Luminary Learning Gastrointestinal Disorder- Issue 1

56  • LUMINARY LEARNING: GASTROINTESTINAL DISORDERS Shortcomings of Practice-Based Learning in Medicine: When Communication Breaks Down, Learning Breaks Down The achievements of modern healthcare are, unfortunately, accompanied by errors that have the potential to harm patients. A majority of them result from breakdowns in communication, which we are only beginning to understand. These relate to a number of factors, including author- ity gradients and power differentials (Cosby and Croskerry, 2004; Nugus, Greenfield, Travaglia, Westbrook, and Braithwaite, 2010), conflict (Janss, Rispens, Segers, and Jehn, 2012), incomplete information sharing (Manser, 2011; Maughan, Lei, and Cydulka, 2011), and failures to speak up about questions or concerns (Okuyama, Wagner, and Bijnen, 2014; Rainer, 2015). Team commu- nication in operating rooms (ORs), for example, was characterized by ‘high-tension’ events that impacted whole teams including trainees (Lingard, Reznick, Espin, Regehr, and DeVito, 2002) and led trainees either to disengage from the communication or mimic their senior colleagues whose behaviour contributed to the tension. Thirty percent of over 400 communication events in ORs reflected communication failures, which compromised patient safety (Lingard et al., 2004). These failures included not sharing information at all or giving inaccurate information, failing to take account of important contextual issues, and communication without clear purpose. Effects included delays, inefficiency, patient inconvenience, procedural error, and tension. Accurate information sharing is particularly important at times of transition of care, such as patient handoffs or handovers, which are highly contextualized forms of oral case presentations. A handoff is the verbal exchange of information between health professionals when responsibility for patient care changes hands (Cohen and Hilligoss, 2010). This verbal communication occurs in person or by phone and is called handover or handoff—both are interchangeable terms. An example would be a physician or team of providers handing over care of patients at the end of a shift to a new physician or team before leaving the hospital, thus passing the baton of account- ability. Handoffs are also essential when patients are transferred from one area of a hospital to another, such transfer from intensive care units to hospital wards when life-threatening illness has improved. Factors that predict handoff quality include conveying clear, reliable, and salient infor- mation, developing shared understanding, and having a supportive working atmosphere (Manser, Foster, Gisin, Jaeckel, and Ummenhofer, 2010). An effective handoff includes a clear assessment of a patient’s status and anticipated problems (Manser, Foster, Flin, and Patey, 2013) with the goal of co-constructing a shared understanding of the patient (Cohen, Hilligoss, and Kajdacsy-Balla Amaral, 2012). In surveys, however, residents in emergency medicine report receiving little train- ing in effective handoff practices, increasing the likelihood of communication errors; standard- ized handoff tools are rarely used (Kessler, Scott, et al., 2014; Kessler, Shakeel, et al., 2014). There are several essential needs: enhancing our conceptual understanding of handoff communication (Beach et al. 2012; Patterson and Wears, 2009, 2010) and then developing comprehensive strate- gies to promote effective communication (Cheung et al., 2010). In high-risk settings of emergency departments (EDs), despite the best intentions, informa- tion can be erroneous or omitted altogether when one physician hands over patients to another at change of shift (Maughan et al., 2011). In addition to within-unit handoffs, which are generally