Luminary Learning Gastrointestinal Disorder- Issue 1

Learning to Work Together Through Talk: Continuing Professional Development in Medicine •  57 planned and involve team members from the same unit who know each other, between-unit handoffs require particular negotiation and coordination skills, such as when patients require hospital admission from the ED to the ward for ongoing care. Patient admission handoffs are more complex due to differences between health professions in their orientations towards illness and treatment, unequal power distribution, and lack of established relationships (Hilligoss and Cohen, 2013; Nugus et al., 2010). During handoff from ED doctors to inpatient teams, a par- ticularly crass discourse is ‘selling’ patients; in other words, to persuade the inpatient surgical or medical teams to accept patients for hospital admission by minimizing and/or embellishing aspects of their cases (Nugus, Bridges, and Braithwaite, 2009). The goal is procuring inpatient beds expeditiously in order to maintain the flow of patients out of EDs (Nugus et al., 2011), espe- cially when waiting rooms are full of patients still needing care. Selling patients is but one of four metaphors for handoffs between doctors in EDs, who are hospital gatekeepers, and physicians who care for patients after admission. Three others (Hilligoss, 2014) are: 1. Sports and games: handoffs as competition 2. Packaging: handoffs as expectation matching 3. Teamwork and conversation: handoffs as collaboration These metaphors highlight that handoffs represent more than just information transmission. Handoffs are social interactions in which conversation partners co-construct meaning in the heat of clinical care (Cohen et al., 2012; Patterson and Wears, 2010). This explains why simple technical fixes such as handoff tools to structure information exchange are insufficient to prevent communi- cation breakdowns. Importantly, the social nature of such dialogues develops professional identity (Burford, 2012) and a tribe mentality (Weller, Boyd, and Cumin, 2014). There is an interesting relationship, moreover, between those dialogues and the media through which they take place. In-person compared with telephone conversations, for example, are differently shaped by their social contexts in ways that are familiar to all physicians but currently ill-understood by research- ers (Henn et al., 2012). An insidious and pervasive communication deficit is a failure to ‘speak up’, or raise concerns to colleagues or supervisors (Okuyama et al., 2014); in other words giving ‘voice’ (Morrison, 2011) to information, ideas, and opinions (Van Dyne, Ang, and Botero, 2003). In contrast to commu- nication lapses that represent honest mistakes (Reason, 2000), not speaking up and giving voice to concerns represent deliberate choices to remain silent (Maxfield, Grenny, Lavandero, and Groah, 2011) about poor and unsafe patient care or deficient actions by healthcare teammembers. Factors influencing whether or not providers speak up include (Okuyama et al., 2014): (a) being motivated by a perceived risk to patients depending on how clear the clinical situation appears and what needs to happen; (b) contextual factors such as relationships among teammembers, atti- tudes of leaders/supervisors, and organizational support; (c) individual factors such as confidence in skills and education and feelings of responsibility toward patients; (d) feeling that speaking up will make a difference, and (e) the perceived impact of speaking up, for example, fear of reprisals or being made to feel incompetent. The ability to ask questions, express concerns or admit mis- takes—thus taking risks—is part of learning (Edmondson, 1999). An important counterpart to trainees feeling empowered to speak up is supervisors being sensitive to unease in colleagues, such