Barriers to the Enhancement of Effective Communication in Neurosurgery

From the Annals of Weill Cornell Neurological Surgery

Barriers to the Enhancement of Effective Communication in Neurosurgery Benjamin R. Hartley and Eric Elowitz

Communication issues play a major role within neurosurgery. There has been a growing awareness of the necessity of enhanced patient-centered communication between the physician and patient to improve patient satisfaction, compliance, and outcomes. In addition, the threat of malpractice litigation within neurosurgery is of particular concern, and improved communication may lead to some degree of risk mitigation. Within the neurosurgical and medical team, effective transmittal of vital clinical data is essential for patient safety. Despite the recent recognition of the critical role that communication plays in all aspects of medical care, multiple impediments hinder the improvement and use of effective techniques. We have identified 8 unique barriers to the advancement of communication practices: lack of recognition of the importance of communication skills; cognitive bias; sense that it “takes too much time”; cultural hierarchy within medicine; lack of formal communication skill training; fear that disclosure of medical errors will lead to malpractice litigation; the electronic medical record; and frequent shift changes and handoffs.

INTRODUCTION

T

he care of the neurosurgical patient requires the coordination of a complex medical team, often featuring the interaction of multiple specialties. Proper communication between and among all team members is critical for success. In addition, communication with the patient and family is of paramount importance to aid in the understanding of the risks of surgery as well as in obtaining proper informed consent. It has been shown that the physicianepatient relationship is affected by

communication issues and that poor communication can lead to patient dissatisfaction—or even malpractice litigation. Most medical professionals acknowledge the vital importance of communication in all aspects of patient care, and complex neurosurgery operations with a potential risk of morbidity, as well as frequent care team handoffs, can lead to unique, challenging communication situations. The role of communication among and between the neurosurgery team members, administration, and patients and their families plays a vital role.1 Unfortunately, multiple barriers can arise—and are even implicit—in the current health care model, leading to challenges in communication. As a first step, it is necessary to recognize and understand these barriers and how they can interfere with proper medical care as well as negatively impact the physiciane patient relationship. Why do some of these barriers remain unaddressed, and how can we facilitate optimally effective communication in neurosurgery? Although there has long been a general sense among physicians that proper communication is important, only in recent years has there been sufficient peer-reviewed literature confirming the vital nature of communication in medicine. There is currently a greater appreciation for the dangers involved with miscommunication; proper communication techniques are integral for the delivery of high-quality neurosurgical patient care. A majority of neurosurgeons intuitively understand this important connection, but how can we transform the health care model to take advantage of these proper communication techniques? Without a strong recognition of the vital role that communication plays in all aspects of medical treatment, it is difficult to overcome the inertia that is inherently present in any system. Before we can motivate change, we also have to understand the challenges that the medical system faces in regard to adopting better communication among all stakeholders. We have identified 8 important barriers to the incorporation of better communication practices and will review each in depth (Figure 1). These include lack of recognition of the importance of communication skills; cognitive bias; sense that optimal communication “takes too much time”; cultural hierarchy within

Key words Cognitive bias - Electronic medical record - Medical communication - Medical handoffs

To whom correspondence should be addressed: Eric Elowitz, M.D. [E-mail: [email protected]]

Abbreviations and Acronyms EMR: Electronic medical record

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Citation: World Neurosurg. (2020) 133:466-473. https://doi.org/10.1016/j.wneu.2019.08.133 Journal homepage: www.journals.elsevier.com/world-neurosurgery 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.

Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA

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improvement, they receive very little active feedback. In his paper discussing expert performance in medicine, Ericsson7 states that the framework he proposes is “based on the assumption that expert performance requires engagement in deliberate practice and that continued deliberate practice is necessary for maintenance of many types of professional performance.” In the operating room, residents are continuously observed and given feedback, but this rarely occurs with respect to communication skills during training. Once a neurosurgeon has completed training and is in practice, opportunities for feedback relating to communication skills are essentially non-existent.

Figure 1. Eight specific barriers or challenges to effective communication within the field of neurosurgery.

medicine; lack of formal communication skill training; fear that disclosure of medical errors will lead to malpractice litigation; the electronic medical record (EMR); and frequent shift changes and handoffs. LACK OF RECOGNITION There has been a belief among many physicians that an individual is either an effective or an ineffective communicator and that effective communication is an innate skill; this perception can engender a sense that there is no need to be concerned about patient-centered communication if it cannot be improved. Accordingly, there can be a lack of recognition of the importance of effective communication skills and their impact on medical care. In fact, multiple studies have shown that patient-centered communication skills can be effectively taught.2-5 Riess et al.2 randomly assigned residents and fellows from several specialties to three 60-minute empathy training modules designed to improve skills in detecting nonverbal signs of emotion and how to respond in ways to build support; this study showed significantly improved physician empathy, as rated by patients, in the group assigned to the training. Interruptions and Feedback In the outpatient setting, most physicians are unaware of how often they interrupt their patients as they relate their history and concerns. No one likes being interrupted, and most providers do not appreciate the negative impact interrupting can have on the physicianepatient relationship. Multiple studies have demonstrated how frequently patients are not allowed to fully state their concerns. Marvel et al.6 found that primary care physicians redirected patients’ opening statements after a mean of just 23.1 seconds. Interestingly, patients who were allowed to complete their statements only took 6 seconds more, on average, than those who were redirected. It would not be surprising if neurosurgeons interrupted patients after less than 23.1 seconds and were not cognizant of this habit. Even when medical personnel have had appropriate training and are aware of the benefits of communication skill

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Aviation Industry Lessons Many of the lessons learned in the aviation industry, particularly after a tragic airline accident, have been applied to other fields, including medicine.8-10 The airline industry stresses the importance of open lines of communication among team members and has recognized the vital role that they play. Only recently have these lessons been actively transferred to the field of medicine. Neurosurgery, in particular, can benefit from the lessons learned in the aviation industry. So much of our care of patients in critical condition depends on excellent communication among medical team members, including attending physicians, residents, anesthesiology, physician assistants, nurse practitioners, nurses, and consulting staff. A proper health care team should function like the dancers in a synchronized ballet, with frequent give and take among members. Recognition of the importance of this team interaction should be paramount.11 Operating Room The neurosurgery operating room is an area in which recognition of communication is vital for patient safety.10 In the operating room a patient often relies on 10 or more staff members, including the neurosurgeon, assistant, resident, anesthesiologist, nurse, scrub technologist, and also possibly a co-surgeon, neurophysiologist, and/or radiology technician. All team members need to feel empowered to express any concerns at any point.12 Neurosurgeons should not discount or belittle concerns from any of the operating room staff and, conversely, all staff should feel comfortable voicing any issues they may perceive relating to patient care. A clear recognition of the lines of communication is important in order to prevent adverse surgical outcomes. As neurosurgeons, we are naturally focused on the successful performance of surgery and positive outcomes. We have significant responsibilities for multiple patients, and it can be easy to overlook the experience of our patients and their family members. So much of our time is spent on technical matters and clinical care, yet communication with patients about their progress can be neglected. In theory, most neurosurgeons would want to spend time communicating with their patients, but time constraints may make such communication less of a priority than other tasks. A lack of recognition of the critical importance of the patiente physician communication can sometimes lead to spending less time with patients than might be optimal. The overall relationship can suffer and lead to potential conflict, particularly in cases with adverse outcomes.

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COGNITIVE BIAS It is important to recognize that everyone has biases, with some being conscious and others unconscious. The term “cognitive bias” refers to using one’s pre-existing subjective beliefs and preferences, often over objective information, in decision making. There has been significant work in the social sciences relating to the various kinds of cognitive bias and how they affect reasoning.13,14 In formulating a diagnosis or treatment plan, we often deal with multiple complex data as well ambiguity and uncertainty. We bring our academic knowledge and previous experiences, as well as our biases, into this process. As an example, we may be unduly influenced by our last case, and may make a decision based on that case rather than our years of experience or the literature. The role that cognitive bias plays within health care has recently gained greater appreciation.15,16 Subtypes of Cognitive Bias Cognitive bias clearly plays a role in medical decision making and communication among health care professionals (Figure 2). Croskerry and others have discussed how cognitive bias affects medical decisions, often for the worse; in some specialties, the rate of diagnostic error is thought to be as high as 15%.17-19 He cites 32 separate types of bias and how they affects outcomes.17 These biases can lead to a failure of rational and logical thought. For instance, if a physician has a preconceived notion about a diagnosis, or even a patient’s background, subsequent decision making and diagnosis may be flawed. In addition, various biases relating to the patient’s background can also negatively affect the decision-making process. Examples of these types of biases include sex, age, religion, sex, and racial views. Even obesity may cause patients to face a type of bias affecting their health care. One health care team member can unduly influence the entire medical team and can lead to a form of bias known as “diagnosis momentum.”17 For instance, if the physician who initially treats the patient formulates a particular diagnosis, then it is much more likely that subsequent staff members treating the patient will continue this view, even if erroneous. Once established, it can be quite challenging to modify a diagnosis or treatment plan. Triage cueing is another form of bias.17 Patients are triaged in the health care system continuously, with results determining factors ranging from their location in the hospital to the choice of consultant. Clinical judgment can be influenced by something as mundane as the type of bed a patient is assigned; for instance, our “radar” for deterioration of a patient’s condition may be less acute when the patient is in a standard floor bed rather than an intensive care unit. Confirmation bias is the tendency to “look for confirming evidence to support a diagnosis rather than look for disconfirming evidence to refute it.”17 Anchoring bias is when a diagnosis or plan is “locked in” too early in a patient’s course. These 2 forms of bias can be self-reinforcing and potentially lead to a serious medical error. Effects on the Physician and Patient The physicianepatient relationship may also suffer because of pre-existing biases. While we all may try to view patients as unique

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Figure 2. Cognitive bias. Selected subtypes of cognitive bias, as described by Croskerry.17

individuals, it is often impossible to completely eliminate preconceived notions related to their background. Conversely, patients may also have certain biases related to doctors and nurses. Some patients may perceive a younger physician—or even a female physician—as less competent and may express this concern. Understandably, the provider will be upset by this expression and may, in turn, view the patient in an unfavorable light. Other cognitive bias factors also can have a negative influence on the physicianepatient relationship. Unfortunately, some patients anticipate that their concerns will not be taken seriously and that they will not be adequately listened to. One patient expressed such a viewpoint to the senior author (E.E.), stating: “These are my concerns. They may seem trivial to you but are important to me.” Clearly this patient had a negative, preconceived view towards physicians and how she would be treated; while this cognitive bias was likely based on the patient’s previous experiences, not all practitioners would neglect her concerns. This type of cognitive bias can jeopardize a relationship even at its outset. Consciously recognizing the various types of cognitive biases and their impact on communication within the health care team and between team members and the patient is the first step to improvement. Cognitive bias mitigation strategies have been proposed.18,20 Although it has been said that individuals cannot be “de-biased,” the effect of their biases can be reduced.21 It is critical to acknowledge the role of cognitive bias and how it can lead to significant communication and treatment challenges. Perhaps just simply raising awareness of cognitive bias can aid in preventing misperceptions and errors. More importantly, systems must be created that overcome the inertia of continued, transmitted cognitive bias. CULTURAL HIERARCHY We must recognize that traditionally the field of medicine has had a strong hierarchical culture—like a pyramid, with the chairman on top, followed by the attendings, with residents and other staff as the base. Understandably, nurses and other non-physician providers have had serious concerns related to their position

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within the health care structure. This type of perceived hierarchical structure can clearly impact open lines of communication; for example, some health care team members may feel quite limited in their ability to express concerns relating to a patient’s care or diagnosis. Without the free and open communication of ideas and concerns, patient safety can be in jeopardy.22 Over time, there has been a growing acknowledgement of the importance of the efficient functioning of the health care team and how cultural hierarchy can negatively impact the free flow of information and medical concerns. As in the airline industry, where all crew members are empowered to speak up, the importance of open communication is now gaining traction within the medical community.12 Nevertheless, cultural hierarchy continues to pose challenges within the field of neurosurgery. Residents may feel limited in confronting or challenging their attending physicians’ care plans and decisions.23 Nurses may have a similar sense of limited impact. Cultural hierarchy can be an added barrier to effective communication within the health care team. All members of the team should feel empowered to transmit their concerns at any point. In addition, this sense of cultural hierarchy can jeopardize the physicianepatient relationship.24 Some patients may feel reluctant to ask a neurosurgeon questions and may not view their role as health care advocates for themselves. Patients from other countries may have specific cultural barriers to asking questions and expressing their concerns about a diagnosis or treatment plan.25 Patients who are not fluent in English can have other unique communication challenges based not only on language but also on perceived hierarchical issues. LACK OF TRAINING It has been estimated that, on average, over the course of a physician’s career he or she will have more than 200,000 face-to-face interactions with patients.26 Yet, most physicians have had very little or no formal training in communication skills. Multiple studies have shown the benefit of effective patient-centered communication in terms of improved patient experience and outcomes.27-30 Ambady et al.27 demonstrated a relationship between surgeons’ tone of voice in routine office visits and malpractice claims history; surgeons whose tone was rated as showing less dominance and more concern were significantly less likely to have a history of litigation. In a study of patients’ perception of an allergic reaction, Leibowitz et al.28 showed that even a brief, one-sentence assurance from a physician significantly reduced participants’ ratings of itchiness/irritation compared with a control condition in which patients received no assurance. A summary of issues related to lack of training in communication techniques is shown in Figure 3. Deliberate Practice Other authors have indicated that communication skills can be improved with training.2-5 Even physicians who feel they are innately effective communicators can still develop their skills. A neurosurgeon may spend 7 years in training learning about technical procedures and neurosurgical diagnoses yet spend barely any time focusing on the benefits of proper patient communication.

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Figure 3. Lack of training in communication skills. Issues relating to the lack of training in communication skills among neurosurgical providers are shown.

Nakagawa,31 who trained in both general surgery and internal medicine, compares his approach to deliberately practicing communication skills to learning surgical procedures: “In pondering the best way to improve my communication, I returned to the methods that served me so well as a surgical resident. Of course the tools were different: in surgery, the tool is a scalpel; in communication, the tool is language. Yet both surgical and communication skills have 3 steps in common: preparation, procedure, and review. Interestingly, the mental process is exactly the same in preparation and review.” An additional barrier to proper medical communication is that the training of senior neurosurgeons in communication skills has been limited. While it is possible for senior leaders to have superb communication skills, they may not know the terminology involved. How is it possible to teach a younger generation of neurosurgeons if the professors do not have the tools to name the specific types of communication techniques? Many of us discuss using empathy with patients, but, in fact, there are multiple subtypes of empathic statements. For instance, Chou et al.32 have described 6 specific types of empathic expressions with examples given (partnership, emotion, acknowledgment, respect, legitimization, and support). It is extremely difficult to teach a subject without having the appropriate terminology at one’s avail. Formal Training Programs Although formal communication training is now part of the medical school and neurosurgery residency curriculum, it still plays a minuscule role; the amount of time spent on communication training is far less than that spent on other technical areas. While this is understandable considering the complexity and depth of the field of neurosurgery, proper communication skills should be stressed as well. Moreover, when these communications skills are introduced, they often are discussed only at the very beginning of neurosurgery training, when a resident has very limited clinical experience; in this way, communications skills are being taught in a vacuum. Communication education may be better incorporated, and more impactful, with refresher workshops throughout training and also following residency, when the neurosurgeon is actually out in practice.

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FEAR OF DISCLOSURE OF ADVERSE OUTCOMES Neurosurgery is a field in which many high-risk operations are performed on critically ill patients; similarly, neurosurgical procedures have the potential for significant morbidity with unanticipated outcomes. Adverse outcomes can be defined as harm related to medical treatment or lack thereof and are not necessarily caused by a “mistake.”33 Nevertheless, adverse outcomes can lead to a challenge, or even a barrier, to effective physicianepatient communication. Although the majority of adverse events may not be related to a medical error, the patient’s perception can be different from the neurosurgeon's. Still, we should acknowledge that there are cases where medical error may be involved, such as wrong site surgery or the inadvertent administration of an incorrect medication, which makes discussion with the patient and family even more problematic.34 There has been a greater recognition of the need to disclose adverse events to patients and their families.35 It is now accepted proper medical practice to provide the patient and his or her family a prompt explanation of any health careerelated injury, including discussion of how the injury occurred as well as the short-term and long-term effects. In addition, patients generally want to know what steps can be taken to reduce the likelihood of similar injury to other patients. The disclosure of medical adverse events is now considered standard of care.36 In 2006, Hilary Rodham Clinton and Barack Obama co-authored a paper in the New England Journal of Medicine, in which they stated, “malpractice suits often result when an unexpected adverse outcome is met with a lack of empathy from physicians and withholding of essential information.”37 Unfortunately, there has been a sense among physicians that disclosing an adverse outcome or medical error will increase the risk of malpractice litigation. In fact, the opposite may be true; there is good literature to suggest that the malpractice risk may actually be decreased with timely disclosure.37,38 Disclosing adverse outcomes, as well as medical errors, can lead to a very challenging conversation for the medical provider. In addition, the development of an adverse outcome or medical error, as well as the subsequent disclosure, can place an emotional toll on the physician.39,40 No one likes delivering bad news, especially when there may be perceived fault involved. A frank and open discussion, in a timely manner, is clearly called for.41 The use of the word “apology,” or an admission of fault, is still quite controversial.42,43 Many hospital lawyers advocate expressing empathy under these circumstances, while still avoiding an admission of “guilt.” Other lawyers and administrators have a different view when it comes to acknowledging fault. Some U.S. states have adopted “apology laws” in the hope that they would facilitate disclosure of medical errors.43 Adverse health outcomes are not the only “challenging news” that neurosurgeons relay to patients; industry sponsorships, consulting, and other ventures can be construed as a conflict of interest. Although disclosure is required for peer-reviewed publications and continuing medical education seminars, no such standard exists for transparency with patients. The recent “Sunshine Laws” made public these financial relationships and they now are published online by the CMS (Centers for Medicare & Medicaid Services) for all physicians in the United States. Their

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discussion with patients can be delicate and is often given inadequate attention or neglected altogether. One serious barrier to the proper disclosure of an adverse outcome, medical error, or conflict to the patient and family is limited communication training of the health care provider. Clearly these are stressful conversations to plan and anticipate. Relaying these types of disclosures without knowing a proper communication framework can be like going into the operating room without a surgical plan. Defined strategies for the delivery of “bad news” have been developed, and teaching programs have been initiated.44,45 Like any other medical procedure, once a technique is understood, practiced, and mastered, it can be performed with better outcome. “It TAKES TOO MUCH TIME” One of the perceived barriers to proper and effective physicianpatient communication is the sense that it simply “takes too long.” As neurosurgeons, we are frequently under significant time constraints; we may be running late in the office or have to deal with emergencies, necessitating an eye on the clock. Unfortunately, many physicians worry that employing patient-centered communication techniques and expressions of empathy will add time to the encounter and further slow them down. Instead of allowing patients to fully state their history or express their concerns, physicians have a strong tendency to interrupt,6 often for fear that the patient will not stop speaking. However, studies have shown that if patients are not interrupted in their initial statement, most will stop speaking within 2 minutes.46,47 Any new technique will require more time when initially employed. This applies not only to medical procedures and surgeries but also to patient-centered communication techniques and expressions of empathy. Yet, with deliberate practice and repeated performance, the use of relationship-centered communication techniques can facilitate the patient encounter; instead of “slowing down” the exchange, the effective use of communication skills can actually shorten the encounter. In their study, Levinson et al.48 analyzed clinic visits focusing on “clues” given by patients (direct or indirect comments about personal aspects of their lives or their emotions) and the physicians’ responses; they found that expressions of empathy, in response to a “clue” given by the patient, led to shorter visit times for both surgeons and primary care physicians. Although some physicians express worry that employing communication skills just “takes too long,” these techniques can, in fact, improve the physician-patient relationship and make subsequent discussions proceed more quickly. Once good rapport is established, second or third visits can be shorter than the primary visit. Furthermore, effective communication techniques can lay the groundwork for a subsequent challenging “bad-news” conversation, such as conveying a poor prognosis or revealing an adverse outcome. Having already established a good rapport will make an explanation or disclosure easier for both the patient and the neurosurgeon, as well as time efficient. ELECTRONIC MEDICAL RECORDS The use of EMR systems has become ubiquitous over the past decade. There are clearly multiple benefits for both the patient and

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the health care team with EMR use as well as with patientaccessible electronic health records. As an example, it is possible to have all the results of radiologic and laboratory testing accessible in one place. Devine et al.49 demonstrated a reduction in medication errors with the introduction of computers into the outpatient medical setting. The EMR also can facilitate of communication among different health care team professionals. In addition, most patient portals allow patients to send electronic queries to their health care team in a manner that is compliant with the Health Information Portability and Accountability Act (HIPAA). Patients are also encouraged to read their own results, which can aid as a second check for any abnormal findings. However, the introduction of electronic record systems has added multiple challenges to communication between and among the health care team and patients. Counterintuitively, the EMR sometimes acts as an impediment, rather than an enhancer of communication. Atul Gawande reviewed many of the inefficiencies and challenges created by the EMR in a 2018 article in The New Yorker.50 Overwhelming Clinical Data One of the perceived goals of the EMR is to streamline the most clinically relevant material to each health care team member, thereby facilitating decision making. Unfortunately, the amount of information contained within the EMR can be staggering. Insignificant laboratory results are frequently mixed in with important, major test findings. For the clinician, there can be a tendency to enter more, rather than less, information, making it difficult to distill meaningful clinical data. Many encounter notes are examples of quantity over quality; sorting through an EMR for vital clinical information can sometimes be like trying to find a needle in a haystack. One of the features of the outpatient EMR is that it also encourages multiple forms of electronic communication among the health care team members. Again, some of these are clinically vital whereas others may be of a more mundane character. Is it really necessary to send an electronic reply back stating “Thank you” or “I appreciate your input?” Inpatient Notes For neurosurgery inpatient care, the daily notes are an important way to document a patient’s status, as well as to communicate with other team members regarding the status of the neurologic examination, consultants’ recommendations, and treatment plans. As with the EMR in the outpatient setting, the amount of information in the inpatient hospital record can be staggering and often difficult to synthesize. Important, meaningful notes can be hard to distinguish from trivial, quotidian entries. For neurosurgery patients who have prolonged hospital stays, it can be nearly impossible to review each separate entry. Complicating this picture even further, there is a tendency among many team members, often residents, to include virtually every test result in the EMR daily note; this can be accomplished easily by simply “copy and pasting” laboratory values and radiographic reports, but it many of these results have little clinical relevance to a patient’s main problem. Yet another barrier to effective health care team communication is the practice of

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“copy-forwarding” notes, duplicating a previous day's note and using it this as the basis for subsequent chart entries. We have all seen examples where this has made the daily clinical information less relevant, or even wrong. PhysicianePatient Relationship The EMR also can create barriers to effective patientephysician communication. It is considered appropriate medical care for each clinical encounter to be documented in the EMR, both for inpatient and outpatient care. Medical insurance companies, as well as the Centers for Medicare & Medicaid Services, will evaluate a patient’s record for several different types of historical data, including smoking and drug use. For outpatients, the evaluation and management billing coding generally require a comprehensive amount of information to be entered into the EMR, and with limited time available for each patient, a significant portion of the visit is often spent “buffing the chart.” How much of this information is truly medically relevant? The need for creating the “perfect” chart can take away time and focus from direct patient interaction. The neurosurgeon may be understandably preoccupied with documentation and thus offer the patient less attention. It has become quite common for physicians to document in the computer while they are in the room with the patient. This can clearly have a negative impact on the physicianepatient relationship; not only is the clinician’s attention often focused on the computer, rather than the patient, but direct eye contact is also minimized. Sometimes the layout of the office, or patient hospital room, requires health care providers to position themselves with their back to the patient, which is clearly going to diminish rapport. While electronic record keeping necessary and here to stay, the challenges posed to medical team communication, as well as to the patient relationship, have not been well explored. Even in formal physicianepatient relationship training, the use of the computer is often neglected. A greater appreciation for the impact that the EMR, and computers in general, have in altering the longestablished dynamics of medical communication needs to be recognized. FREQUENT SHIFT CHANGES AND HANDOFFS Modern neurosurgical care requires multiple team members working in concert and transmitting appropriate clinical information in a timely fashion. Although the patient is in the hospital 24 hours a day, the health care team works in shifts; this is true for nurses, residents, intensive care unit staff, and in some cases, attending neurosurgeons. The frequency of handoffs can be quite staggering, particularly with team members who work in 8-hour shifts. Imagine a patient who is in the hospital for just 1 week; in that situation, there could be over 20 handoffs within the medical team. It would not be surprising that for patients with even moderate hospital stays there could be hundreds of shift changes and handoffs. This creates a real potential danger to patients if any critical clinical information is miscommunicated. Resident Work Hour Restrictions In 1989, New York State instituted resident work hour restrictions, which eventually spread nationwide.51 The impetus

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for this arose from the Libby Zion case at New York Hospital. In addition, concerns for patient safety and resident well-being motivated these duty hour rules. Liu and Wissow52 evaluated communication techniques in pediatric critical care residents and found that, compared with residents who left the hospital on time, residents who stayed late displayed less patientcenteredness in their communication the following day, likely due to fatigue. Although one can debate the benefits, or downsides, associated with resident work hour restrictions, it is clear that this has become a permanent feature of medical training along with frequent shift changes and the communication of vital patient data. The proper transmittal of medical information during the handoff process is critical for safe and effective patient care but unfortunately, the process is often far from optimal. One study reported that 31% of internal medicine and general surgery residents at Massachusetts General Hospital rated the overall quality of handoffs to be fair or poor and that 59% of residents admitted to 1 or more patients being harmed in their most recent clinical rotation due to handoff problems.53 Individual neurosurgery programs handle the work hour restrictions in slightly different ways. Some, such as Weill Cornell Neurosurgery, employ a night float system in which a resident is working for 12 hours and is home during the daytime to rest. Other programs use a 24-hour call system, with residents going home the morning after being on call. No matter what scheme is used to comply with the work hour restrictions, the common byproduct is the creation of frequent handoffs where the opportunity for miscommunication can be rife. At times, it can seem that more effort is spent on the handoff process than on actual direct patient care.

REFERENCES 1. Hartley BR, Hong C, Elowitz E. Communication in neurosurgery—the tower of Babel. World Neurosurg. 2020;133:457-465. 2. Riess H, Kelley JM, Bailey RW, Dunn EJ, Phillips M. Empathy training for resident physicians: a randomized controlled trial of a neuroscience-informed curriculum. J Gen Intern Med. 2012;27:1280-1286. 3. Dwamena F, Holmes-Rovner M, Gaulden CM, et al. Interventions for providers to promote a patient-centered approach in clinical consultations. Cochrane Database Syst Rev. 2012;12: CD003267.

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CONCLUSIONS Communication plays a vital role in modern-day medicine. The high-risk nature of neurosurgery requires perhaps even more attention to communication issues both within the health care team and between the providers and patients. We have examined the relationship that communication has on proper medical care, treatment outcomes, medical malpractice litigation risk, and patient satisfaction.1 We explored the barriers to the enhancement of effective communication within neurosurgery. New and innovative programs must be enacted in order to improve communication issues among the health care team and with patients.54 ACKNOWLEDGMENTS The authors thank Dr. Michael L. J. Apuzzo for his insight and guidance and Dr. Philip Stieg for his leadership and support for the Annals of Weill Cornell Neurological Surgery.

7. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79: S70-S81. 8. Ray SJ. Strategic Communication in Crisis Management: Lessons from the Airline Industry. London: Greenwood Publishing Group; 1999. 9. Coxon JP, Pattison SH, Parks JW, Stevenson PK, Kirby RS. Reducing human error in urology: lessons from aviation. BJU Int. 2003;91:1-3. 10. O’Daniel M, Rosenstein AH, Professional Communication and Team Collaboration. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. 11. Kuehster CR, Hall CD. Simulation: learning from mistakes while building communication and teamwork. J Nurses Prof Dev. 2003;26:123-127.

5. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patientcentered care. Health Aff. 2010;29:1310-1318.

12. D’ Agincourt-Canning LG, Kissoon N, Singal M, Pitfield AF. Culture, communication and safety: lessons from the airline industry. Indian J Pediatr. 2011;78:703-708.

6. Marvel K, Epstein RM, Flowers J, Beckman HB. Soliciting the patient’s agenda: have we improved? JAMA. 1999;281:283-287.

13. Schwenk CR. Cognitive simplification processes in strategic decision-making. Strateg Manage J. 1984;5:111-128.

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Frequent shift changes can also impact the way patients interact with their health care team, adding another impediment to effective physician-patient communication. During an inpatient stay, a neurosurgical patient is likely to be exposed to literally dozens of different health care team members. Even for highly functional and sophisticated patients, it can be nearly impossible to remember all the various staff members they meet and their respective roles. Many patients do not know the difference between an intern, a resident, a nurse practitioner, a physician assistant, and am attending neurosurgeon and have an understandable tendency to blur the individuals. While it is important that patients have faith in their neurosurgery team, it can be quite a challenge with so many different faces.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 10 May 2019; accepted 19 August 2019 Citation: World Neurosurg. (2020) 133:466-473. https://doi.org/10.1016/j.wneu.2019.08.133 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.

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