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Licensed Unlicensed Requires Authentication Published by De Gruyter November 13, 2020

The effects of rudeness, experience, and perspective-taking on challenging premature closure after pediatric ICU physicians receive hand-off with the wrong diagnosis: a randomized controlled simulation trial

  • Michael Avesar EMAIL logo , Amir Erez , Jenna Essakow , Caulette Young , Binyamin Cooper ORCID logo , Denizhan Akan , Margaret J. Klein , Todd P. Chang and Alyssa Rake
From the journal Diagnosis



Rudeness exposure has been shown to inhibit diagnostic performance. The effects of rudeness on challenging a handed-off diagnostic error has not been studied.


This was a randomized controlled study of attending, fellow, and resident physicians in a tertiary care pediatric ICU. Participants underwent a standardized simulation that started with the wrong diagnosis in hand-off. The hand-off was randomized to neutral vs. rude. Participants were not informed of the randomization nor diagnostic error prior to the simulation. Perspective taking questionnaires were administrated for each participant. Primary outcome was challenging diagnostic error post-simulation. Secondary outcomes included rate and frequency of diagnostic error challenge during simulation.


Among 41 simulations (16 residents, 14 fellows, and 11 attendings), the neutral group challenged the diagnostic error more than the rude group (neutral: 71%, rude: 55%, p=0.28). The magnitude of this trend was larger among resident physicians only, although not statistically significant (neutral: 50%, rude: 12.5%, p=0.11). Experience was associated with a higher percentage of challenging diagnostic error (residents: 31%, fellows: 86%, attendings: 82%, p=0.003). Experienced physicians were faster to challenge diagnostic error (p<0.0003), and experience was associated with a greater frequency of diagnostic error challenges (p<0.0001). High perspective taking scores were also associated with 1.63 times more diagnostic error challenges (p=0.007).


Experience was strongly associated with likelihood to challenge diagnostic error. Rudeness may disproportionally hinder diagnostic performance among less experienced physicians. Perspective taking merits further research in possibly reducing diagnostic error momentum.

Corresponding author: Michael Avesar, MD, Assistant Professor of Pediatrics, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Loma Linda University Children’s Hospital, Suite A1117, 11175 Campus St., Loma Linda CA 92354, USA, E-mail:

Award Identifier / Grant number: Critical Care Medicine Department

  1. Research funding: Interdepartmental Funds at Children’s Hospital Los Angeles.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Informed consent was obtained from all individuals included in this study.

  5. Ethical approval: The research was IRB approved at the location of the study, Children’s Hospital Los Angeles/University of Southern California.


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Supplementary Material

The online version of this article offers supplementary material (

Received: 2020-06-11
Accepted: 2020-09-30
Published Online: 2020-11-13
Published in Print: 2021-08-26

© 2020 Walter de Gruyter GmbH, Berlin/Boston

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