As a former USAF fighter pilot and career airline captain my training was always focused on error avoidance and error management. In the aviation world, errors can kill us and others. The concepts of Human Factors and Error Management for aviation, transfer directly to the medical community. While the aviation community has been addressing the issue of error mitigation/management for quite some time, it is relatively new to the operating room (Helmreich, 2000). Studies indicate that as many as 100,000 patients die in the US each year from medical errors (Bohnen & Lingard, 2003; Helmreich, 2000). Recently, a Johns Hopkins Study places medical errors as the third leading cause of death in the US, topping 250,000 per year. Emotional Intelligence (EI) is gaining importance as a major component for improvement in leadership and Human Factors (HF) integration.
The concept of EI is fairly new and is still the subject of debate. For the purpose of this discussion let’s look at Daniel Golemen’s definition of Emotional Intelligence as cited by Wiley (2003).
The good news is that, according to Goleman, Emotional Intelligence can be learned. There are five dimensions to this, he says. These are:
- Self-awareness: We seldom pay attention to what we feel. A stream of moods runs in parallel to our thoughts. This and previous emotional experiences provide a context for our decision-making.
- Managing emotions: All effective leaders learn to manage their emotions, especially the big three: anger, anxiety, and sadness. This is a decisive life ski
- Motivating others: The root meaning of motive is the same as the root of emotion: to move.
- Showing empathy: The flip side of self-awareness is the ability to read emotions in others.
- Staying connected: Emotions are contagious. There is an unseen transaction that passes between us in every interaction that makes us feel either a little better or a little worse. Goleman calls this a ‘secret economy’. It holds the key to motivating the people we work with. (Wiley, 2003)
EI has documented acceptance in the psychological and business communities. This exploration is not contingent upon detailed variations in the concept of EI but in the gross application of the general concept as a skill. The need for improved EI is cross cultural as presented in the article, Doctors’ emotional intelligence and the patient-doctor relationship (Weng, Chen, H., Chen, H., Lu, & Hung 2008). This article begins by confirming that EI is an important component in the patient-doctor relationship. Weng et al. describe how EI is being assessed in some medical schools to screen applicants (p. 703). Most importantly for this discussion, they identify that their study is unique from previous studies because they did not rely on doctors’ self-ratings (p. 704). In comparing the relative EI score of the doctors, it was discovered that self-assessments did not correlate to EI scores garnered from external evaluators relative to the doctor patient relationship (p. 706). This particular point is developed in Helmreich’s article “On error management: Lessons from aviation.”(Helmreich, 2000) Helmreich discusses the personality commonalities of pilots and doctors, how both groups suffer from inaccurate self-perceptions (p. 782). Epstein and Hundert further define this problem in their analysis (2002). They claim that errors in medicine may be due to doctors believing in the infallibility of their judgment, especially during times of stress (Epstein & Hundert, 2002). One can see how each article identifies the same problem using different terms based on their perspective. The inability of doctors, like pilots, to accurately assess their emotional state and thereby misjudge their abilities and impact on other members of the team, is definitely a clear problem that can result in errors.
Identifying a problem and addressing it properly is not always easy. It is important to drill down to the foundation and ensure that the causal factors involved are identified. Of the referenced studies only one identified the base contributor. The other authors failed to go deep enough. Weng et al. identify that communication skills, the basal factor missed by the other authors, are based on EI (p 705). Helmreich (2000 p. 783), Epstein and Hundert (2002 p. 227,) and Bohnen and Lingard (2003 p. 328) all identify the need for doctors to communicate better. They clearly understand that better communication is needed to avoid errors, however, they do not describe how improved communication occurs and do not provide a basis for that improvement. There are many scholarly articles written about EI, most agree that EI is developmental (Weng et al. 2008 p.704).
My training and background in communication led me to understand that one’s ability, or lack thereof, in exercising EI will dictate one’s interpersonal relationships through the communication expressed. Our emotions are expressed in body language, facial expressions, tone, volume and tempo of our words, etc. and to the least amount, the words themselves. Any attempt to improve communication with permanence will have to improve the awareness and management of the emotions behind the communication through improved emotional intelligence.
Bohnen and Lingard correctly identify the vector for change in the operating room. First they identify the fact that there are few systems developed for error reduction, they then place the responsibility for improvement on the Surgeon/Leader. Mentoring, avoiding intimidation, improving communication, and reducing tension on the team are all improvement tactics recommended (2003, p. 328). Managing one’s emotional state prior to communicating, through EI skills, or taking action, is foundational to most of the recommendations. Helmreich discusses behavior countermeasures to combat errors (2000, p. 783). He does not go beneath the data to evaluate how to change the causal factors that dictate the behavior in question. He, like Bohnen and Lingard, places the primary responsibility for improvement on the team, therefore the leader in the operating room…the surgeon. Epstein and Hundert focused on assessing competence and also arrived at the need for mentoring (2002, p. 233). Mentoring can be done from various positions in a team environment, however, it is generally accomplished by the most experienced or knowledgeable individual.
Clearly, an effective way to mitigate the huge problem of medical/surgical error is through coaching physicians. If physicians understood the negative impact they have on others in their team through lack of EI skills, they will be motivated to participate. Once the team leader (physician) is demonstrating improved skills the rest of the team will follow. It is unrealistic to expect our healthcare system to be able to train every person who is involved in surgery on error reduction through improved communication by enhanced emotional intelligence. That would be costly and time consuming. However, if the medical community is seeded with skilled EI/HF practitioners who mentor those around them during every medical event, measureable improvement will occur with resultant error reduction, patient satisfaction and organizational prestige.
As a trained instructor/facilitator I have experience in improving error reduction through increased self-awareness and the resulting HF behavior modification. I can now support this anecdotal experience with scholarly research in an attempt to further define Emotional Intelligence as an actionable skill more easily evaluated in the surgical theater. The resources available that discuss surgical error reduction methods are few (Bohnen & Lingard, 2003 p. 328). This research is just the beginning, although I believe it is representative of the current medical/surgical environment in many of our communities. By using Human Factors Error Management processes, the improvements described above can have an exponential impact on the organization, reducing HR costs, improving employee satisfaction and stability, and reducing risk management costs.
Captain Paul Westfield is available for group presentations and facilitated discussions.
Bohnen, J. M. A., & Lingard, L. (2003). Error and surgery: Can we do better? Canadian Journal of Surgery. Journal Canadien De Chirurgie, 46(5), 327-329.
Epstein, R. M., & Hundert, E. M. (2002). Defining and assessing professional competence. JAMA, 287(2), 226-35. Retrieved from http://search.proquest.com.library.capella.edu/docview/211381260?accountid=2796
Daniel Goleman, emotional intelligence, 1995. (2003). In The ultimate business library, Wiley. Retrieved from http://search.credoreference.com.library.capella.edu/content/entry/wileyultbuslib/daniel_goleman_emotional_intelligence_1995/0
Robert L Helmreich. (2000). On error management: Lessons from aviation. British Medical Journal, 320(7237), 781-785. www.bmj.com
Weng, H., Chen, H., Chen, H., Lu, K., & Hung, S. (2008). Doctors’ emotional intelligence and the patient-doctor relationship. Medical Education, 42(7), 703-711.