key: cord-1035740-9n37j2lc
authors: Dubb, Sukhpreet Singh; Ferro, Ashley; Fowell, Christopher
title: “Shh-Don’t say the Q-word” or do you?
date: 2020-08-20
journal: Br J Oral Maxillofac Surg
DOI: 10.1016/j.bjoms.2020.08.044
sha: c91ef2903f29ed2b114a2b8f935f9c872158e49d
doc_id: 1035740
cord_uid: 9n37j2lc

Abstract Purpose Assessment of the superstitious belief that saying the word “quiet” during an on-call period in Oral and Maxillofacial surgery (OMFS) causes a disproportionate increase in work-load. Methods A 2-armed, single centre randomised trial was performed in a single-blinded fashion within the OMFS department at Addenbrookes hospital, Cambridge. Duty on-call OMFS SHO's were assigned to a “quiet group” and “Non-quiet group”. Former group actively told on-call period would be quiet whilst this word was refrained from use in all contexts in the latter. Results Data was collected from 8am to 7pm from a period spanning a total of 40 week-day on-calls. Total number of bleeps encountered was 491, average bleep count per day irrespective of treatment was 12.3 (SD 4.6). Bleep count for the control group and 13.1 (4.9) bleeps for the quiet (treatment) group. Welches independent-sample T test identified no significant difference in the mean number of bleeps encountered between treatment and control groups. Moreover, ANOVA identified no significant difference in mean number of bleeps between days (F(4,35)=0.086, p=0.986). Statistical analysis was performed using R version 3.6.2 Conclusion Our study refutes the central dogma of all of medicine that suggests saying the word quiet increases clinician workload during the working day. We identified no significant difference in bleep number between different days of the week. OMFS sees a large breadth of presentations within the head & neck arena requiring a diverse set of skills to manage the varying presentations on-call.

Since the Neolithic period of drilling holes in skulls to release evil spirits thought to cause headaches, surgeons have a history of believing in superstition 1 . Be it "Friday the 13 th " lunar cycles or zodiac signs 2 a plethora of supposed superstitious beliefs are firmly related to the onset of increased admissions within that specialty 3 . The most famous and long held superstition is of course the use of the word "quiet" in relation to the day's on-call activities. Any mention of this to a colleague who is on-call is usually met with dismay and the inevitable wait for an acute increase in workload. This belief, although largely anecdotal applies across multiple specialties within the UK but also internationally such as the USA 4 and Japan 3 amongst others. To our J o u r n a l P r e -p r o o f knowledge this phenomenon has not been investigated within the realm of Oral and Maxillofacial Surgery (OMFS).

We have therefore conducted a randomized trial to evaluate the hypothesis that specific mention of the word "quiet" in relation to on-call activities causes an increase in clinical workload. This was measured through the recording of bleep frequency.

A 2-armed randomised trial was conducted within a single-centre, Addenbrooke's Hospital, Cambridge in a single-blinded fashion. An OMFS trainee is 1 st on-call from 8am to 7pm and alerted to on-call duties through a hospital bleep. The same duty doctor is on-call during a 5 day period excluding weekends. All 1 st on-call OMFS trainees were randomly allocated to either "quiet group" (intervention group) or "non-quiet" group (control group). The intervention group during their on-call week were actively told the on-call period would be quiet whilst it was refrained from saying the word quiet in any context to the control group during their week. The on-call team were blinded to the intervention whilst the assessor by definition was aware of the intervention and control group. Since the outcome measure was the objective recording of data it was not felt to be additionally beneficial to conduct in a double-blind manner.

Outcome measures was primarily the number of bleeps received by the OMFS 1 st on-call during their on-call week from 8am to 7pm. Each of these bleeps represented an objective, relevant measure of workload.

No patients were involved in the formulation of the research question, outcome measures implementation of this study. No patients were recruited to this study and results are not aimed to be released into the patient community. Ethics approval was not sought or considered necessary.

Statistical analysis was performed using R version 3.6.2. Normality was first visually assessed using density and qq-plots, before quantitative confirmation using the Shapiro-Wilk test.

Homoscedasticity of bleep number between groups was assessed using Levene's test. Given conformation to the aforementioned assumptions, Welch's independent-samples T-test was used to determine if a significant difference exists in mean bleep number per day between treatment (mention of quiet) and control, and one-way analysis of variance (ANOVA) was used to determine differences in mean number of bleeps between days (irrespective of treatment).

Significance was accepted as p<0.05.

Data was collected from a total of 40 days, spanning 8 weeks from Monday to Friday. The total number of bleeps encountered during this period was 491 bleeps. The mean number of bleeps per day, irrespective of treatment, was 12.3 (SD 4.6). The mean number of bleeps per day, irrespective of specific day, was 11.45 (SD 4.15) bleeps for the control group and 13.1 (4.9) bleeps for the quiet (treatment) group. Figure 2 ).

The findings of our study do not support the anecdotal and often quoted superstition that voicing the word "quiet" is related the clinical workload during the OMFS on-call period. Moreover no one day was found to busier than another including days that precede or follow a weekend. All workers should be able to wish their colleagues that their on-call is indeed quiet without fear that this may detriment the remainder of their shift. Indeed although this study is somewhat tongue-in cheek during this considerably stressful period of Coronavirus any attempts to relieve workload and add levity we feel is a positive direction to take.

With the current pressures that the NHS incurs across each department it is of no surprise that staff feel overworked, over-stressed and over-stretched. This has measurable impacts on staff output, with a Royal College of Physicians 2016 report stating patient experience, staff morale and productivity had all suffered due to a poorly resourced NHS 5 . Work-related stress was linked to 38% of illness suffered at work according to an NHS staff survey 6 We recognise that there are limitations to the current study methodology. First, although bleep number per day provides an objective proxy to daily workload, other factors may contribute, resulting in potential under-reporting of work burden. In our trust, the rota system provides access to colleague mobile numbers, providing a direct route by which workload may be J o u r n a l P r e -p r o o f increased but not recorded using our methodology. Moreover, sister teams may wish to discuss directly with more senior colleagues, thereby bypassing junior DCTs, but workload may be impacted as a consequence of these discussions (through passing down jobs for example).

Second, our data are dependent upon reliable recording of bleep number by the DCTs. Third, although in an ideal situation the sole source of 'quiet' should be provided by the unbiased investigator here, we cannot account for possible undue 'secondary treatment' by other members of hospital staff (or even patients) as the DCTs perform jobs throughout the hospital. The additive effect of 'quiet' from non-controlled means was not accounted for here.

A further outcome measure worth investigating in future studies would be 'perceived work burden'. It may well be the case that saying 'quiet' has no influence on objective workload.

However, given the well-established association between this term and the perceptive of anticipated increase in workload, a subjective trainee-centered questionnaire recording how the mention of 'quiet' influences stress and perceived work-load would be valuable. Given recent work on human factors, an association between stress, error and patient outcomes is well established 7 . Striving to minimise perceived stress would be as important in optimising patient outcomes as improving objective workload.

Our results refute our null hypothesis (and the central dogma of ALL of medicine) that suggesting that a day is going be quiet increases doctor workload during the working day. We 

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