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In medicine, be wary of "misspeakers" who "shoot from the hip"

From the November 29, 2000 issue

PROBLEM: Have you ever been tempted to answer a question even though you were not sure your answer was correct? Such occurrences in healthcare are more common than we would like to admit. Earlier this year, one of the editors of The Nurse Practitioner encountered several instances of "misspeaking" from healthcare providers who felt a need to say something authoritative, despite their lack of knowledge on the issue. 1 While camping, the editor was bitten by a bat. A 911 medical dispatcher who was unfamiliar with this rare occurrence "misspoke" and told her that treatment was not necessary. But the editor had recently published an article on rabies and insisted on being connected to a medical clinic where she was correctly told to begin rabies treatment within 48 hours. While receiving her fourth rabies vaccine, she noticed that the substance in the syringe looked different than previous injections. Again, a healthcare provider "misspoke," saying that the drug was from a different manufacturer. When the editor persisted, the nurse found that the drug was immune globulin, not the vaccine. After receiving the final vaccine, the editor realized that it had been given one week early. Both the ED physician and the vaccine manufacturer "misspoke" and suggested that she receive one additional injection. Yet, when the editor called the CDC, she was told that no more vaccines were necessary.

The editor noted that, for complex reasons, children often talk authoritatively on topics about which they know little. If they are not redirected to speak truthfully, they may become adults who feel the need to "shoot from the hip" and provide an answer regardless of what they know. Additionally, healthcare providers are often pressured to give an answer instantly. The editor believes that these conditions, more than an intentional desire to deceive, cause "misspeaking." But intentional deception sometimes occurs in healthcare, too. In a study with internal medicine residents, subjects clearly indicated that it was wrong to deceive their colleagues.2 But over 40% reported that they had witnessed residents intentionally deceiving attending physicians and other residents. The study found that the likelihood of deception was dependent on circumstances. For example, twice as many residents (19%) admitted they would make up a plausible answer for a forgotten laboratory value if the attending physician was likely to ridicule and embarrass them. Perhaps more important, a full 10% would still make up the laboratory value even if they knew they would not be reprimanded for not knowing it.

SAFE PRACTICE RECOMMENDATION: "Shooting from the hip" sometimes hits the target, but seldom precisely. Serious errors are possible when imprecision and misinformation are introduced into patient care. Thus, it's important to evaluate your environment to identify particular circumstances under which providers are more likely to answer questions without confirmation. To lessen the risk of off-the-cuff or less-than-truthful answers, enhance awareness among educators, managers, and administrators about the impact that their teaching or management style may have on staff's behavior. They should serve as role models and demonstrate that staff should not be afraid to admit that they do not know the answer to all questions. Further, rather than rush people for any answer, they should allow adequate time for staff to provide the correct answer. Address the issue during training programs using group discussions, simulations, and role-playing. Finally, encourage patients to take an active role in their healthcare and persistently ask questions if they are not satisfied with the answers they receive.

1. Pearson L. Medical errors hit home. The Nurse Practitioner. May 2000;11-13.;
2. Green MJ, Farber NJ, Ubel PA, et al. Lying to each other: When internal medicine residents use deception with their colleagues. Arch of Intern Med. 2000;160 (15):2317-23.

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