrators and governments are serious in their intention to reduce workplace violence and provide staff with safe work environments, they should be seen to act on all reported [incidents],&quot; which is rare today, Chapman&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;However, currently there&apos;s no strong lever or incentive to address this kind of workplace abuse since hospitals focus mainly on patient safety as part of accreditation, and national and state workplace safety organizations have little mechanism for monitoring such incidents, McPhaul noted.&lt;/p&gt;
&lt;p&gt;The researchers&apos; survey was intended to reach all 332 nurses working at one nontertiary hospital across all departments  --  emergency, medical, surgical, maternity, pediatric, and mental health.&lt;/p&gt;
&lt;p&gt;The 113 nurses who responded were mainly women in their early 40s who worked part time.&lt;/p&gt;
&lt;p&gt;Among them, about three-quarters reported at least one incident of workplace violence over the preceding 12 months  --  25% said it occurred weekly, 27% said monthly, and for 25% it was rarer, at once every six months. &lt;ul&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Fully 30% of the nurses said they had been involved in an episode involving a weapon  --  often hospital equipment and more rarely a knife or gun.&lt;/p&gt;
&lt;p&gt;The number of total incidents was lowest among nurse midwives, with a mean of 1.67 per year.&lt;/p&gt;
&lt;p&gt;Not surprisingly, the rate was highest among emergency department and mental health staff, who reported an average of 46.43 and 40.39 episodes over 12 months.&lt;/p&gt;
&lt;p&gt;One reason behind the high risk in these two departments may be the &quot;shift to a community-based approach to mental health care and a reduction in mental health beds&quot; such that the same psychiatric patients that assault mental health department nurses are mainstreamed to the emergency department as their point of entry to the hospital, the researchers said.&lt;/p&gt;
&lt;p&gt;However, more years of experience or higher educational qualification didn&apos;t appear to protect nurses. Senior nurse unit managers and clinical nurse specialists actually reported more physical assaults than less senior nurses.&lt;/p&gt;
&lt;p&gt;Age and gender didn&apos;t predict occurrence or type of incident either.&lt;/p&gt;
&lt;p&gt;When nurses did report workplace violence or verbal abuse, it was most often to their immediate manager (29%), other senior nursing staff (14.5%), or to their friends and colleagues (6%).&lt;/p&gt;
&lt;p&gt;Overall, 30% of nurses who responded to the survey gave as their reason for not reporting that workplace violence happens all the time and is simply part of the job.&lt;/p&gt;
&lt;p&gt;Even among those who did make a report of some sort, half said they thought hospital management failed to act on it.&lt;/p&gt;
&lt;p&gt;In fact, when the researchers audited hospital records, they found that 42 official incident reports had been filed by nurses over the prior one year period, nearly always involving injuries.&lt;/p&gt;
&lt;p&gt;In 95% of the cases, the only action taken by the hospital was making staff in the area aware of the incident. No other actions had been documented.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that the voluntary nature and limited scope of the study may have limited generalizability, although the occurrence of violence against nurses is likely similar across developed countries.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The researchers provided no information on conflicts of interest.&lt;/p&gt;&lt;p&gt;McPhaul reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_418"
                     title="Consumer Group Calls for More Sleep for Residents"
                     score="0.01"
                     href="http://www.medpagetoday.com/HospitalBasedMedicine/WorkForce/tb/18332?impressionId=1265797487650"
                     
      &lt;p&gt;WASHINGTON  --  More that a year after the Institute of Medicine (IOM) issued a &lt;a href=&quot;http://www.medpagetoday.com/PracticeManagement/StaffingScheduling/12004&quot; mce_href=&quot;http://www.medpagetoday.com/PracticeManagement/StaffingScheduling/12004&quot; target=&quot;_blank&quot; title=&quot;IOM&amp;#8200;Calls&amp;#8200;for&amp;#8200;Mandatory&amp;#8200;Naps&amp;#8200;and&amp;#8200;Other&amp;#8200;New&amp;#8200;Sleep&amp;#8200;Rules&amp;#8200;for&amp;#8200;Residents&amp;#8200;&quot;&gt;report &lt;/a&gt;calling for mandatory naps for medical residents, the organization responsible for implementing  --  or rejecting  --  the IOM&apos;s controversial recommendation has yet to make a decision.&lt;/p&gt;
&lt;p&gt;The Accreditation Council for Graduate Medical Education (ACGME), which has formed a work safety task force, has said it will release its recommendations on the 2008 report in the upcoming months, collect comments, and schedule a board of directors vote no sooner than fall.&lt;/p&gt;
&lt;p&gt;In the meantime, the consumer advocacy group Public Citizen is trying to rally support behind adoption of the IOM report, which recommends, among other things, that residents take a five-hour nap for every 16 hour shift. Current standards allow residents to work for 30 hours straight.&lt;/p&gt;
&lt;p&gt;The IOM report determined that standards adopted in 2003  --  which mandated a maximum of 80 hours of work a week, when averaged over a four-week period, and no more than 30 hours straight  --  are not easing the problem of overworked and overtired resident physicians.&lt;/p&gt;
&lt;p&gt;As part of its campaign, Public Citizen launched a Web site this week, &lt;a href=&quot;http://www.wakeupdoctor.org&quot; mce_href=&quot;http://www.wakeupdoctor.org&quot; target=&quot;_blank&quot;&gt;www.wakeupdoctor.org&lt;/a&gt;, to promote safer work hours and more supervision for medical residents.&lt;/p&gt;
&lt;p&gt;In a press call Thursday  --  led by Sidney Wolfe, MD, director of Health Programs for Public Citizen  --  physicians and patient advocates said that current work schedules of residents are dangerous and criticized ACGME for failing to have taken any action.&lt;/p&gt;
&lt;p&gt;&quot;Resident physicians find it very hard to concentrate as exhaustion sets in, especially when operating or evaluating patients beyond 16 hours in a single day on a regular basis,&quot; said John Ingle, MD, an ear, nose, and throat surgery resident at the University of New Mexico Health Sciences Center in Albuquerque, N.M. &quot;During times of extreme fatigue, I find myself less compassionate toward my patients and less tolerant of my colleagues.&quot;&lt;/p&gt;
&lt;p&gt;&quot;My body is not made to work 30 hours or more,&quot; said Dan Henderson, a third-year medical student at the University of Connecticut. &quot;If I&apos;m truly going to do no harm as I pledged, I need a system to protect patients against errors caused by my fatigue. If ACGME isn&apos;t willing to do the right thing, hopefully consumers and lawmakers will be ready to step in.&quot;&lt;/p&gt;
&lt;p&gt;A sleep specialist went through a list of the dangers of sleep-deprivation in a medical setting:&lt;/p&gt;
&lt;p&gt;&quot;Resident physicians working 30-hour shifts make 36% more medical errors caring for women in the intensive care unit ... including 460% more serious diagnostic mistakes than those scheduled to work for 16 hours,&quot; said &lt;span&gt;Chuck &lt;span&gt;Czeisler&lt;/span&gt;, MD, of Harvard and Brigham and Women&apos;s Hospital.&lt;/span&gt;&lt;/p&gt;
&lt;p&gt;&quot;They are 73% more likely to stab themselves with a scalpel or needle,&quot; he said.&lt;/p&gt;
&lt;p&gt;Czeisler cited a survey that found after a year of working &quot;marathon shifts&quot; one in five residents admitted to making a fatigue-related mistake that injured a patient, and one in 20 said they made a fatigue-related mistake that resulted in the death of a patient.&lt;/p&gt;
&lt;p&gt;However, not everyone is sold on those statistics.&lt;/p&gt;
&lt;p&gt;Perry Pugno, MD, a director of a family practice residency program for 20 years, asserted that no definitive study has proven that the 2003 guidelines aren&apos;t working. He said most sleep studies are performed in a lab or in the transportation industry, and questions their applicability to the hospital setting.&lt;/p&gt;
&lt;p&gt;Besides, he said, &quot;Many people come to work in many industries sleep deprived. Restricting the hours of work doesn&apos;t necessarily mean you&apos;re going to get a well-rested person during the period you&apos;re going to be working.&quot;&lt;/p&gt;
&lt;p&gt;He doubts that residents would be willing or able comply with the 2008 IOM recommendation that they take an uninterrupted nap for five hours between every 16 hour shift. It&apos;s nearly impossible to take a nap in the middle of an intense work shift, said Pugno, who is now the director of the Division of Medical Education at the American Academy of Family Physicians.&lt;/p&gt;
&lt;p&gt;As other critics of the IOM report point out, if more residents are forced to work shorter shifts, they will be handing off the care of their patients to another resident, physician, or nurse more often. And medical errors are more likely to occur when the care of the patient is transferred, Pugno said.&lt;/p&gt;
&lt;p&gt;He recently co-authored a paper that presented results from a survey of 265 residency program directors that asked their opinions of the IOM recommendations. More than 60% disagreed or strongly disagreed with them.&lt;/p&gt;
&lt;p&gt;The long hours serve to educate, Pugno said, and to help build intimate doctor-patient relationships that mandatory nap time would sever. He also said that most directors of residency programs are sympathetic to the sleep needs of their residents and schedule shifts accordingly.&lt;/p&gt;
&lt;p&gt;Cost is also a major issue in implementing the IOM recommendations. In the 2008 report, the IOM authors estimated the changes they recommended  --  which also included greater supervision of residents and transportation home for bleary-eyed residents after a long shift  --  would cost $1.7 billion annually.&lt;/p&gt;
&lt;p&gt;&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_402"
                     title="Minimally Invasive Surgery Takes Toll on MDs, Poll Shows (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Surgery/GeneralSurgery/tb/18306?impressionId=1265797487650"
                     
      &lt;p&gt;Four out of five surgeons agree: Laparoscopic procedures cause substantial discomfort and pain for the surgeons who perform them.&lt;/p&gt;
&lt;p&gt;More than 80% of surgeons completing an online questionnaire reported pain or stiffness in the hands, neck, back, or legs after performing minimally invasive surgeries, according to Adrian Park, MD, of the University of Maryland Medical Center in Baltimore, and colleagues.&lt;/p&gt;
&lt;p&gt;For most symptoms, the strongest predictor was high case volume, the researchers reported online in the &lt;em&gt;Journal of the American College of Surgeons&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Park and colleagues warned of &quot;an impending epidemic&quot; of occupational injuries among clinicians specializing in minimally invasive surgeries, as such procedures become more common.&lt;/p&gt;
&lt;p&gt;&quot;Now, especially in the face of an impending shortage of general surgeons in the U.S., the last thing that we as a society can afford is surgical careers shortened by occupationally related symptoms and conditions,&quot; they asserted.&lt;/p&gt;
&lt;p&gt;The researchers recommended more research into the ergonomics of laparoscopic surgery, as well as better implementation of existing guidelines meant to reduce injuries associated with the awkward postures and long surgical times often required with these procedures.&lt;/p&gt;
&lt;p&gt;&quot;That research must more clearly and emphatically define the ergonomic impact of minimally invasive surgery on the practicing surgeon (then set about improving it) is now all too painfully clear,&quot; Park and colleagues concluded.&lt;/p&gt;
&lt;p&gt;The researchers invited some 2,000 board-certified members of the Society of American Gastrointestinal and Endoscopic Surgeons (of which Park is currently secretary) to complete the online survey.&lt;/p&gt;
&lt;p&gt;The response rate was 14.4%, with 317 surgeons identified as actively and regularly involved in laparoscopic practices participating.&lt;/p&gt;
&lt;p&gt;Of these, 272 reported experiencing physical symptoms or discomfort that they believed were the result of performing minimally invasive procedures.&lt;/p&gt;
&lt;p&gt;This rate of reported symptoms is markedly higher than that found in earlier studies and surveys, in which the prevalences were in the range of 15% to 60%, Park and colleagues noted.&lt;/p&gt;
&lt;p&gt;They speculated that the current survey, as the most recent, may better reflect the accumulation of injuries over time as surgeons&apos; careers doing minimally invasive surgery have grown longer.&lt;/p&gt;
&lt;p&gt;Fortunately, they found, symptoms were generally not persistent. Only 10.8% of respondents indicated that pain or discomfort continued beyond the immediate aftermath of surgery.&lt;/p&gt;
&lt;p&gt;The largest class of symptoms were those occurring during surgery, with 20.8% of surgeons saying they had symptoms only during procedures and 27.8% reporting symptoms both during and immediately after surgery.&lt;/p&gt;
&lt;p&gt;Another 22.4% indicated that symptoms occurred only immediately after surgery and not persistently.&lt;/p&gt;
&lt;p&gt;About 15% chose &quot;nothing bothers me&quot; in the questionnaire.&lt;/p&gt;
&lt;p&gt;Age appeared to be a factor in the incidence of some complaints, although the pattern was not what might be expected. In particular, hand pain was most common among surgeons younger than 40 and in those older than 60, whereas it was least frequent among surgeons in their 50s.&lt;/p&gt;
&lt;p&gt;Park and colleagues did not report specific hazard ratios or correlation coefficients for case volume as a predictor of symptoms, but they indicated that it was associated with complaints more strongly than other factors such as age, career duration, gender, and height.&lt;/p&gt;
&lt;p&gt;About three-quarters of respondents attributed symptoms to instrument design. Some 40% indicated that operating room table setup and the display monitor location were also contributing factors.&lt;/p&gt;
&lt;p&gt;On the other hand, more than 180 respondents said they had slight or no awareness of published recommendations on surgical ergonomics, such as guidelines published last year in the journal &lt;em&gt;Surgical Endoscopy&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Among those reporting any level of knowledge about the guidelines, only 60% indicated that they had applied it in their practices, Park and colleagues indicated. But more than 90% of surgeons who said they had high awareness of ergonomic guidelines reported putting it to use.&lt;/p&gt;
&lt;p&gt;The researchers said future studies should address other issues not covered adequately in the survey, such as the effects of different monitor positions and instrument designs, as well as whether surgeon discomfort during laparoscopic surgery leads to adverse patient outcomes.&lt;/p&gt;
&lt;p&gt;Park and colleagues also suggested that similar research be conducted on open surgery.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;No external funding for the study was reported.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_339"
                     title="Flexner Report Linked to Growth of Specialty Medicine"
                     score="0.006"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/MedicalEducation/tb/18222?impressionId=1265797487650"
                     
      &lt;p&gt;WASHINGTON  --  A century ago, Abraham Flexner&apos;s pivotal report redefined medical education and laid the groundwork for the growth of academic medical centers, but increasing medical specialization was an unintended consequence and threatens patient care, according to a paper published in an anniversary issue of &lt;em&gt;Academic Medicine&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;The growing importance of academic medical centers during the last century has caused medicine&apos;s &quot;social contract&quot; to &quot;erode,&quot; to be replaced by &quot;a money culture that dominates the academic health system and has led to distortions in medical education and to our present maldistribution of physicians by specialty.&quot;&lt;/p&gt;
&lt;p&gt;So wrote Michael Prislin, MD, professor of family medicine at the University of California, and colleagues who authored the paper, one of a special series of articles commemorating the 100th anniversary of the Flexner Report.&lt;/p&gt;
&lt;p&gt;In his 1910 report, Flexner, an educator on the staff of the Carnegie Foundation, criticized the quality of the 160 U.S. medical schools, noting that many of the smaller, proprietary schools taught a curriculum not based in science. He advocated that medical schools be university based, have stringent entry and graduation standards, provide a clinical setting as well as an academic one in which students would learn, and encourage faculty research.&lt;/p&gt;
&lt;p&gt;By 1920, nearly half the medical schools had closed and the remaining 85 were university-based and under tight regulatory oversight by the American Medical Association&apos;s Committee on Medical Education.&lt;/p&gt;
&lt;p&gt;Although the Flexner report is universally acknowledged as having an overall positive impact on medicine, it has also been blamed for eliminating diversity in the profession  --  forcing closure of smaller schools that admitted minorities, women, and low-income students.&lt;/p&gt;
&lt;p&gt;Even today, Prislin and colleagues wrote, 75% of U.S. medical students come from families whose income classifies them as upper- or upper-middle-class.&lt;/p&gt;
&lt;p&gt;The growth of academic medical centers and a less diverse physician population, created a climate that allowed other societal changes &quot;resulting in the proliferation of specialties,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;&quot;In the contemporary educational and practice environments, the generalist disciplines seem to be at grave risk,&quot; they wrote, arguing that the current faculty clinical practice model would &quot;likely be abhorrent to Flexner,&quot; who said that &quot;university hospitals, academic salaries, etc.&quot; can create good conditions for learning medicine, but they cannot create the &quot;ideals&quot; necessary for compassionate medicine.&lt;/p&gt;
&lt;p&gt;Prislin and colleagues also sited the role the founding of the National Institutes of Health in the 1930s and the enactment of Medicare and Medicaid in the &apos;60s played ain advancing Flexner&apos;s goals and encouraging specialization.&lt;/p&gt;
&lt;p&gt;The NIH provided  --  and still provides  --  funding for the research Flexner had urged medical school faculty to engage in. That funding focuses researchers on narrow subject areas.&lt;/p&gt;
&lt;p&gt;Medicare and Medicaid brought dollars into the academic medical centers, paying for what had previously been charity care, the number of clinical faculty increased and the fellows and residents they taught became revenue generators.&lt;/p&gt;
&lt;p&gt;In 1965, the authors noted, federally funded research brought $350 million to medical schools and patient care revenue totaled about $49 million ( just 6% of their revenue). In 2007, patient care income, at $36 billion accounted for half of overall medical school revenue.&lt;/p&gt;
&lt;p&gt;Over the years, insurers, including Medicare and Medicaid have also developed reimbursement mechanisms that reward physicians who practice in procedure-based specialties at much higher levels than those who practice general medicine.&lt;/p&gt;
&lt;p&gt;Even the managed care era of the 1980s and &apos;90s, meant to emphasize primary, preventive care backfired. As the nation&apos;s view of managed care soured, primary care doctors were &quot;vilified by patients and their specialty colleagues alike as &apos;gatekeepers,&apos;&quot; Prislin and colleagues wrote.&lt;/p&gt;
&lt;p&gt;By 2002, just 21% of graduating medical school students expressed an interest in pursuing a career in primary care, and a 2007 survey found just 2% of graduates had an interest in a career in internal medicine, they noted.&lt;/p&gt;
&lt;p&gt;The authors suggested several ideas for post-Flexnerian medical education reform including:&lt;ul&gt; &lt;li&gt;Refocusing the medical school admissions process to move beyond aptitude in science courses and standardized texts.&lt;/li&gt; &lt;li&gt;Encouraging medical schools to adopt new initiatives to increase diversity among student populations. &lt;/li&gt; &lt;li&gt;Providing public funding to support a larger number of medical students. &lt;/li&gt; &lt;li&gt;Creating effective strategies in medical schools to shift the emphasis from subspecialties to primary care. &lt;/li&gt; &lt;li&gt;Placing a greater emphasis on social science such as sociology, behavioral psychology, and economics, to correct the &quot;excessive focus on disease management.&quot;&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Prislin and colleagues also strongly supported passage of healthcare reform legislation that would provide coverage to every American. (One of the authors is a past president of Physicians for a National Health Plan, which advocates a single-payer system).&lt;/p&gt;
&lt;p&gt;&quot;The public has lost faith in organized medicine as an answer to this crisis and tends to see physicians as part of the problem  --  not part of the solution,&quot; the authors wrote. &quot;If the medical profession can put its own interests aside and strongly advocate universal coverage for all Americans, it can reclaim much of its traditional legacy of service.&quot;&lt;/p&gt;
&lt;p&gt;They further urged that the academic medicine community &quot;decide how active it wishes to be in this dialogue and it must also confront important existential questions regarding the continuing contribution of the generalist disciplines to the physician workforce.&quot;&lt;/p&gt;
&lt;p&gt;Prislin and colleagues noted the increase in non-physician providers and arguments that they can handle much of what primary care physicians do. &quot;Ideally, evolving practice models will allow collaborative primary care practices to develop, they wrote.&lt;/p&gt;
&lt;p&gt;But, they warned, &quot;if instead the result is the loss of the generalist-physician primary care disciplines, the nature of the unique bond between patient and physician epitomized by the Hippocratic tradition will likely also be lost as physicians will increasingly provide only fragmented and episodic technical services to patients.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors of the paper reported no financial disclosures or conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_287"
                     title="COLUMN: Outliers: The Story of Success"
                     score="0.004"
                     href="http://www.medpagetoday.com/Columns/18148?impressionId=1265797487650"
                     
      &lt;p&gt;Popular author Malcolm Gladwell has become something of a fixture on the healthcare speaking circuit and it&apos;s easy to understand why. Taken collectively, his books go further than most in explaining the factors that influence and facilitate societal change.&lt;/p&gt;
&lt;p&gt;In his groundbreaking book, &lt;em&gt;The Tipping Point&lt;/em&gt;, Gladwell challenged  --  and eventually changed  --  the way we understand the world. He contends that one imaginative person applying a well-placed lever can move the world.&lt;/p&gt;
&lt;p&gt;His second book, &lt;em&gt;Blink&lt;/em&gt;, examined the power of intuition and its influence on our thinking. One concept that particularly struck me was the idea of &quot;thin slicing&quot;  --  filtering the few factors that matter from an overwhelming number of variables. In the context of medical malpractice, Gladwell advises readers to &quot;thin slice&quot; new physicians, trusting their intuition if they sense a physician is not listening to them.&lt;/p&gt;
&lt;p&gt;Gladwell has done it again! His newest book, &lt;em&gt;Outliers&lt;/em&gt;, is destined to transform the way we understand success.&lt;/p&gt;
&lt;p&gt;In &lt;em&gt;Outliers&lt;/em&gt;, Gladwell explains the extraordinary success of the Beatles and Bill Gates in the context of generation, family, culture, and class. The lives of these Outliers  --  people whose achievements fall outside normal experience  --  actually follow a peculiar and unexpected logic, suggesting that context and background matter a great deal.&lt;/p&gt;
&lt;p&gt;How does this apply to healthcare? The answer is in a chapter entitled, &quot;The Ethnic Theory of Plane Crashes.&quot;&lt;/p&gt;
&lt;p&gt;In the late 1990s, Korean Air was internationally admonished following a series of dramatic cockpit failures and subsequent crashes. Multiple investigations led to the same conclusion: poor cockpit communication, rooted in deep cultural barriers, led to circumstances that became deadly.&lt;/p&gt;
&lt;p&gt;The chapter discusses three important messages regarding communication: mitigation, crew resource management (CRM), and a concept known as the power distance index (PDI).&lt;/p&gt;
&lt;p&gt;Mitigation is a term used by linguists to describe an attempt to downplay or sugarcoat the meaning of what is being said. According to Gladwell, &quot;We mitigate when we&apos;re being polite, when we are ashamed or embarrassed, and when we are being deferential to authority.&quot;&lt;/p&gt;
&lt;p&gt;Although mitigation may be appropriate or even desirable in some situations, it can be disastrous in a cockpit on a stormy night, or an operating room or trauma bay. For the past 15 years, combating mitigation has been a major crusade in commercial aviation.&lt;/p&gt;
&lt;p&gt;Gladwell contends that the unprecedented decline in airline accidents in recent years is attributable, in part, to this war on mitigation.&lt;/p&gt;
&lt;p&gt;CRM training is designed to teach junior crew members how to communicate clearly and assertively in order to reduce dangerous mitigation. Airlines teach copilots how to challenge the pilot if he or she thinks something is going awry.&lt;/p&gt;
&lt;p&gt;For example, the copilot might begin with &quot;Captain, I&apos;m concerned about...,&quot; then proceed to &quot;Captain, I&apos;m uncomfortable with...,&quot; and if the Captain still doesn&apos;t respond, &quot;Captain, I believe this situation is unsafe.&quot;&lt;/p&gt;
&lt;p&gt;Today, CRM is also playing a major role in efforts to improve healthcare quality and safety.&lt;/p&gt;
&lt;p&gt;One staunch proponent is John Nance, a decorated Vietnam pilot, attorney, and author of &lt;em&gt;Why Hospitals Should Fly&lt;/em&gt;, a clever book depicting a fictional hospital wherein the tenets of CRM have been completely internalized by the administrative leadership, medical staff, and all front-line caretakers.&lt;/p&gt;
&lt;p&gt;The third key communication concept outlined in &lt;em&gt;Outliers&lt;/em&gt;, PDI, is one aspect of a model developed by Dutch psychologist, Geert Hofstede. It is rooted in cross-cultural psychology and concerns attitudes toward hierarchy, especially those relating to how much a particular culture values and respects authority.&lt;/p&gt;
&lt;p&gt;In cultures with low PDI, power holders try to underplay their power. In cultures with high PDI, the leader&apos;s authority is unassailable.&lt;/p&gt;
&lt;p&gt;Gladwell relates the impact of Hofstede&apos;s findings on aviation industry research. Their battle over mitigated speech and teamwork was actually an attempt to reduce power distance in the cockpit! He notes that Hofstede&apos;s work &quot;suggested something that had not occurred to anyone in the aviation world; that the task of convincing first officers to assert themselves was going to depend ... on their culture&apos;s power distance rating.&quot;&lt;/p&gt;
&lt;p&gt;So, what does PDI have to do with healthcare? I think that lowering the PDI  --  by means as simple as introducing one another and referring to one another by first names  --  can be helpful in improving communication on patient rounds, the intensive care unit, and elsewhere in the hospital setting.&lt;/p&gt;
&lt;p&gt;Surely, this may be provocative and threatening to the status quo. It might not work everywhere, but solid ethnographic research has concluded that when things go awry in a cockpit it is much easier to address a captain by his first name than by his title.&lt;/p&gt;
&lt;p&gt;I am not suggesting that we must suddenly become buddies on rounds, but knowing who is who and taking a moment to recognize everyone&apos;s role on the team would go a long way to improving communication  --  and, perhaps, clinical outcomes.&lt;/p&gt;
&lt;p&gt;&lt;em&gt;&lt;/em&gt;Gladwell&apos;s books, and their provocative messages regarding how we think, challenge many of the tightly held, seemingly scientific aspects of our clinical decision-making at the bedside.&lt;/p&gt;
&lt;p&gt;But irrespective of varying reactions to &lt;em&gt;Outliers&lt;/em&gt;, I believe it would enhance our individual and collective ability to improve communication if we knew a little bit more about CRM and PDI.&lt;/p&gt;
&lt;p&gt;Maybe &lt;em&gt;Outliers&lt;/em&gt; and &lt;em&gt;Why Hospitals Should Fly&lt;/em&gt; should be required reading for every medical student and house officer as a part of the training experience.&lt;/p&gt;
&lt;p&gt;Could the way we address one another have an impact on clinical outcomes? If this is the case  --  and I believe it is  --  we should learn how to communicate appropriately in a simulated training environment so that it becomes routine in the hurly burly of everyday work.&lt;/p&gt;
&lt;p&gt;Gladwell asks why it is so difficult to acknowledge the fact that each of us comes from a culture with its own distinctive mix of strengths and weaknesses, tendencies, and predispositions. &quot;Who we are cannot be separated from where we are from  --  and when we ignore that fact, planes crash.&quot;&lt;/p&gt;
&lt;p&gt;And patients die.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Want More on Health Policy?&lt;/strong&gt; &lt;a href=&quot;http://nashhealthpolicy.blogspot.com/&quot; mce_href=&quot;http://nashhealthpolicy.blogspot.com/&quot; target=&quot;_blank&quot;&gt;Read David Nash&apos;s blog&lt;/a&gt;.&lt;/p&gt;

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