Restrictions on physician work hours may lead to more miscommunication

University of Chicago Medical CenterMar 11 2010

As shifts change in a hospital, outgoing physicians must "hand off" important information to their replacements in a brief meeting. But a new study of this hand-off process finds that the most important information is not fully conveyed in a majority of cases, even as physicians rate their communication as successful.

The research, published by University of Chicago researchers in the March issue of Pediatrics, highlights the importance of educating doctors about successful communication skills during hand-offs. The results also emphasize the risk inherent in increased hand-offs necessitated by restrictions on medical resident work hours, even as further work limits are being discussed.

"When resident hours are shortened, you have more hand-offs," said Vineet Arora, MD, assistant professor of medicine at the University of Chicago Medical Center. "You could have concerns about either a tired physician who knows the patient or a well-rested physician that may not know the patient. The tradeoff is between fatigue and familiarity."

Conducted through a unique collaboration between physicians and psychologists at the University of Chicago, the study observed hand-off communication between pediatric interns - first-year residents - at Comer Children's Hospital at the University of Chicago. Interns at the end of an overnight shift would spend a total of 10-15 minutes sharing information about hospitalized patients with the resident relieving them in a designated hand-off room.

Both the outgoing and incoming interns were then asked by researchers about what they thought was the most important information conveyed during the hand-off about each patient. Surprisingly, what the outgoing intern identified as the most important information was not successfully communicated to the incoming intern 60 percent of the time. The rationale for certain medical decisions - such as why a patient is on a particular drug or why the primary care physician should be contacted - was also not understood by the receiving intern in a majority of cases.

But despite these miscommunications, interns on both sides of the hand-off consistently rated the quality of their communication as very high. Boaz Keysar, PhD, a professor of psychology at the University of Chicago and co- author of the paper, said that this disconnect between perceived and actual success of communication is common in other settings.

"You would imagine the kind of miscommunication we discover elsewhere actually might be reduced when the stakes are high in a clinical setting, because it matters so much," Keysar said. "But the opposite is true, which I think is counter-intuitive and important to know."

The results were even more striking given the optimal hand-off conditions for interns at Comer Children's Hospital. In each hand-off, a conversation takes place in a designated room under supervision by more experienced physicians. In previous research, Arora found that many hospitals and programs have much less organized hand-off procedures - if they occur at all.

In illustrating the communication breakdowns that plague even best-case hand-off conditions, Arora and Keysar hope to inform medical centers and schools of the need for better education about hand-offs. The study found that "anticipatory guidance" - offering to-do items or if-then advice - was a more effective way of communicating information between interns than passing on knowledge items in bulk. Currently, Arora and colleagues are working on a simulation exercise for fourth-year medical students to train more effective hand-off communication skills.

Such training, they hope, will be more effective than relying upon computer programs and electronic medical records to facilitate hand-off communication. A verbal exchange of information remains important so that young doctors can make quick, informed decisions about patients, Arora said.

"IT solutions cannot substitute for a successful communication act," Arora said. "We aren't at the point where computers are going to do that for us. Technology solutions can help so that you have the information that you need when you need it, but to look at that information and be able to make a judgment about what to do, that is what the hand-off conversation is for."

But while researchers look for the best way to improve those conversations, Arora and Keysar hope that medical policymakers are aware of the risks inherent in the current hand-off model. As the Accreditation Council for General Medical Education ponders further restrictions upon the number of hours residents and interns can work, the consequences of those reduced hours must be acknowledged, they said.

"We tend to be very myopic in the way we think about this problem," Keysar said. "Reducing hours is good, but there's a cost that is not obvious at all, and this study really spells that cost out. It's very difficult for us to gauge how well we are understood, and this should be taken into account in the trade-off between number of work hours and fatigue."