The “Stranger Effect” — A Look at Interactions Between Consultants and Care Teams Through the Lens of Social Science

Article · December 27, 2017

An anesthesiologist is called to an intensive care unit (ICU) to intubate a patient in respiratory distress. She arrives in a hectic room filled with bustling clinicians and beeping machinery. The ICU personnel do not know the anesthesiologist. The patient needs ventilatory support: the ICU team has chosen mechanical ventilation, and the anesthesiologist possesses technical expertise they lack. Intubation is completed and the patient is stabilized, for the moment. The anesthesiologist leaves, having fulfilled the role of proceduralist — of airway technician. The team has not sought her input regarding the indication for airway management nor post-intubation sedation. She may have suggested another means of ventilation support or recommended an alternative sedation technique after intubation that better supported cardiovascular integrity, potentially leading to a better outcome. Or she may have noted that the patient had a do-not-resuscitate/intubate order, thereby halting performance of a procedure that was not in accordance with the patient’s wishes.

The Undefined Relationship Between Team and Consultant

Due to the dearth of scholarship examining the quality of interactions between medical teams and physician consultants, we don’t know what an ideal collaboration looks like and what situations call for what type of interaction. In some cases, would it be advantageous to limit the contribution of a consulting physician to the performance of well-practiced procedures like intubation or dialysis? In other cases, would the consultant’s distance from the case enable a fresh perspective leading to improved problem solving? Do unrecognized social dynamics sometimes inhibit the consultant from applying other expertise that could significantly improve a patient’s outcomes or better align care with patient desires?

These questions are increasingly relevant to health care. The central act of our medical system is diagnosis; afterward, patients are sent on clinical journeys in which they see an array of physicians, each specializing in different biological facets of their diseases. Health policy researchers have sought to enhance the efficiency, effectiveness, and safety of this system. One solution has been the development of integrated, multidisciplinary care teams, tailored to optimally treat and manage particular conditions. As such collaborations become more common, they increase the frequency and intensity of teamwork among physicians of different specialties. These developments have captured the interest of health services researchers, who in recent years have examined other industries to identify strategies for improving team dynamics that can be translated to clinical settings.

Despite the increasing focus on medical teamwork, the interaction of physician consultants with care teams has received little attention. The course of care chosen — and, ultimately, its outcome — depends heavily on the nature of consultant-team communication. Deciphering why these interactions occur in the way they do, and how their specific characteristics relate to decisions and outcomes, is a complex task. Encounters between consultants and teams are shaped by a dizzying mix of factors, including the medical situation, how it is understood by both consultants and teams, how the team typically relates to consultants from particular specialties and how those specialties typically relate to teams, the history and composition of the team, and the institutional norms of specific health care settings.

The Consultant as “the Stranger”

In light of the centrality of social relations in medical decision-making involving consultants, it’s instructive to examine these situations using concepts from the social sciences, which have for many years been used to analyze insider-outsider group dynamics. For example, the seminal early–20th century sociologist Georg Simmel introduced a figure he called the “stranger.” Simmel’s paradigmatic stranger was the travelling merchant: a recurrent figure but somehow distant, a functioning and intermittently vital element of the group, yet usually operating outside of it. What makes the stranger indispensable to the group is the possession of a skill or service not otherwise available. In addition, the stranger is unconstrained by or unconcerned with norms that regulate the behavior of group members, and is consequently able to offer a more unbiased and innovative perspective on a problem.

Yet, as Simmel observed, the stranger’s opinion may not carry much weight with the group: dismissing or ignoring the stranger is not likely to result in sanction, as it might were he or she a group member. The liminal status of the stranger — just enough of an outsider to offer a fresh approach, but not enough of an insider to have the authority to implement it — captures an essential component of the physician consultant experience. The anesthesiologist arriving at a code may possess a novel insight about the case, but her stranger status may mean that she is not given sufficient opportunity to communicate her idea. The team may also be less incentivized to follow her directive than they would the instruction of a senior team member.

The Discrepancy in Registers

A seemingly straightforward way to overcome this stranger effect would be for the team to defer to the consultant regarding matters deemed most relevant to his or her specialty, and vice versa. Yet, in practice, this demarcation of expertise is not simple. To understand why, we can turn again to the social sciences. A core concept of sociolinguistics, which studies the role of language in social relations and culture, is the register — a set of linguistic behaviors that one believes a certain type of person should exhibit in a specific situation. For example, when we think of an anesthesiologist responding to a code in the ICU, we assume she will direct her attention toward certain elements of patient care, use particular terms, and interact with other clinicians in certain ways. These expectations come from our own experiences interacting with anesthesiologists or hearing others talk about them. So the social behaviors that each ICU team member associates with the register of anesthesiologist consultant will vary. They will also differ from the anesthesiologist’s own perception of how she should act when consulting with an ICU team.

This register asymmetry, if severe enough, can have medical consequences. The anesthesiologist will focus her communication with the team on a particular range of case components, and her language will range from deferential to authoritative, depending on whether she is addressing an aspect of care she believes she should take the lead on. But the ICU team’s ideas about when she should be deferential versus authoritative may not align with hers. This mismatch could disrupt the team’s normal cohesion if the consultant assumes authority over case components for which they already had a sound plan. Conversely, it could result in a team bringing in a consultant for much-needed advice or assistance only to have the consultant fail to take control over areas the team was least prepared to handle. While it is possible for such misunderstandings to be corrected, in hectic medical environments, there is no guarantee that register asymmetries will be identified, much less rectified.

The Proposed Solutions

How do we prevent miscommunication in scenarios where high-quality care relies on successful interaction between teams and consultants? As a start, we should undertake descriptive studies to identify the factors that influence how teams communicate with consultants and the manner in which consultants end up contributing to cases. Further investigation should then focus on linking medical outcomes with those features of team-consultant interaction that tend to exhibit variation. For example, when an adverse event occurs that involves a consultant, the root cause analysis should look at group dynamics. How did the team and the consultant communicate? Toward what aspects of the case did the consultant direct his or her attention? Did the team and consultant have similar notions of the consultant’s role in this scenario? If they didn’t, how did this misalignment contribute to the poor outcome? Was there a missed opportunity for the consultant to be better utilized in the patient’s care? The findings of these analyses will reveal levers that can be used to improve interactions between physician consultants and care teams.

Subsequently, educational initiatives should be designed to teach consultants techniques for enhancing the utility of their expertise — techniques that acknowledge the social dynamics at play. Teams and the physicians with whom they frequently consult can participate in simulated cases that highlight the types of miscommunication that can occur. They can be taught strategies to avoid or mitigate these disconnects — for instance, approaches for introducing themselves that call attention to their presence in the room and clarify their roles. Clinical tools can also be implemented, such as checklists with prompts designed to ensure that teams and consultants avoid communication pitfalls. For example, in the ICU scenario, a prompt might have cued the team to present the consultant with the problem the team is attempting to solve, rather than seeking from the consultant the implementation of a solution the team believes it has already determined. Over time, as we learn more about team-consultant interaction and we develop interventions tailored to these findings, we can reach shared understandings about how specialists’ capabilities are best utilized in various medical scenarios.

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