Monday, July 30, 2012

Attitudes are one thing, behavior is another

A recent article in Medical Education, "Changes in intern attitudes toward medical error and disclosure," compares the results of a survey conducted ten years apart:

Two cohorts of interns for the academic years 1999, 2000 and 2001 (n = 304) and 2008 and 2009 (n = 206) at a university hospital were presented with two hypothetical scenarios involving errors that resulted in, respectively, no permanent harm and an adverse outcome. The interns were questioned regarding their likely responses to error and disclosure.

Here are excerpts from the results:

For both scenarios, the percentage of interns who would be willing to fully disclose their mistakes increased substantially from 1999–2001 to 2008–2009.... 

About two thirds of fully disclosing interns in both scenarios believed ‘the patient’s right to full information’ to be the primary reason for their disclosure.

Prior training about medical mistakes increased more than four-fold between the cohorts.

The conclusion:

This comparison of intern responses to a survey administered at either end of the last decade reveals that there may have been some important changes in interns’ intended disclosure practices and attitudes toward medical error.

"Hold on," says my colleague David Mayer, who has been at the forefront of medical student and residency training programs in quality, safety, communications, and disclosure.  He warns us to be wary about believing attitude data:

We all say the right thing – we are not prejudiced about race or religion, we love mom and apple pie, etc. But what do we do when no one is watching is what makes the difference. Behaviors are much more important than attitudes.

An example is in reporting of adverse events, near misses, and unsafe conditions:

People say it is important for safety, but how many reports do people submit? AHRQ data say the vast majority of care givers submit none or a rare one that has to be submitted because of seriousness of harm.

He also reminds us to distinguish between real training and a lecture:

Medicine loves to give a 50 minute lecture on something and then call it training and part of a curriculum. We do this with ethics, professionalism, human factors, etc.

He elaborates:

The question I would have liked to see studied is (1) how many had serious training and (2) saw a disclosure role modeled in the real world by an MD/organization, and (3) then went to work in a place that made disclosure part of their culture (e.g. Michigan, UIC). That would be interesting because I believe most students would say the education and TRAINING (heard real patients describe how bad they were treated when lied to, got to do a simulated disclosure with an SP, appreciated how difficult a conversation it is to do, got feedback through debriefing, etc) helped them prepare for the time they had to do the disclosure communication. That is how we train students to give other bad news (e.g., telling patients they have cancer) and there is lots of data that shows the educational model is beneficial to them later when they have to have that conversation. I believe that is how you change culture…and behavior (not attitude).


Anonymous said...

Dr. Mayer's comments clearly come from the real world and are right on target, especially this:

'Medicine loves to give a 50 minute lecture on something and then call it training and part of a curriculum. '

I also wonder if they administered the survey at the beginning of the internship year or the end and were consistent across both time frames; it could make a big difference.

nonlocal MD

Jeremy Engdahl-Johnson said...

Medical errors research in latest Health Affairs. Society of Actuaries study indicates more than 2 million patient injuries each year.

Anonymous said...

OK---speaking as a patient, if an error happens to me that does me absolutely no harm at all, I don't want to be told about it. Yes, it's "honest" but as a physician, I have met too many people who are upset years later by something that they never would have known about if someone hadn't told them. (e.g. "I moved in the middle of my surgery." "Do you remember that?" "No, my doctor told me.") Not at all being paternalistic here.

Confession makes the confessor feel better about themselves but often causes distress to the one receiving the confession. Famous example: Jimmy Carter was giving honest full disclosure when he told an interviewer "I have lusted in my mind" (or similar) but that falls in the category of something NONE of us wants to know (!) and undoubtedly caused angst to his wife.