WHEN NASA took a long hard look at commercial airline crashes a decade ago, it expected to find weather and mechanical failure as major culprits. But the surprising answer was that the cause of 60 percent of the crashes could be traced to poor communication in the cockpit.
The airline industry shrugged and continued on with an average of one fatal crash for every 1.5 million hours. But United Airlines took a major step that resulted in an improvement to one fatal crash per 5 million hours.What sophisticated technology was responsible? United required its crews to take intensive communications training. Pilots learned to listen to what crew members said in the cockpit.
It's a long distance from the Friendly Skies to the paneled office of your family doctor, but physicians crash and burn, too. Only they call it a malpractice suit.
A "crash/court" parallel was discovered by Dr. Stephen E. Prather, an obstetrician practicing at Holy Cross Hospital, and a colleague, when they investigated the records of multimillion-dollar medical malpractice lawsuits in Utah. "We found one common denominator," wrote Prather in the national magazine Medical Economics. "Almost without exception, they involved some kind of failure of communication - with patient, family or a medical team member."
But communication is a subject area that Prather said warrants only an hour or two here and there in medical school. "You study some psychology, learn some interviewing techniques," he said. Communication is a door that only the physician can open or that he can close with just a glance, Prather noted.
Not being one to shrug off problems, Prather started looking for solutions. He thought about a plaque on the wall of one of his professors, "Not Always Right But Never in Doubt." That attitude fostered in medical school had a lot to do with the problems raised by autocratic doctors and dissatisfied patients who took their disappointments to court.
Prather recognized that doctors need statistical control and a measurable standard of performance. He took a simple but effective concept, the management grid, and applied it to medicine. The grid is a square numbered from one to nine on two sides and measures "concern for people" up the left side and "concern for production" on the bottom and can be applied to different aspects of medical concern such as the "Physician Informed Consent Grid" shown below. When "mapping" how a patient would respond to the issue of obtaining consent, a difficult patient might rate a 1,1 in grid terminology, low for both concern for people and concern for production, passive and resigned to whatever care her or she is getting. The "pushover" patient would rate 1,9 and might be excessively complimentary, while the defensive patient would be a 9,1 - not trusting of the system and watchful that the physician doesn't take advantage of him.
But the patient grid is just half of the equation; Prather realized each doctor fits into a style as well. Again concentrating on concern for people and concern for production, Prather can map out the profile of the 9,1 doctor who delivers technical information in a one-way lecture and then proceeds if no questions are asked. Prather's goal for both patient and physician is informed consent (a 9,9). In this scenario, the doctor achieves agreement to the highest degree possible after dealing with all doubts. The patient is clear about his needs and finds the physician who can meet his needs while allowing him to participate in the process.
"In medical school you might be told to `sit down and look like you care,' " Prather said. "When you (the doctor) feel the caring from the heart, the patient can feel it."
Prather developed seminars to train physicians to meet the human as well as medical needs of patients. It is his hope that doctors can become true team players.
"When the physician is seen as a captain who makes decisions and utilizes resources - performance dramatically worsens," Prather said. "Negligence just breaks down into poor teamwork." As an example he described the problems he had with a pregnant teenager who refused to take care of herself despite repeated lectures. A nurse took a few minutes to talk with the girl and realized that she was in a rebellious mode at home and viewed the doctor as simply another authority figure. With this insight from the nurse, Prather changed from monologue to dialogue and let the teen know he valued her opinion. She burst into tears and a healthy doctor-patient relationship was established.
Prather's work has brought him national recognition. He was named to the Pew Health Professions Commission Advisory Panel for Medicine, where he will meet with physicians such as Dr. Louis W. Sullivan, U.S. health and human services secretary; and Dr. Samuel O. Thier, president of the Institute of Medicine National Academy of Sciences.
"I am in a practical position to influence this commission," Prather said. "The reward is when a patient looks you in the eye with an air of optimism about the potential for being cured."