Dr. Peter Nugus

By Philip Fine

Third-year McGill MDCM student Jessica Drury researched an important challenge facing health practitioners. It’s not one talked about during training, but it certainly affects a professional’s ability to best do her or his job: interruptions.

Drury documented her findings in a paper called Do Not Disturb: Managing interruptions during patient visits, written for a second-year MDCM class called Observing Healthcare in Action (OHA).

OHA is taught by Peter Nugus, a Professor at the Centre for Medical Education and in the Department of Family Medicine, who has conducted his own ethnographic research in emergency departments and various hospital and community settings in various countries. As part of the Transition-to-Clinical-Practice curriculum component, he has been persuading cohorts of MDCM students, more comfortable with lymphatic and circulatory systems than administrative and organizational systems, to think about their profession through a sociological lens. Students spend time at a medical facility and shadow personnel in an effort to better understand the non-medical roles and structures of the system that will eventually be employing them. They are also tasked with drawing on health care principles written by physician-social scientists and sociological literature in order to place their findings in a broader academic context.

Nugus argues that hospitals and clinics, with their unique physical settings and power structures, are complex systems that play an important role in the way medicine is practiced, and so it’s incumbent on medical students to better know those complexities. “How can you be an advocate for patients, or be socially accountable to the Canadian people whose taxes fund the health system, if you don’t understand the system, don’t understand what the influences are on people’s health?” says Nugus.

Which brings us to Drury and the fieldwork that had her spending two three-hour sessions with nurses at a family medical centre, notepad at the ready and scribbling down what she saw. Like her classmates, she had to come up with a research subject from her observations. She eventually noticed that the medical centre experienced interruptions on a regular basis.

“One registered nurse told me ‘Sometimes when I’m with patients, people just open the door. It drives me crazy!’” Drury recounted at a recent gathering. That same nurse told her about an incident where she was removing sutures, the door opened, she turned to see who it was and dropped the instrument she was using. Another nurse told Drury that the high number of interruptions left her with little time to complete her notes.

But the student also observed how interruptions could sometimes be a good thing, such as when she was walking down the hallway with a nurse and they ran into a doctor at the photocopier. The nurse and the doctor briefly discussed a case that was coming up in the afternoon and figured out a care strategy.

Drury was one of five students whose presentations were deemed the best of the 180 students who participated in the classes last year and who presented their findings at a reception for faculty and representatives of primary care clinics, organized by Nugus.

For the course, the students were also expected to come up with suggestions on how to improve the services. For Drury, she suggests a hotel-room type of Do Not Disturb sign on the nurses’ doors to be hung during sensitive procedures. But she also saw from the exercise how interdependent the system is and that interruptions are a natural part of dealing with other professionals.

“You’re going to need to consult with colleagues and interrupt sometimes and that’s okay. Interruptions are going to happen and we can expect that as practitioners. So we need to prioritize the demands placed on us,” she said.

Over the three years Nugus has been teaching OHA, other students’ suggestions on how to improve various aspects of the health care system have ranged  from managing medical appointment “no shows” (offer tentative appointments as a probationary measure to those who regularly fail to show up) to screening for domestic violence (share information early and deliver common messages to patients).

Nugus brings up a telling statistic: 60-80 percent of medical errors relate to communication or coordination (Kohn et al, 2000; Østergaard et al, 1994; Schaefer et al, 1994). So, while the image of a medical error may bring to mind a surgeon leaving a sponge in a patient, a more likely scenario has to do with one of the many moving parts of the system being out of sync.

Hopefully that lesson won’t be lost by someone barging into your office. 

Peter Nugus was recently recognized for his work on the course, Observing Healthcare in Action. On Feb. 8, he received a 2017 Transition-to-Clinical Practice Teaching Award, a prize for which he was nominated by his students.

February 22, 2018