Impact of Attending Physicians' Comments on Residents' Workloads in the Emergency Department: Results from Two J(^o^)PAN Randomized Controlled Trials

A quiet place: The impact of the word “quiet” on clinical workload

Purpose

This study aimed to determine the impact of uttering the word "quiet" on clinical workload during the overnight otolaryngology call shift and understand the factors contributing to resident busyness.

Materials and Methods

A multicenter, single-blind, randomized-controlled trial was conducted. A total of 80 overnight call shifts covered by a pool of 10 residents were randomized to the quiet or to the control group. At the start of shift, residents were asked to state aloud, "Today will be a quiet night" (quiet group) or "Today will be a good night" (control group). Clinical workload, as measured by number of consults, was the primary outcome. Secondary measures included number of sign-out tasks, unplanned inpatient and operating room visits, number of phone calls and hours of sleep, and self-perceived busyness.

Results

There was no difference in the number of total (P = 0.23), nonurgent (P = 0.18), and urgent (P = 0.18) consults. Tasks at signout, total phone calls, unplanned inpatient visits, and unplanned operating room visits did not differ between the control and quiet groups. While there were more unplanned operating room visits in the quiet group (29, 80.6%) compared to the control group (34, 94.4%), this was not found to be significant (P = 0.07). The majority of residents reported feeling "not busy" during control nights (18, 50.0%) compared to feeling "somewhat busy" during quiet nights (17, 47.2%; P = 0.42).

Conclusion

Contrary to popular belief, there is no clear evidence that uttering the word "quiet" significantly increases clinical workload.

"Shh-don't say the Q-word" or do you?

We aimed to assess the superstitious belief that saying the word ‘quiet’ during an on-call period in oral and maxillofacial surgery (OMFS) causes a disproportionate increase in workload. A two-armed, single-centre, randomised trial was performed in a single-blinded fashion within the OMFS department at Addenbrookes Hospital, Cambridge. Duty on-call OMFS SHOs were assigned to a ‘quiet group’ or ‘non-quiet group’. The former group was actively told that the on-call period would be ‘quiet’ whilst in all contexts in the latter this word was not used. Data were collected from 8am to 7pm from a period that spanned a total of 40 week-day on calls. The total number of bleeps was 491, the mean (SD) bleep count/day irrespective of treatment was 12.3 (4.6). The mean (SD) bleep count was 11.45 (4.15) for the control group and 13.1 (4.9) for the quiet (treatment) group. Welch’s independent-sample t test identified no significant difference in the mean number of bleeps encountered between groups. Moreover, ANOVA identified no significant difference in the mean number of bleeps between days (F(4,35) = 0.086, p = 0.986). Statistical analysis was performed using R package version 3.6.2 (The R Foundation). Our study refutes the central dogma of all of medicine, which suggests that saying the word ‘quiet’ increases the clinician’s workload during the working day. We identified no significant difference in the number of bleeps between different days of the week. OMFS sees a large breadth of presentations within the head and neck that requires a diverse set of skills to manage the varying presentations when on call.

Q fever-the superstition of avoiding the word "quiet" as a coping mechanism: randomised controlled non-inferiority trial

OBJECTIVE

To determine the validity of the superstition that utterance of the word "quiet" in a clinical setting increases workload.

DESIGN

Prospective randomised controlled non-inferiority study.

SETTING

Microbiology department of a large teaching hospital in Lancashire, UK.

PARTICIPANTS

Two members of the medical microbiology team carried out the duty work on any given week day and an on-call team member on any weekend day. 29 days were assigned in which staff were to say "Today will be a quiet day" and 32 days were assigned in which staff were to refrain from saying the word "quiet" in any context.

INTERVENTIONS

Each day was randomly allocated to either saying "Today will be a quiet day" (intervention group) or refraining from saying the word "quiet" (control group) in any context.

MAIN OUTCOME MEASURES

The primary outcome was mean overall workload: a composite of number of clinically related telephone calls, clinically significant results, or validated results processed by the duty medical microbiology team during a 24 hour period referred to collectively as "clinical episodes." A difference of 30 clinical episodes was considered as the margin of non-inferiority. Secondary outcomes included the individual components of the primary outcome.

RESULTS

Workload was measured each day over a 61 day period (1 May to 30 June 2019). A mean 139.0 clinical episodes occurred on control days compared with 144.9 on days when the experimental intervention was uttered, a difference of 5.9 (95% confidence interval-12.9 to 24.7). The upper bound was less than the specified margin of 30, providing evidence for non-inferiority. No evidence of a difference in workload was found between interventions with any of the four components, whether considering unadjusted or adjusted analyses, or looking at the subgroups of week days or weekends.

CONCLUSIONS

The study findings refute the long held superstition that utterance of the word "quiet" impacts on clinical workload, and therefore it should not be avoided. In the era of considerable staff shortages and increased work related stress, doctors should look to other methods to increase resilience and protect their wellbeing and mental health.

TRIAL REGISTRATION

Lancashire Teaching Hospitals NHS Foundation Trust's research department SE-259.

The influence of quotations uttered in emergency service triage traffic and hospitalization (Quiet)

This study aims to determine whether the use of the word, Quiet increases veterinary emergency service triage traffic or hospital admissions. Days were randomized to be a control or test phrase day. On control days, the phrase, Have a nice day! was announced to the entire hospital staff. On test days, the phrase, Have a quiet day! was announced. No statistical difference in mean number of the patients presenting to the emergency service for triage (test phrase 30.1 ± 10.4 cases vs control phrase 30.3 cases ± 10.5, p = 0.91) or hospital admissions (test phrase 3.5 ± 1.9 cases vs control phrase 4.3 ± 2.4 cases, p = 0.13) was found for 24-h following phrase utterance. No statistical difference in mean number of patients presenting to the emergency service for triage (test phrase 2.7 ± 1.4 cases vs control phrase 2.6 ± 1.9 cases, p = 0.84) or hospital admissions (test phrase 0.3 ± 0.5 cases vs control phrase 0.5 ± 0.8 cases, p = 0.08) was found in the 2-h window immediately following phrase announcement. Despite popular myth, using the word, Quiet does not increase veterinary emergency service triage traffic or hospital admissions.