Patient safety vs social hierarchy – too close to call?
Patient safety vs social hierarchy – too close to call?
复制标题
患者安全与社会等级——势均力敌？
作者：
A. Palanisamy;B. Jenkins
在紧急情况下的决策背景下，一般医疗理事会（GMC）对医生个人的指导是明确的[1]。有一个“过度的责任或原则。. . [to] . . .如认为病人的安全、尊严或舒适受到损害，应迅速采取行动。当病人护理是两个或两个以上医生的共同责任时，就有可能对正确的行动方针产生分歧。用来解决这种冲突的方法可能受到专业地位、资历和许多其他因素的影响，例如在特定情况下谁被视为“专家”。弗里德曼等人的一篇文章，在这一期的《麻醉》中，探讨了麻醉训练中等级训练关系对模拟紧急情况管理的影响[2]。在他们的论文中，受训者被分配到两组，主要区别是顾问的沟通行为（“包容性”vs“排他性”）。无论他们被分配到哪个小组，受训者都没有按照模拟病人的最佳利益行事。Friedman et al.的结论是，预先存在的权力动态，而不是沟通动态，在咨询师和学员之间的关系，在某种程度上阻止了学员采取行动，以防止病人的伤害。然而，这类研究的挑战是相当大的。为了在顾问和受训者之间造成决策冲突的情况，使用了故意欺骗，使参与者相信将进行不同类型的模拟。以顾问干预将导致患者病情恶化的方式构建“无法插管，无法插管”场景。受训者预期的是不同的场景，他们是模拟中唯一不知道顾问管理层会故意伤害模拟患者的参与者。为了防止患者受到伤害，受训者不仅必须无视顾问明显糟糕的管理，他们也不能指望团队其他成员的任何帮助，这在真实的生活中可能不是这样，受训者的挑战可能得到其他团队成员的支持，或者其他团队成员可能已经发起了管理方面的变化。假设团队的其他成员是被动的参与者。与受训者不同，论文的读者可以自由地用错误行为的后见之明来解释场景。这通常是一个还原的过程，在这个过程中，回顾性解释确定了一些“出错”的关键行动。当然，这不是参与者的经历，他们必须平衡干预的风险和不干预的风险，并且还需要改变他们没有准备好的想法。从受训者的角度来看，关于顾问的唯一信息在背景准备中给出。目前还不清楚，当参与者被故意欺骗研究的实际目的时，受训者和顾问之间的三分钟互动是否足以建立一种关系动态。有可能是受训者在心理上为实际的模拟做准备，而不是注意场景前的互动。这也许可以部分解释为什么两组之间的结果没有差异。故意欺骗的效用，虽然在心理学研究中得到了很好的证实，但在模拟研究中仍有待确定[3]。让我们来做一个思想实验。假设受训者被告知困难气道算法将被违反。可以肯定的是，一些（如果不是大多数）学员会指出明显的错误。
In the context of decision-making in emergency situations, guidance from the General Medical Council (GMC) for the individual doctor is clear [1]. There is an “overiding duty or principle. . . [to] . . .take prompt action if you think that patient safety, dignity or comfort is being compromised”. Where patient care is the joint responsibility of two or more doctors, there is potential for disagreement about the correct course of action. The methods used to resolve such conflicts may be influenced by professional status, seniority and many other factors such as who is seen as the ‘expert’ in a particular situation. An article by Friedman et al., in this issue of Anaesthesia, explores the effect of hierarchical training relationships on the (mis)management of a simulated emergency scenario in anaesthetic training [2]. In their paper, trainees were assigned to two groups where the main difference was the communication behaviour of the consultant (‘inclusive’ vs ‘exclusive’). Regardless of the group they were assigned to, the trainees failed to act in the best interests of the simulated patient. Friedman et al.’s conclusion is that the pre-existing power dynamic, but not the communication dynamic, in the relationship between consultant and trainee acted in a way that stopped the trainee from taking actions to prevent patient harm. However, the challenges of this type of research are considerable. In order to create a situation of conflict in decision-making between the consultant and trainee, deliberate deception was used, where the participant was led to believe that a different type of simulation was to take place. A ‘can’t-intubate, can’t ventilate’ scenario was constructed in such a way that intervention from the consultant would lead to deterioration of the patient’s condition. The trainees expected a different scenario, and they were the only participants in the simulation who did not know that the consultant’s management would intentionally lead to harm to the simulated patient. In order to prevent patient harm, not only would the trainee have to override the consultant’s obviously poor management, they could not expect any help from the rest of the team either, which may not be the case in real life where a challenge from the trainee could have been supported by other team members, or other team members may have initiated changes in management. The assumption was that other members of the team were passive participants. Unlike the trainee, the reader of the paper has the freedom to interpret the scenario with the hindsight of incorrect actions. This is often a reductive process where retrospective interpretation identifies a number of key actions where things ‘went wrong’. This of course was not the experience of the participants, who had to balance the risks of intervention with the risks of not intervening, and also were required to change mindset to a scenario for which they were not prepared. The only information about the consultant from the trainee’s perspective was given in the background preparation. It is unclear if three minutes of interaction between the trainee and the consultant would be enough to establish a relationship dynamic, when the participants were deliberately deceived about the actual purpose of the study. It is possible that the trainees were mentally gearing-up for the actual simulation, rather than paying attention to the pre-scenario interaction. This, perhaps, could partly explain why there were no differences in outcomes between the two groups. The utility of deliberate deception, though well established in psychological research, remains to be determined in simulation research [3]. Consider, for a moment, a thought experiment. Suppose the trainees were informed that the difficult airway algorithm would be violated. It is certain that some, if not most, trainees would have pointed out the obvious mistakes.