On Rudeness

“Hey Tessa, I didn’t realise you were such a genius”.

I was on my way back to ED from my lunch break and the ortho reg was sitting laughing with one of our locum SHOs.

I smiled nervously, “Oh thanks for coming to see the patient”.

“I didn’t realise you were a genius”. He said it again. He was still smiling. It was weird.

“I’m not sure what you mean, but something about this is making me nervous”. I was trying to make a joke of it. But let’s be honest, I’m not a genius, so I had a sense that something wasn’t right.

“You told my patient that they could eat and drink. They need an operation and now they aren’t fasted. Thanks for that, genius!”

I have since thought of a gazillion things I could have said. Like, “I didn’t tell them they could eat and drink!” or “Hang on, there’s no need to be rude” or “You’re setting a really bad example to this locum SHO about how to be courteous to your fellow colleagues” or “It doesn’t cost to be kind!”.

Actually, he walked away before I could say anything else. I’ve spent the weeks since pondering over it endlessly. That’s pathetic, right?

Yes, we work in busy and stressful environment. We have all snapped from time to time, it doesn’t mean that you’re a bad person, or a terrible doctor. But at the same time, we need to let people know that it’s not ok to be spoken to like that. We need to set a good example for our juniors, to help change the culture, and also to preserve our own self-respect. My reaction was disappointing (at least to me anyway). How should I have done it better?

 

The DFTB team asked a few docs whose opinions we value greatly – how should you respond when someone at work is rude to you?

Here are the collated answers and themes from: Dara Kass (DK); Vic Brazil (VB); Simon Judkins (SJ); Damian Roland (DR); and Natalie May (NM).

 

Most people aren’t actually horrible people who want to see you suffer…

In the hectic nature of acute medical practice, clinicians can become tired,  hungry or the deadly combination of both. This can lead to frayed tensions and communication challenges. Sadly it’s often the case that rudeness is a part of normal process, rather than an unacceptable professional dynamic. DR

And sometimes, it’s possible it wasn’t meant in the way it came across…

There are many perceptual challenges around ‘rudeness’ as there is no strict definition of what it actually is. You know it when you see or hear it, but can’t necessarily always describe it. I personally believe that many people honestly don’t believe they are being rude, or if that is being too charitable, that the impact of the tone of their voice or choice of language isn’t considered. DR

We all have plenty of everyday reasons to feel some anger at work…

Usually the person is rude because they are frustrated, either with the system, the medical issue or their own lives. Rarely, the patient’s rudeness is just a personality disorder, and then I just try to interact with them as little as possible while delivering excellent care. 🙂 DK

As a senior, if this rude behaviour happens, we jump on it early, but it is also very important to listen to both sides of the story; there is often a tale of grief/stress on the other side which we need to also recognise and support. I don’t think there are many true asses out there, but many people who feel unsupported and vulnerable. SJ

Try to look on it in the most positive light and give them the benefit of the doubt…

Follow Jenny Rudolph’s #WTF2WTF … take a breath and think why? Trying to be generous in possible motivations might help. VB

 

But if it’s clearly rude, then we really need a strategy on how to deal with this. The key is to reframe is – move away from it being about the words they used or their tone when they spoke to you and try to find some common ground…

I am rarely responsible for the cause of their frustration but try to validate their experience and see what I can do do diffuse the issue. DK

Try to keep the focus on the patient i.e. both parties needs to keep the focus on the patient and not get lost in a personal dispute…

Frame all conversations with colleagues in the context of the patient’s needs – and believe first and always that your colleagues have the patient’s best interests at the centre of their intentions. NM

It’s also important to acknowledge the positives. Being kind and professional make for a happier work environment for all…

Emphasise how important good behaviour is e.g. ‘we really want to get along with our work colleagues here’. VB

And an important point to consider is that being right and being rude are two separate things. There will be times when something doesn’t go smoothly, and it might be your fault. The person being rude may be right i.e. you did indeed do something wrong, but that doesn’t give them the all-clear to be rude…

Separate the issue from the rudeness ie the person being rude might actually be ‘right’, but the conversation should clarify that the issues are separate and being right doesn’t justify the rudeness. VB

Debate around patient care is vital, in fact it is an essential element of patient safety. However, there is no reason the tone of that debate should cause discomfort to those having it. DR

 

There will be times, where you need to just confront the problem and ‘call it’. Choose your language carefully…

Use words like ‘disappointed’, ‘surprised’, and ‘what a shame’ VB

I tend to call things out, “I’m really sorry, but I don’t think I deserve to be spoken to like that. I appreciate your different point of view but how can we resolve this in the best interests of the patient.” Written down, playing the ‘patient card’ sounds glib, but in practice directing attention towards the one thing you have in common with the other person tends to clarify thinking. DR

When confronted with rudeness, pause – count to five in silence (it might need to be ten!) – then prompt reflection (the sentence I’m trying to use is “you might like to think about how that came across”). NM

It’s tough when your not expecting it..my responses vary, but usually involves highlighting the unprofessional behaviour, asking them to reflect and continue the conversation when they are ready…like I do with my teenage boys! SJ

 

‘Calling it’ doesn’t mean start an argument with them. Otherwise that defeats the purpose of your response…

Avoid interrupting or talking over people who have already escalated their behaviour – this fire will usually burn out on its own and is best countered with coolness, not more fire! NM

If rudeness/hostility continues, use graded assertiveness or giraffe feedback to shift focus to immediate needs and patient safety. Rudeness is potentially a patient safety issue. NM

 

It might not be appropriate to respond at the time for a multitude of reasons, and that’s ok…

There is nothing wrong with having the conversation later (and in many respects it might be better)….keeping the ‘marriage counselling’ lingo focused on behaviour and impact -“when you did x, I felt like y” VB

 

You don’t need to perseverate on your own about this, speak to your colleagues. They’ll all have been in a similar situation.

Consider cold debrief after such incidents with a trusted colleague and appropriate escalation as warranted by the incident (this will vary). NM

There is also nothing weak about others having these conversations for us, at least to open it up…. “My intern is pretty upset about a discussion you guys had. I truly don’t know what happened , but the impact was pretty bad . I thought you’d like to know as I doubt that was intended …..” VB

The other approach we use with our DITs is to suggest that “ it seems that we aren’t going to agree on this issue, so I think we should end this conversation. I’ll ask my Boss to call your Consultant and they can discuss a solution “. SJ

 

These lessons shouldn’t be just for one someone speaks rudely to you. It’s our job to look after our colleagues too…

Calling out rudeness when witnessed is also vital. As a senior clinician while it is easy to pretend you haven’t overheard conversations, letting things go because they don’t directly affect you propagates a culture in which the status quo remains acceptable. DR

 

Sometimes, your response will make the person realise they were rude. And they might even apologise. Allow them to do so!

Allow space for insight and apology – if the person being rude apologises, accept the apology and move on. Harbouring negativity helps no-one. NM

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Two new wellness resources

Wellness and wellbeing are current hot topics. Yes, we know that systems need to be changed, and we are all working hard every day to bring about change. But in the meantime, as junior doctors, we still need to go to work every day.

The reality of dealing with life and death situations, the responsibility of decision-making, the shift work and lack of sleep, the inevitable errors, the time away from our families, can all lead to increased stress, anxiety, burnout, and depression.

It’s not a case of telling junior doctors that they have to toughen up, it’s about supporting ourselves to manage our work-life balance as well. That’s our individual responsibility.

And that’s why I was so pleased to see two fabulous, and different, resources launched this week.

First off the starting block was Australia, with WRapEM.org. WRaPEM was built by a team of Queensland-based Emergency Physicians with an interest in wellbeing.

WRapEM has a set of ten modules which are fully designed and collated so that you could run them in your department next week. Modules topics include communication, performance optimisation, reflection, and self-care. Each module has a comprehensive lesson plan consisting of pre-reading material, a guide for facilitators, a guide for learners, and some have slides already prepared, and quizzes for the end of the session. The modules allow user participation and can be adapted depending on how you would like to use them.

Example of the facilitator guide from the Communication Module

Next is You Got This, by a UK team of EM healthcare professionals in Bristol Children’s Emergency Department. This is a wellness website and blog specific to those working in Emergency Departments, which also contains links to a range of organisations that can offer support and advice when we need it. It has a promising wellness blog with some great posts to get their library started. And it has a department-specific wellness section which includes bespoke elements focused on support; activities (like an annual Wellness Week); innovations (things like positive incident reporting); resources (to share with your staff what the local wellbeing support is, social events in the department, wellbeing projects).

 

 

Both of these resources are excellent and they have something different to offer. Here at DFTB, we cannot wait to watch them grow and develop over the coming months, and I look forward to using them in my own department.

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Steroids for pre-school wheeze

Wheeze must be one of the most common paediatric presentations to the emergency department and up till now most of us have been reassuring parents and sending them away without treatment. But should we be doing more?  A paper, released just last week, suggests that we could.

Foster SJ, Cooper MN, Oosterhof S, Borland ML. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. The Lancet Respiratory Medicine. 2018 Jan 17.

Background

There has always been some uncertainty about the benefit of prednisolone for viral wheeze in pre-school children. In 2009, a study by Panickar et al found that there was no positive effect in giving steroids to pre-school children with wheeze. Since then, our practice, and our treatment guidelines, have changed, in spite of questions about the applicability of this study.

This study aimed to assess the efficacy of oral prednisolone in children presenting to a paediatric emergency department with suspected viral wheeze.

Objective

The study had a clear objective, although the initial hypothesis was revised. The initial hypothesis (placebo is not inferior to prednisolone) was changed to prednisolone is superior to placebo. The authors explained that the reason for this change was to ensure the results were comparable with existing literature in the field.


Population, patient and problem

Eligible patients were 2 to 6 years of age.

Patients were excluded with: sats <92% in air;  a silent chest; shock or sepsis; previous PICU admission with wheeze; prematurity; other cardiac or respiratory disease; likely alternative diagnosis for the wheeze; or steroid treatment within the preceding 14 days.

From an initial 3727 patients who were assessed for eligibility, after exclusions, 312 were assigned to placebo, and 312 to the prednisolone group. Following withdrawals, 300 were included in the analysis for the placebo group, and 305 in the analysis for the prednisolone group.

 

Design

The study design was suitable for the objective and looked at the population we see regularly with viral wheeze. By excluding the 10 month to 2 year age group, the authors have removed the bronchiolitis age group.  These should be managed differently and respond to different treatments.

A sample size estimation was calculated. Appropriate outcomes measures were considered, although the current article only aims to explore outcomes up to seven days. We will need to wait for future publications to find out the rest of the results.

Intervention

The intervention was a three day course of oral prednisolone (1mg/kg once daily).

The severity of the wheeze was assessed using a pulmonary score (calculated based on the severity of the wheeze). The family also completed a questionnaire about home management and previous symptoms. Finally, a  viral swab was taken from each patient.

 

Measurements

The pulmonary score was the initial measurement. It should be noted that this pulmonary score is only validated in children under five years of age and  is not validated for the in the 5-6 year old group. The score was calculated to help rate the severity of the patient’s symptoms in order to determine whether that severity made a difference to outcome.

 

Comparison

This was a randomised double-blind trial. Patients were randomly allocated to either group. The placebo group received an identical medication bottle with contents that looked, smelled, and tasted like prednisolone.

Randomisation

Randomisation was carried out appropriately and this was a double-blind study. Placebo and prednisolone samples were made to be indistinguishable to the clinicians and the parents.

However, patients left the study if a clinician felt this was ‘necessary’. So, if a patient was admitted to the ward and a doctor felt that they should receive steroids, then they were given them.  23 patients in the placebo group were given steroids later by a clinician. It is not clear what happened to these patients in the analysis, but it seems as though they were included in the placebo group for analysis. If anything, this would have made it more difficult to find a significant difference between the group.

Outcomes

The primary outcome was length of stay in the hospital. Secondary outcomes (in the first 7 days) included: reattendance; readmission; salbutamol usage; and residual symptoms after discharge.

Outcomes

One of the initial primary outcomes was length of stay in the Emergency Department. During the course of recruitment, the authors established that this was not a helpful measurement. Length of stay in an Emergency Department will depend on many non-clinical factors including bed availability, use of an emergency short-stay unit, and working to the dreaded four-hour target. Because of these extrinsic it was removed as a primary outcome, leaving the single primary outcome being length of stay in  hospital until the patient was ready for discharge. Again, this change was clearly explained.

Analysis of results

The authors analysis looked at four key areas:

  1. In patients with a pulmonary score of <5 (mild), prednisolone resulted in a reduced risk of a length of stay over 12 hours. In patients with a pulmonary score of >5 (severe), prednisolone resulted in a reduced risk of length of stay exceeding 7 hours. There was no significant different in those with a pulmonary score of 5 (moderate)
  2. Prednisolone was more effective in children who had salbutamol at home prior to presentation. In this group, patients receiving prednisolone had an overall reduced length of stay, and were less likely have stays exceeding 7 or 12 hours. This was independent of their pulmonary score on presentation. The authors state that this demonstrates that if a patient has already tried and failed with bronchodilators, then early prednisolone may be helpful.
  3. There were no significant findings between groups based on the presence or absence of viral antigens.
  4. In children with a diagnosis of asthma, prednisolone was associated with a reduced risk of length of stay exceeding 7 hours or 12 hours (although this isn’t the same as having presented previously with wheeze or used an inhaler before).

Interestingly none of the results were significant in the group of patients who were discharged within four hours.

Family history or personal history of atopy, although previously identified as a major risk factor for ongoing wheeze did not affect the outcomes in this study. At pre-school age, they do not modify steroid responsiveness in viral-induced wheeze

Secondary outcomes were around representation post-discharge. 26 patients re-attended (15 in the prednisolone group and 13 in the placebo group). Of the re-attenders, some were prescribed steroids (3 in the prednisolone group and 2 in the placebo group),  One patient (from the prednisolone group) was admitted to PICU. 

 

Analysis

The two study groups were stated to be comparable with no significant differences in the demographics, pulmonary score, or history of atopy or previous salbutamol use. This is demonstrated in Table 1, however the statistical analysis is not explained here (i.e. how did the authors confirm that there was no difference between the group). It may be that a t test or chi squared test was conducted here to compare the two groups, but this is not mentioned in the article.

The numbers all add up consistently, and side effects were reported. Two children (one from each group) were reported to be hyperactive – an interesting result given anecdotal advice often given to parents (and received from parents) about the effects of prednisolone.

The data are suitable for analysis and the methods used are appropriate, however their statistical analysis is not that easy to follow. Chi squared and t tests are referred to as well as logistic regression. It is not clear what questions these different analyses were used to answer. The chi squared and t tests were likely used to explore whether the groups were different from each other, but they do not seem to be reported in this article. The authors seem to assert there were no differences in the various parameters without reporting the statistical evidence from the tests. The logistic regression is the main analysis used to see if outcomes differ for the two groups.

The statistical analysis of the re-attenders (secondary outcomes) was not fully explained in the article, and although the initial plan for secondary outcomes was stated to be in the first seven days post-discharge, these were actually reported over three months.

Discussion

The results are discussed in relation to prior evidence (specifically Panickar et al), and the study was designed and analysed with comparable studies and future meta-analysis in mind.

The authors spent time discussing the reasons for the change in age range. Panickar et al included from 10 months of age, but this study only included patients from 2 years of age. The author explain that this was to exclude patients with bronchiolitis from their study. It should be noted that Panickar et al included patients from 10 months of age. The 10 months to 2 year group will include bronchiolitis which is known to be non-responsive to steroids, and therefore may have affected the Panickar et al conclusions.

 

Will I change my practice? – Damian Roland

In my first year as a doctor my hospital’s management of children with wheeze was to give nebulisers, steroids and if it was their first presentation, to order an x-ray. Since that time evidence has suggested steroids may not be useful in children not formally diagnosed with asthma, and that an x-ray isn’t a helpful initial test.

As my experience has grown I increasingly recognise a number of phenotypes of the “wheezy child” which don’t fit nicely into current evidence. There is certainly a group of children below the age of five who appear steroid responsive. Anecdote suggests they are likely to have atopic backgrounds (or come from families with a strong atopic history) and are at the more acutely unwell end of the acuity spectrum. There is face validity to this observation as it makes sense these children would have the greater steroid responsiveness. So what should we make of the fact atopy wasn’t a risk factor. Which inflammatory pathway is the steroid then acting on?

This study isn’t going to change what I currently do as I think it supports my intuition that as yet we still don’t have a good diagnostic system for infant and childhood wheeze. A theory which would support both the Panickar and Foster work is that there are different cohorts of children between the age of 1-5 who present with similar symptomatology but for different pathophysiological reasons. The spectrum of bronchiolitis to viral wheeze to asthma is not precise enough to guide the most effective management. As recent discussion around dexamethasone and prednisolone has shown, if we can’t define the group we are treating how can we adequately assess the response to treatment?

What I will be doing is thinking carefully about the diagnosis in patients I see, or are reviewed by me, and asking “Why shouldn’t this patient have steroids?”

 

References

Panickar J, Lakhanpaul M, Lambert PC, Kenia P, Stephenson T, Smyth A, Grigg J. Oral prednisolone for preschool children with acute virus-induced wheezing. New England Journal of Medicine. 2009 Jan 22;360(4):329-38.

Smith SR, Baty JD, Hodge D. Validation of the pulmonary score: an asthma severity score for children. Academic emergency medicine. 2002 Feb 1;9(2):99-104.