Friday, November 07, 2008

Tom teaches about apology

This seems to be the week for meetings about error, disclosure, and apology. I am currently at a very worthwhile seminar today entitled "Medical Errors: The Power of Apology, Action and Forgiveness" at Hebrew Senior Life (co-sponsored with BIDMC.) The lead-off speaker is Dr. Tom Delbanco who reminded us that people who have been injured in the health care system often suffer from guilt, fear, and isolation. He noted that guilt, fear, and isolation are equally shared by the doctors and nurses who have been involved in medical errors. His point was that we need to bring down the walls that separate the two groups, and he offered strategies for doing that.

Tom noted that the anatomy of an apology is extraordinarily important. One person is in the mood to apologize and one is in the mood to be very upset. He created a scenario (based on someone crashing into someone else's car) and asked the audience to work in pairs, and take the two roles and spend a few minutes apologizing and receiving the apology. He then changed the scenario, and asked one person to be an injured post-surgical patient and the other the apologizing MD. Quickly, the buzz in the room changed as the one case, with lots of noise and laughing, transmogrified into the other, quieter and more serious.

"This is hard work. It's not easy. Most of you are not trained to do this," noted Tom. The same is true, he noted, for doctors. He talked about medical students he teaches, many of whom have seen an error in the course of their training, who say, "I don't have a clue how to deal with this."

What are the necessary steps in a proper and effective apology? Here's the summary. First, go over details openly and clearly with the patient about what happened. Second, display and feel real empathy, and say "I am really sorry." Third, tell the patient that a root cause analysis will be done, and that I'm going to find out what was the cause of the accident. Fourth, and most important, say what I am going to do about this so it won't happen in the future to another person. Research indicates that this last part is what patients really want.

He ended by charging the group with taking what they had learned today and trying to apply it in their practice of medicine. The talk was very well received by a diverse audience of care providers and lay people.

6 comments:

Megan said...

As a patient, I find the statement on the screen in the photo very poignant:

"Nothing about me without me..."

Can you tell us the context of it?

Anonymous said...

Tom will explain . . .

Tom Delbanco said...

Dear Megan,

"Nothing about me without me" is the unifying principle developed by a highly diverse, international group of storytellers, poets, philanthropists, doctors, theatre artists, nurses, health policy experts, and reporters who gathered in Salzburg for a week to give advice to "PeoplePower," a mythical land whose new prime minister asked her citizenry to design a new health care system through the eyes of lay people, rather than health professionals alone.

This phrase has gained international currency, but full credit for its invention goes to a nurse from Norway who suggested transparency was paramount in a really healthy system. Today, transparency is all the rage, but she came up with this more than 10 years ago. I was privileged to lead this Salzburg Seminar, and we published a paper subsequently that describes in detail what we came up with (Delbanco T, Berwick DM, Boufford JI, Edgman-Levitan S, Ollenschl├Ąger G, Plamping D, Rockefeller RG. Healthcare in a land called PeoplePower: nothing about me without me. Health Expect 2001 Sep;4(3):144-50.).

Tom Delbanco, MD

Anonymous said...

I think the outlined steps to the apology are great. Having personally had the misfortune to have an issue at your institution the Patient Relations department did all of that and more. I got a written proposed improvement plan and apology from the Charge nurse as well. One more step I personally would have liked is a communication from the hospital after the "plan" was implemented and a summary of the procedural changes that took place as a result. Many components of the plan were staff meetings and formal communication training/workshops. I don't know if they ever took place or if improvements were actually made. Closing that loop would be important to acknowledging the incident also show respect for the patient involved.

Anonymous said...

Excellent point. Thanks.

Megan said...

Thank you, Dr. Delbanco.

The article is interesting reading. While some of the ideas presented are not technically feasible, many of them could be implemented in a modified format.

For example, it would be difficult to implement a system where every clinic visit is recorded and automatically transcribed. But my PCP makes a point of telling her patients on every visit that she will not be able to document every detail that they discuss, and asks her patients to please point out to her when something is important to them so that she can write it down. This requires her to admit that she is not perfect, but you can imagine how many charting errors could be avoided if all clinicians followed this simple step.

I was also thinking of having the phrase "Nothing about me without me..." printed on t-shirts to wear to my medical appointments, (and maybe even some stickers for my charts to go next to my allergies) as an ice breaker for a patient safety discussion.