INTER-PROFESSIONAL RELATIONS and

COMMUNICATION

AAOS ETHICS COMMITTEE

S. Jay Jayasankar, MD.

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Objectives• Learn what ‘competent medical care’

(AMA)1 entails in the context of the orthopaedic surgeon’s ‘primary purpose of caring for the patient’ (AAOS)2

• Investigate the nuances in applying 3 of 6 physician core competencies (ACGME, ABMS-MOC)3,4

oPatient Careo Interpersonal and Communication SkillsoProfessionalism

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• Understand the essential elements of effective communication and learn communication’s key role in:

o Physician-patient and inter-professional relationships (AAOS)1 (AMA)2

o Developing, utilizing expert teams (AAOS)1

o Using talents of other professionals (AMA)2

• Learn what resources are available from the AAOS for improving communication skills5,6

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Ethical Guidance

AAOS Code of Ethics, V.A.2

“Good relationships among physicians, nurses, and other health care professionals are essential for good patient care. The orthopaedic surgeon should promote the development and utilization of an expert health care team that will work together harmoniously to provide optimal patient care.”

AMA Principles of Medical Ethics. V.1

A physician shall …use the talents of other health professionals when indicated.

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Case Mr. Boudreau is a 45-year-old male with a left knee patellar tendon

rupture from abasketball injury.

Yesterday theemergency room physician instructed Mr. Boudreau to

iStockphoto/Thinkstock return to see Dr. Winter, the on call orthopaedic surgeon.

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Dr. Winter structures the evaluation around the hospital “H&P Short Form” for day surgery patients. Dr. Winter completes the form while Mr. Boudreau answers his questions. The notes indicate iStockphoto/Thinkstock

previous surgery on the right knee and hernia repair. Dr. Winter obtains informed consent and arranges for outpatient surgery that same day.

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“Bleeding/Clotting” is checked in the nurse’s notes, and clotting is circled.

The nurse also notes that the patient had

hernia repair at age 16 and a history of deep venous thrombosis (DVT) Ingram

Publishing/Thinkstock following anterior cruciate ligament (ACL), medial collateral ligament (MCL) repair and full reconstruction of the right knee six years earlier.

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The nurse anesthetist also noted DVT related to a prior ACL surgery.

Dr. Winter repairs the tendon under general anesthesia and discharges Mr. Boudreau on oral oxycodone. Fuse/Thinkstock

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Do Dr. Winter’s evaluation and management constitute:

A. Competency (AMA- I.)1 and

B. Effective communication for good patient-physician relationship (AAOS- I.A.)?2

What actions of Dr. Winter lead you to your conclusion?

Do the nurse’s notes provide good communication necessary to deliver competent medical care?

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Dr. Winter did not read the nurse’s notes and thus was unaware of Mr. Boudreau’s history of DVT. In addition, he did not askMr. Boudreau about theoutcome of prior surgeries, orwhether any complications or medical issues arose afterwards. In Dr. Winter’s experience a patient will volunteer this iStockphoto/Thinkstock information, so customarily he does not ask.

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Does Mr. Boudreau have a responsibility to inform Dr. Winter of his DVT?

What physician skills are necessary to elicit relevant history?

Does Dr. Winter have a responsibility to read the nurses’ notes?

Do the nurses have a responsibility to personally inform Dr. Winter of Mr. Boudreau’s DVT history?

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Two weeks post op, Mr. Boudreau returns to Dr. Winter’s office for

suture removal. In the office visit questionnaire that Mr. Boudreau completes, he reveals that

iStockphoto/Thinkstock there is a family history of blood clotting disorders.

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Dr. Winter remembers having reviewed the form briefly with the

patient and recalls asking about this and learning that the patient’s brother had sustained a stroke. Dr. Winter

iStockphoto/Thinkstock does not ask Mr. Boudreau about his personal history of clotting disorder.

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Dr. Winter’s notes at this visit indicate that Mr. Boudreau is doing well with intact neurovascular status of the leg. There was no notation re: examination for signs of DVT. He is advised to stay in an immobilizer for an additional 3½ weeks and a follow-up appointment is scheduled.

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Do Dr. Winter’s evaluation and management at this visit constitute competency?

What actions of Dr. Winter lead you to this conclusion?

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The orthopaedist who performed the ACL reconstruction on the opposite knee six years earlier is a colleague of Dr. Winter in the same practice. The office records indicated that 6½ weeks after the previous ACL surgery, Mr. Boudreau had non-tender but substantial swelling in his right calf.

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An ultrasound revealed “a very large, deep clot up tothe femoral region.”Mr. Boudreau was hospitalized, treated with heparin, and discharged four days Oleg Shipov/iStock/Thinkstock

later on Coumadin which he took for about six months. There was no indication in Dr. Winter’s post op visit notes that he had read these notes from the earlier treatment.

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Were any ethical norms transgressed by Dr. Winter by not reading the notes of his colleague from the previous treatment?

If so, which of the ones referred to in this module?

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Two days after the post op visit, the patient was found dead in his home due to a massive pulmonary embolism.

Dr. Winter acknowledged that had he known of Mr. Boudreau’s prior DVT, he would have investigated it, and, there being no contraindications for anticoagulation therapy, would have prescribed it.

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Dr. Winter did not anticoagulate as he indicated he would have. Which core competencies (ACGME, ABMS- MOC)3,4 are involved?

•Patient Care

•Medical Knowledge

•Interpersonal and Communication Skills

•Professionalism

•System-based Practice

•Practice-based Learning and Improvement20

Summary Mr. Boudreau had a past history of DVT which was well documented. Dr. Winter did not obtain nor read the nurse’s notes, nor did he read, at Mr. Boudreau’s postop office visit, the office notes of his practice colleague who had done the prior surgery and treated the DVT episode.

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There is no unanimity of evidence/consensus-based best practice for prophylaxis against postop DVT, even for a person with a prior history.14 Dr. Winter stated that had he known of Mr. Boudreau’s DVT history, he would have prophylactically anti-coagulated the patient because of the high risk. Unfortunately Mr. Boudreau died of pulmonary embolism two days after the postop office visit.

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What role did each of the following have in the events that led to Mr. Boudreau’s death?

•Inter-professional Relations •Communication •Teamwork

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Recommendations Related toInter-professional Relations

and Communication Knowledge and surgical skills are important, but in addition:

•Be mindful and aware of self and environment•Practice ‘active listening’ to patients and team members•Utilize the talents of other team members •Elicit, seek, organize, and transmit information•Acknowledge/appreciate communication•Encourage non-hierarchical interaction

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References:1. American Medical Association. Principles of Medical

Ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/principles-medical-ethics.page

2. American Academy of Orthopaedic Surgeons. Code of Ethics and Professionalism for Orthopaedic Surgeons, I.A., II.A., V.A. Accessed on Sept. 26.2013 at http://www.aaos.org/about/papers/ethics/code.asp

3. Common Program Requirements: General Competencies. Approved by the ACGME Board February 13, 2007. http://www.cme.hsc.usf.edu/latestdocs/05-ACGME%20COMPETENCIES.pdf

4. American Board of Medical Specialties. MOC Competencies and Criteria. http://www.abms.org/Maintenance_of_Certification/MOC_competencies.aspx

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5. American Academy of Orthopaedic Surgeons Communication Skills Mentorship Program. http://www3.aaos.org/education/csmp/about.cfm

6. Gebhardt MC: Communication matters. AAOS Now, May 2011. http://www.aaos.org/news/aaosnow/may11/managing5.asp

7. American Academy of Orthopaedic Surgeons TeamStepps Program. http://www.aaos.org/education/TeamSTEPPS/teamhome.asp

8. Mevis H: AAOS begins second year of TeamSTEPPS

project. AAOS Now, April 2013. http://www.aaos.org/news/aaosnow/april13/clinical6.asp 5. Beckman HB, Frankel RM: The Effect of Physician Behavior on the Collection of Data. Ann Intern Med. 1984;101(5):692-696.10. Leape LI, Brennan TA, Laird N, Lawthers AG, Localio

AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. N Engl J Med 1991;324:377-84.

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11. American Academy of Orthopaedic Surgeons: Shared physician-patient responsibilities. Position Statement 1182. Adopted Decemer 2011. http://www.aaos.org/about/papers/position/1182.asp

12. AAOS Standards of Professionalism, Professional Relationships, Mandatory Standard 4. Adopted April 18, 2005. http://www3.aaos.org/member/profcomp/profrelation.pdf

13. Perneger TV. The Swiss cheese model of safety incidents: Are there holes in the metaphor? BMC Health Serv Res. 2005; 5:71.

14. Reason J: Human error: models and management. BMJ 2000;320:768–70.

15. Kelly L. Listening to patients: a lifetime perspective from Ian McWhinney. CJRM 1998;3:168–9.

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16. American Academy of orthopaedic Surgeons: Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. Evidence-based guideline and evidence report, 2011. http://www.aaos.org/Research/guidelines/VTE/VTE_full_guideline.pdf

17. Jayasankar SJ: What does it take to make our practices safe? AAOS Now, May 2011. http://www.aaos.org/news/aaosnow/may11/managing6.asp

18. Epstein RM: Mindful practice. JAMA, 1999;282(9):833-839.

19. Quote from Knight S. in: Robertson K. Active listening. Australian Family Physician, 2005;34:1053-1055

20. Crew Resource Management: An Introductory Handbook. US Department of Transportation, Federal Aviation Administration. August 1992. ADA257441

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21. The Joint Commission Sentinel Alert on Preventing Unintended Retention of Foreign Objects.

http://www.jointcommission.org/sea_issue_51/

22. Institute for Healthcare Improvement: SBAR Technique for Communication: A Situational Briefing Model. Accessed on October 3, 2013 at: http://www.ihi.org/knowledge/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx

23. Graham KC, Cvach M: Monitor Alarm Fatigue: Standardizing Use of Physiological Monitors and Decreasing Nuisance Alarms. Am J Crit Care, 2010;19:28-34.

24. Makary MA, Sexton JB, Freischlag JA, Holzmuller CG, Millman EA, Rowen L, Pronovost PJ: Operating room teamwork among physicians and nurses: Teamwork in the eye of the beholder. J Am Coll Surg, 2006;202(5):746-752.

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25. Harden SW: Surgeons and teamwork. AAOS Now, March 2011. http://www.aaos.org/news/aaosnow/mar11/managing3.asp

26. American Academy of Orthopaedic Surgeons: Patient-Physician Communication. Information Statement 1017. Adopted December 2000. Revised 2005 and 2011.

http://www.aaos.org/about/papers/advistmt/1017.asp

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