Challenging Authority During an Emergency—the Effect of a Teaching Intervention. Issue 8 (August 2017) - Friedman, Zeev
Abstract : Objectives: Previous research has shown that residents were unable to effectively challenge a superior's wrong decision during a crisis situation, a problem that can contribute to preventable mortality. We aimed to assess whether a teaching intervention enabled residents to effectively challenge clearly wrong clinical decisions made by their staff. Subjects and Intervention: Following ethics board approval, second year residents were randomized to a teaching intervention targeting cognitive skills needed to challenge a superior's decision, or a control group receiving general crisis management instruction. Two weeks later, subjects participated in a simulated crisis that presented them with opportunities to challenge clearly wrong decisions in a can't-intubate-can't-ventilate scenario. It was only disclosed that the staff was a confederate during the debriefing. Performances were video recorded and assessed by two raters blinded to group allocation using the modified Advocacy-Inquiry Score. Measurements and Main Results: Fifty residents completed the study. The interrater reliability of the modified Advocacy-Inquiry Scores (intraclass correlation coefficient = 0.87) was excellent. The median (interquartile range) best modified Advocacy-Inquiry Score was significantly better in the intervention group 5.0 (4.50–5.62 [4–6]) than in the control group 3.5 (3.0–4.75 [3–6]) ( p < 0.001). Conclusions: A short targeted teaching intervention was effective in significantly improving residents' ability to challenge a wrong decision by a superior. This suggests that residents are not given the proper tools to challenge authority during a life-threatening crisis situation. This educational gap can have significant implications for patients' safety.