Communication in Neurosurgery—The Tower of Babel

A Scoping Review of Professionalism in Neurosurgery

BACKGROUND AND OBJECTIVES

The Accreditation Council for Graduate Medical Education's Milestones provides a foundation for professionalism in residency training. Specific professionalism concepts from neurosurgery could augment and expand milestones for the specialty. We reviewed the current literature and identified professionalism concepts within the context of neurosurgical practice and training.

METHODS

We used a scoping review methodology to search PubMed/MEDLINE and Scopus and identify English-language articles with the search terms "professionalism" and "neurosurgery." We excluded articles that were not in English, not relevant to professionalism within neurosurgery, or could not be accessed. Non-peer-reviewed and qualitative publications, such as commentaries, were included in the review.

RESULTS

A total of 193 articles were included in the review. We identified 6 professionalism themes among these results: professional identity (n = 53), burnout and wellness (n = 51), professional development (n = 34), ethics and conflicts of interest (n = 27), diversity and gender (n = 19), and misconduct (n = 9).

CONCLUSION

These 6 concepts illustrate concerns that neurosurgeons have concerning professionalism. Diversity and gender, professional identity, and misconduct are not specifically addressed in the Accreditation Council for Graduate Medical Education's Milestones. This review could be used to aid the development of organizational policy statements on professionalism.

Data-Driven Residency Training: A Scoping Review of Educational Interventions for Neurosurgery Residency Programs

BACKGROUND

Neurosurgery residency programs are tasked with imparting large volumes of both clinical knowledge and technical skill to trainees in limited time. Many investigators have described local practices, which may offer evidence-based interventions in neurosurgical residency education, but this literature has not been systematically reviewed.

OBJECTIVE

To perform a scoping review of educational practices in neurosurgery, which are supported by quantitative, peer-reviewed research.

METHODS

A scoping review of the literature was performed. PubMed, Embase, and Web of Science databases were queried for articles describing educational interventions for neurosurgery residents, which included a quantitative assessment of the effect on resident performance.

RESULTS

From an initial set of 1785 unique articles, 29 studies were ultimately screened and included. Studies were into the following 6 topics: (1) didactics and curricula (n = 13), (2) nontechnical skills (n = 6), (3) wellness and burnout (n = 4), (4) assessment and feedback (n = 2), (5) mentorship and career development (n = 2), and (6) research (n = 2). Individual study results were described.

CONCLUSION

Several educational interventions in neurosurgical training are supported by quantitative evidence. Methodological shortcomings are prevalent among studies of education, particularly in the selection of meaningful outcome measures. A summary of evidence-based considerations is provided for current and future program directors.

Standardizing postoperative handoffs using the evidence-based IPASS framework through a multidisciplinary initiative improves handoff communication for neurosurgical patients in the neuro-intensive care unit

Errors in communication are a major source of preventable medical errors. Neurosurgical patients frequently present to the neuro-intensive care unit (NICU) postoperatively, where handoffs occur to coordinate care within a large multidisciplinary team. A multidisciplinary working group at our institution started an initiative to improve postoperative neurosurgical handoffs using validated quality improvement methodology. Baseline handoff practices were evaluated through staff surveys and serial observations. A formalized handoff protocol was implemented using the evidence based IPASS format (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, Synthesis by receiver). Cycles of objective observations and surveys were employed to track practice improvements and guide iterative process changes over one year. Surveys demonstrated improved perceptions of handoffs as organized (17.1% vs 69.7%, p < 0.001), efficient (27.0% vs. 72.7%, p < 0.001), comprehensive (17.1% vs. 66.7%, p < 0.001), and safe (18.0% vs. 66.7%, p < 0.001), noting improved teamwork (31.5% vs. 69.7%, p < 0.001). Direct observations demonstrated improved communication of airway concerns (47.1% observed vs. 92.3% observed, p < 0.001), hemodynamic concerns (70.6% vs. 97.1%, p = 0.001), intraoperative events (52.9% vs. 100%, p < 0.001), neurological examination (76.5% vs. 100%, p < 0.001), vital sign goals (70.6% vs. 100%, p < 0.001), and required postoperative studies (76.5% vs. 100%, p < 0.001). Receiving teams demonstrating improved rates of summarization (47.1% vs. 94.2%, p = 0.005) and asking questions (76.5% vs 98.1%, p = 0.004). The mean handoff time during long-term follow-up was 4.4 min (95% confidence interval = 3.9-5.0 min). Standardization of handoff practices yields improvements in communication practices for postoperative neurosurgical patients.

Perceptions of Indian neurosurgeons about medicolegal issues and malpractice suits

OBJECTIVE

Despite the rising trend of medicolegal challenges in India, there is an absolute dearth of literature from India on this issue. The authors conducted a survey, to their knowledge a first of its kind, to assess the perceptions of Indian neurosurgeons about the medicolegal challenges faced in everyday practice.

METHODS

An anonymous online survey performed using Google Forms was widely circulated among neurosurgeons practicing in India via email and social media platforms. The questionnaire consisted of 38 questions covering the various aspects of medicolegal issues involved in neurosurgery practice.

RESULTS

A total of 221 survey responses were received, out of which 214 responses were included in the final analysis, barring 7 responders who had no work experience in India. The respondents were categorized according to their working arrangements and work experience. Out of all of the respondents, 20 (9.3%) had ≥ 1 malpractice suits filed against them. More than 90% of the respondents believed that malpractice suits are on the rise in India. Almost half of the respondents believed the advent of teleconsultation is further compounding the risk of malpractice suits, and 66.4% of respondents felt that they were inadequately trained during residency to deal with medicolegal issues. Most respondents (88.8%) felt that neurosurgeons working in the government sector had lesser chances of facing litigations in comparison to those working in the private sector. The practice of obtaining video proof of consent was more commonly reported by respondents working in freelancing and private settings (45.1%) and those with multiple affiliations (61.3%) compared to respondents practicing in government settings (22.8%) (p < 0.001). Neurosurgeons working in the private sector were more likely to alter management and refer sick patients to higher-volume treatment centers to avoid malpractice suits than their government counterparts (p = 0.043 and 0.006, respectively). The practices pertaining to legal preparedness were also found to be significantly higher among the respondents from the private sector (p < 0.001).

CONCLUSIONS

This survey highlights the apprehensions of neurosurgeons in India with regard to rising malpractice suits and the subsequent increase of defensive neurosurgical practices, especially in the private sector. A stronger legal framework for providing for quick redress of patient complaints, while deterring frivolous malpractice suits, can go a long way to allay these fears. There is a dire need for systematic training of neurosurgeons regarding legal preparedness, which should begin during residency.

Feelings experienced in hyperbaric oxygen therapy: the users’ voice

Objetive: To characterize the feelings experienced by users of hyperbaric oxygen therapy (HBOT). Methods: Qualitative study, usingmultiparametric techniques for data collection such as the free word association technique, drawing-and-story procedure with theme and the semistructured interview. For the analysis, the discursive material, together with the visualization of the drawings and the responses of the word-free associations, was cross-referenced and the method of content analysis was employed, thus allowing the feelings experienced at HBOT to be portrayed. Results: The categories emerged: fear and anxiety; feeling of imprisonment and tiredness; happiness and confidence/hope, the latter being subdivided into trust in the therapy and in God. Conclusion: After, the first sessions and especially after the guidance and incentives from the professionals, the negative feelings were softened and gave way to satisfaction, followed by happiness in being able to return to family and social life and all this anchored in the feeling of hope and faith.

Sentimentos vivenciados na oxigenoterapia hiperbárica: a voz dos usuários

Objetivo: Caracterizar os sentimentos vivenciados pelos usuários da oxigenoterapia hiperbárica (OHB). Métodos: Estudo qualitativo, utilizando técnicas multiparamétricas para coleta de dados como a técnica de associação livre de palavras, procedimento desenho-estória com tema e a entrevista semiestruturada. Para a análise, o material discursivo, juntamente com a visualização dos desenhos e as respostas das associações livres de palavras, foi cruzado e empregado o método de análise de conteúdo permitindo, dessa forma, retratar os sentimentos vivenciados na OHB. Resultados: Emergiram as categorias: medo e ansiedade; sentimento de prisão e cansaço; felicidade e confiança/esperança, sendo que esta última subdividida em confiança na terapia e em Deus. Conclusão: Após as primeiras sessões e principalmente após as orientações e incentivos dos profissionais, os sentimentos negativos foram amenizados e cederam espaço para a satisfação, seguidos de felicidade em poder voltar ao convívio familiar e social e tudo isso ancorado no sentimento de esperança e fé

Barriers to the Enhancement of Effective Communication in Neurosurgery

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.

Future Directions in Communication in Neurosurgery

Modern-day care of the neurosurgery patient has grown increasingly complex and typically involves a variety of medical team members. Proper communication and transmission of clinical data within the neurosurgery team is required for successful outcomes, especially within the operating room. Effective communication is also critical to the patient-physician relationship and can aid in improving rapport and possibly reducing malpractice lawsuit risk. In addition, interactions exist between practicing neurosurgeons and members of the administration, often focusing on reimbursement and quality issues. Although most physicians would agree that communication between all these stakeholders should improve, certain barriers are present, including the adoption of newer technologies and the lack of formal training. In this article, we review current and projected trends relating to the enhancement of neurosurgical communication at all levels.