Introduction
Health care provider affective states and emotional processing have direct effects on both patient interaction and medical procedures. Thus, affective states and emotional processing are prime factors in the causation of Medical Errors.
This chapter will define affective error, theorize about some of it’s underpinnings, describe the ways affect can produce Medical Error. In conclusion, educational recommendations directed at reducing the consequences of affective error will be discussed.
I. Affective Error: Definitions and Overview
For purposes of this chapter, Affective Error will be defined as a disorder of affective or emotion regulation, causes a procedural or cognitive error.
Affect, in this definition, refers to general or more persistent objective states of mood. Pathological states, Affective Disorders include depressive states, generalized irritability, anxiety, manic states or extreme emotional blunting. These affective states may arise from a variety of biological, psychological or social factors.
In contrast, Emotion, refers to discrete feeling experiences including the physiological and psychological manifestations. Examples of emotions include the internal experience of rage, guilt, sadness and positive feelings of human attachment. Each of these emotions has it’s own physiological manifestation and general cognitive sets. Thus one may see affect without any actual emotional experience. Emotion Dysregulation refers to destructive intrapsychic and interpersonal behaviors one does in direct response to emotions. As a central cause of medical error, this dysregulation will be focused on in section II B.
Affect, Behavior (or procedure) and Cognition are inextricably linked. (See Figure 1) One may consider these the ABC’s of Medical Error. (Abbass, A, Symposium on Medical Error, 2002) Proceedings of Conference) Affect and emotions have an impact on what one does and how one thinks in the clinical situation. Furthermore, the cognitive view of a patient directly influence a healthcare provider’s affective and emotional states. Additionally, one’s behaviors (eg suppressing anger toward a patient) can result in secondary affect/emotional reactions (eg depression).
Despite these links, a provider may experience a wide range of affect and emotions without actually causing any Medical Error: it is only through flaws in thinking and procedure that error may be said to take place. Accordingly, the emphasis is on the impact of affect and emotions on procedure and cognition.
Most of what is retrievable about affective error comes from the literature on psychotherapist reactions and counter-transference. (Ref Croskerry, The cognitive Imperative: thinking about how we think, Acad Emerg Med 2000) Counter-transference refers to the process of a provider’s past emotions stirring up with a present patient. Therapist reaction is a more general term for the summation of a provider’s emotional, cognitive and behavioral responses to a patient. These areas will be reviewed in some detail in Section 3.
II. How do Affective Disorders and Emotional Dysregulation Manifes
Four categories of affective and emotional states and their secondary effects on provider functioning are described below. (Ref DSM IV: Diagnostic and Statistical manual for Mental Disorders 1994, APA Press Washington, DC)
A. Affective disorders
1.
Depressive disorders
These disorders include Major Depressive Disorder, Dysthymic Disorder, and Depression due to medical conditions or substance abuse.
Cognitively, depressive disorders produce a negative view of the self, future and current activities. This negativity may grow to include a negative view of one’s clinical activities and the potential outcomes from procedures. Behaviourly, depression may be experienced as exhaustion, avoidance, withdrawal and self destructive behaviors. As a result, the clinician may not bring the energy required to perform his/her duties. Further self-destructive behaviours include poor patient care, patient neglect or boundary transgressions.
Affectively, depressed individuals may experience anxiety, irritability, and emotional blunting. These are discussed in sections below.
Concurrently, depressive individuals may exhibit poor memory, poor concentration and poor attention. Those on antidepressants may experience side effects which include sedation, tension, headaches, diarrhea and sexual dysfunction. These can all directly and indirectly influence clinical performance and decision making. (Cross ref Crosskerry /Kovacs) Thus, depressed individuals are at risk for error as a result of these multiple and interrelated phenomena.
2. Anxiety Disorders
Anxiety disorders are disorders of overarousal, fear and avoidance. They include Generalized Anxiety Disorder, Panic Disorder, Phobic Disorders, Obsessive Compulsive Disorder, Post-traumatic Stress Disorder, and Anxiety due to a medical condition or substances.
Cognitively, these disorders are characterized by fear of internal or external stimuli. This fear can be of such intensity that it can interrupt the professional’s cognitive and perceptual function. Thus, high anxiety will have a direct destructive effect on professional performance.
Behaviorally, this fear can lead to terror, avoidance, personality constriction and ritualistic behaviors. Consequently, anxious professionals may be overly cautious with a tendency to over treat and investigate. Conversely, they may be avoidant, neglecting obligations to properly investigate and treat.
Medication treatments for anxiety can themselves produce memory problems (Benzodiazepines), sedation and a variety of other somatic side effects.
The psychophysiology of anxiety will be reviewed in Section B2, since it is specifically relevant to countertransference reactions.
3. Manic Disorders
These disorders include mania and hypomania, which are characterized by elation, grandiosity, irritability, sleep loss and excessive energy.
Cognitively, a manic individual may be over confident about his abilities, or about the potential outcome from a procedure.
Behaviorally, manic disorders may produce irritability, erratic behavior, impulsive behavior and professional boundary violations, thereby disposing the professional to multiple forms of interpersonal problems and error.
Medical treatments may result in a stabilization of professional functioning with relatively minimal side effects that would interrupt professional functioning.
4. Psychotic Disorders
These disorders, including brief psychotic disorder, schizophrenia, schizoaffective disorder and delusional disorder, are characterized with a break from reality plus other phenomena including cognitive dysfunction. Extreme emotional reactions may occur during acute exacerbations, behavior maybe eccentric to bizarre. As a result, individuals with active untreated disorders may be at major risk for error due to a distorted view of the world, the patient and the self.
Table 1: Examples of Error due to Affective Disorder
|
Category of Affective Disorder |
Example of Error |
|
Depressive Disorder |
Lack of treatment efforts, neglect |
|
Anxiety Disorder |
Mental confusion in medical emergency: medication
error |
|
Manic Disorder |
Pressing risky or new procedure due to over
confidence |
|
Psychotic Disorder |
Harming a patient due to perceived threat |
B. Behavior Patterns related to Conscious or Unconscious Emotional
Dysregulation:
Several patterns of emotional avoidance behaviors can also increase risks for error. Each of these behaviors may be a product of countertransference feelings stirring up in relation to the patient.
1. Unconscious defences which prevent emotional awareness and experience:
| a. | Isolation of affect: when one is aware of the emotion but doesn’t experience the emotion: intellectual detachment from the feeling. |
| b. | Repression: When emotions are kept from awareness unconsciously. |
| c. | Projection: When one’s own feeling, usually anger, is seen as being in another person. |
2. Unconscious Anxiety and Defences: This can be seen as a direct result of emotional blockage as described in 1. (Whittemore, 199 Paving the Royal Road to the Unconscious)
| a. | Muscle tension: This is seen clinically with hand clenching, sighing respirations and can result in whole body tension. Clinicians with this unconscious process may experience fibromyalgia, headaches, irritability and fatigue. |
| b. | Smooth muscle tension: The main manifestations are irritable bowel syndrome, bladder spasm, hypertension. This is common among medical professionals seeking counseling services. |
| c. | Somatization to other systems: Examples include rashes, hives, immune system depletion and pain states. |
| d. | Cognitive and perceptual disruption: Common among medical professional seeking counseling, these disruptions may include confusion, visual blurring, the mind going blank, fainting and poor memory. This could obviously result in dangerous procedural error as well as a range of accidents and self injurious behaviors. |
| e. | Depression: Blocked off experiences of intense anger and guilt about the anger may result in transient or sustained depressive reactions. |
| f. | Conversion: Examples include weakness or visual blurring as a direct response to intense emotions. |
2. Other patient-related behaviors are extreme attitudes and approaches to a patient. An understanding of these is discussed in Section III below. Examples of these include the following:
| a. | Unrealistic view of one’s work and skills which can lead to misleading the patient, over use of treatments and recklessness. |
| i. | Excessive optimism, excessive confidence in one’s skills and outcomes. |
| ii. | Overly discouraged attitude, lack of confidence in one’s skills, hopelessness, helplessness. |
| b. | Unbalanced use of services can lead to withholding or overuse of appropriate services. |
| i. | Overly aggressive use of treatments including certification. |
| ii. | Lack of appropriate use of treatments including certification. |
| c. | Power struggle with patient, which prevents informed consent and treatment alliance. |
| i. | Defiance with patient, argument |
| ii. | Excessively strong encouragement for or against a procedure |
| d. | Excessive emotional involvement and engagement with a patient can result in boundary violation and a lack of an objective view of the patient. Examples of this include: |
| i. | sexualizing behaviors |
| ii. | rescuing behaviors and |
| iii. | acting out anger toward a patient |
| e. | Excessive emotional detachment from a patient can result in error of neglect, with the patient feeling they are not being heard and attended to. |
II. What are some causes of Emotional Dysregulation
A. Attribution Error
This cognitive assessment error is the generation of conclusions about a patient based on limited information. An example of this would be the assumption that an old man in dirty clothes found in a park is an alcoholic or that a young woman who cut her arm has borderline personality disorder. This faulty, or at best partial, assessment can result in extreme or inappropriate emotional responses.
B.
Countertransference Reactions
Countertransference refers to the process of a provider’s past feelings being mobilized and coloring a present relationship situation. (See Figure 2 In itself this process is universal, for the reason that any new person is seen in comparison to the sum of previous human contacts. It is pathological, or at least problematic, when the emotions stirred from the past are intense, complex and avoided by the unconscious anxiety and defence mechanisms described in II above. (See Figure 3)
If these feelings are avoided and buried, the clinician can experience anxiety or exhibit defensive behaviors as described above. The clinician may unwittingly relate to the patient as a punitive parent, a victim, an abuser, an idealized other or in some other unidimensional or distorted fashion.
C. The Emotionally Evocative Patients
This is a prominent problem in the case of patients who, by virtue of their behaviors, evoke strong feelings in the provider. An example is patients who exhibit features of severe personality disorders including borderline personality disorder (BPD). Patients with BPD are highly dependant on their environment to shape their self perception: this is referred to as being context bound. As a result, they will respond to what the environment is saying about them. For example, if they are in hospital the self perception is they are very ill or out of control. If they are admitted, they are sicker than if they are discharged. If they are given medications, they feel again more out of control. Thus, increased services, consultations, admission and treatments can result in a worsening behavioral outcome. (Dawson D, Treatment of the Borderline Patient, Relationship Management, Can J Psy 33: 370 374. 1988)
The behavioral extremes exhibited and the different ways these patients relate to particular staff can present unique challenges. For this reason, it is probable that these patients are involved with more Medical Error than most because of the teams response. This may occur by at least 2 mechanisms.
First, the patient’s behavioral extremes can mobilize intense loving feelings, sexualized feelings, intense rage and other strong emotions within the clinician. If the clinician is able to be aware of the emotions and not act on them, they can work effectively with these patients. If the emotions are blocked and defended, the result can be clinician burnout, somatization, anxiety, depression, treatment misalliance and other defensive reactions. These various reactions are major drivers of underdoing and overdoing behaviors.
Secondly, when different team members work with BPD patients, the clinicians may each see the patient from only one perspective. One clinician may see the patient as a “helpless victim who needs rescuing” and another may see the patient as “a manipulating abuser who needs to be taught a lesson”. This creates the potential for the team to conflict over treatment decisions, with one member tending to overdo and the other to under-do. This team misalliance can set the stage for cognitive and procedural error, as well as making work uncomfortable. Thus, it is vital for teams to work collaboratively and openly to prevent rendering itself non effective or harmful to a patient. (The Ailment, Main 1956) (Okelly and Azim staff staff relations In J Group Ther)
IV. Understanding Over and Under-doing Errors
Cognitive and emotional reactions as noted above can result in errors of excessive / inappropriate action or avoidance of appropriate actions. (See Table 2) These “over doing” or “under-doing” behaviors are often seen in the setting of the well meaning but anxious clinician worried about being “too invasive” or conversely about being “neglectful”.
Conflict can arise in a treatment team when there is a mix of people who are in the under-doing pole and in the over-doing pole. The first group views the under-doers as avoidant or neglectful and the other sees the over-doers as controlling or abusive. These splits occur often with patients (or staff) who have certain emotionally evocative behaviors, as described above.
These are not static positions since a clinician will often move from one pole to another in compensation for having over done or under done with that, or another, patient. The key element is a lack of balance in one’s perspective and hence, one’s interventions.
Table 2: Over and Under-doing Error
|
|
Under-doing Pole |
Over-doing Pole |
|
Typical Errors |
Failed to do indicated procedure, consultation,
admission or treatment |
Adverse effects occurred during an invasive procedure which had limited indication |
|
Fears re Own Behavior |
Doing Harm: eg adverse effects Imposing one’s will |
Missing a diagnosis Not doing everything possible |
|
How They See Themselves |
Empowering, flexible, safe, cost effective |
Thorough, safe |
|
Fears re Patient’s Perception |
Being seen as abusive, frightening or controlling |
Being seen as neglectful or uncaring |
|
How they want to be seen by Patient |
Empathic, protective |
Competent |
|
Threshold to invasive procedure, medication,
hospitalization, consultation |
Too High |
Too Low |
V. Recommendations to Clinicians and Administrators
A. Early identification and treatment of affective
disorders, psychotic
Obviously, mental illnesses which predispose a professional to error need to be rapidly detected and managed. This may be more easily said than done due to fear, shame and stigma which are often associated with mental illness. To counter these barriers, a supportive administration, available confidential services and a culture which values and rewards optimal mental health are essential.
B. Combat Unconscious Emotional Dysregulation
Unconscious Emotional dysregulation is driven by a lack of conscious awareness of one’s emotions and their origin from previous experiences. There are several individual and group interventions which help clinicians become aware of their own emotional triggers and patient types they react to.
1. Peer Review and Support
A model approach to improving self awareness is case rounds, peer review and structured or impromptu debriefing sessions with a supportive peer. One excellent approach to this is periodic live observed contact for peer input. This can help develop a culture of self awareness, professional growth and ongoing learning.
2. Videorecord Patient Contacts
We have an expression in videotaped interviewing skills training groups: “The tape never lies”. Trainees are always struck by the subtle and sometimes more obvious things they do in interactions that they were not aware of. This is especially valuable for work with the emotionally evocative patient in which professional reactions are most likely to become problematic.
3.
Culture of Self Examination
A central theme throughout this book is the objective of uncovering error and our own areas we can improve on in our clinical work. A major step toward this is opening the discussion on clinician emotions. This can occur in many ways and settings, but, it always must have the explicit support of clinical leaders and administrators. Self-examination must be considered an essential skill to be rewarded in all clinicians.
4. Other Roads to Self Awareness
There are a number of excellent books available to assist the helper in becoming more self aware. An example of this is the best seller, The Road Less Travelled, by Scott Peck MD. This book is a great guide to the clinician who wants to become more self aware as well as who is in a phase of asking bigger questions about self, relationships and life in general.
Personal dynamic therapy. There are now a number of empirically validated brief psychodynamic psychotherapies, with common goals of bringing awareness of emotions and their connection to past relationships. These maybe the treatment of choice for the professional who wants to get a good look at what is happening within, without entering into a very long therapy with questionable empirical bases.
VI. Recommendations to Educators
A. Education to all providers in the area of emotion.
A core element of medical professional training should be comprised of ample opportunity to develop self awareness and awareness of one’s interpersonal patterns and tendencies. Didactic sessions could present key elements, and practical experiences could cement this learning through the use of video-recording, discussion and selected readings.
B. Peer Learning
Optimally the above noted sessions would be in a group format to teach peer support and peer learning. This can the set the stage for ongoing professional growth and peer learning.
C. Develop a culture of emotional awareness and self-examination
If these exercises were incorporated into the medical curriculum, this would produce the culture of self awareness as well as peer support. The professionals could learn from each other and more comfortably examine and address error.
Conclusions
In summary, affective disorders and emotional dysregulation can produce cognitive ad procedural error. These errors may result in destructive over-doing or neglectul under-doing behaviors: both of these can result in harm to the patient and disruption of treatment teams. Emotional awareness and treatment of affective disorders can help prevent this type of error. Education, clinical leadership and peer communication structures can generate a culture of self awareness and open examination of the emotional underpinnings of Medical Error.