Over two years ago, the folks over at the athenahealth kindly invited
me to submit columns to their Health Leadership Forum, and I have done
so on an occasional basis since them. As I recently reviewed the
columns, I realized that my own thoughts on the topics of leadership and
coaching have evolved a bit, and I thought my readers over here at Not
Running A Hospital might enjoy witnessing the transition. So for several
days, I will be reprinting the posts from the Forum over here. Comments
are welcome at the original site and here. Today's reprint is from a post dated July 23, 2013, "Disclosure and Apology Must be taught Before they Can be Learned."
If
our objective as leaders is to gradually transform the health care
system to make it more patient-centered, we need to ensure the rising
classes of young doctors are trained to carry out this form of medicine.
Unfortunately, as noted by the Lucien Leape Institute, “[M]edical
schools and teaching hospitals have not trained physicians to follow
safe practices, analyze bad outcomes, and work collaboratively in teams
to redesign care processes to make them safer.”
As
Dennis S. O’Leary, MD, President Emeritus of The Joint Commission and a
member of the Institute has said, “Educational strategies need to be
redesigned to emphasize development of the skills, attitudes, and
behaviors that are foundational to the provision of safe care.”
Among the most important skills to be taught to doctors is how to
disclose medical errors to patients and families. Yet, training in this
topic is often relegated to a single lecture sometime during medical
school. Is there any question why the material doesn’t “take” when it is
treated so casually?
The great basketball coach John Wooden liked to say, “You haven’t
taught until they have learned.” How best to design a curriculum that
truly enables young doctors to learn the fundamentals of disclosure?
David Mayer, MedStar Health’s VP for Quality and Safety, is one of
the country’s leaders in undergraduate and graduate medical education.
He explains, “Disclosure training is a process, not a fifty-minute
lecture.” He and colleague Tim MacDonald developed the first four-year,
longitudinal patient safety curriculum for medical students in the
country. That curriculum started on the very first day of school at
8:30 a.m. He notes:
During the first half of the hour-long
session, I always asked the students to share with me the fears they had
on this first day of school, the starting point on their journey to
becoming a physician. Each year I did this, two fears rose to the top –
the fear of failure and the fear of hurting a patient. Students read
the newspapers that share personal stories of harm or talk about the
medical error crisis; many students had a family member harmed from a
medical mistake. As an educator, it was a great teaching moment to start
the safety conversation, and the reason why we started the conversation
on the very first day of school.
Over the years, the students were taught the “Seven Pillars”
disclosure and apology model developed by David and Tim for the
University of Illinois Hospital in Chicago. This model comprises a rapid
response to all unanticipated outcomes, full disclosure related to the
care, apology and early compensation, if warranted, and using
transparency and disclosure to learn from all our mistakes so that we
implement the necessary changes to our system to reduce risk to others. (
The Seven Pillars approach was cited
by Agency for Healthcare Research and Quality [AHRQ] director Dr.
Carolyn Clancy and led AHRQ to fund a three-year project to spread the
model in 10 Chicago-area hospitals.)
For
the last two years, I’ve had the pleasure and privilege of joining
David, Tim, and other colleagues in Telluride, Colorado to conduct
week-long training programs for residents and medical students on this
and other aspects of disclosure and apology. What emerges is often a
cathartic experience for these trainees. Many have borne witness to
medical errors being committed in front of them, often by senior
residents or attending physicians. They bear the guilt of being afraid
to say anything that might arouse the wrath of their instructors. When
provided a safe environment with their peers and empathetic instructors,
they often tearfully relate their experiences.
Together, we design strategies that they can personally employ when
they return to their hospitals. But we also require them, as a condition
of attending our seminar, to design and carry out a safety-related
transformational project in their hospital.
The results from even this one-week session are impressive. Pharmacy
resident Quyen Nguyen stated: “One of the most important lessons I have
learned from the past three days is the urgency in which we need to act
to bring ethics back to the forefront of healthcare systems. Too often
the best interests of the patients and their families are put behind
financial, legal, and personal factors. It may never be possible to
prevent every error, but we have a professional duty to take
responsibility and put patients’ and their families’ needs first in the
aftermath of a medical error.”
Resident
Pat Bigaouette said, “The most important thing that I learned while in
Telluride was the importance of passion. I sat and listened as
passionate after passionate lecturer shared their experience and
expertise with me. I learned how they have all made a difference in
their respective healthcare systems by being enthusiastic and
passionate. I found myself going home and discussing patient safety for
hours after the conference had ended.”
Suresh Mohan returned to his residency program in Rhode Island and
noted: “Discussing my week with peers back home, I was shocked to
realize how little they knew (and, thus, cared) about the topic of
safety. I received responses of, ‘Well, I guess every field has its
downsides’ to ‘Whoa, I didn’t know you were, like, super into that
primary care stuff.’ It reaffirmed my decision to have attended, and the
value of what we learned.”
And Garrett Coyan left us all with an agenda: “The last week I spent
at Telluride was very eye-opening for me. Reinvigorated with ideas for
improving communication and decreasing risk to my patients, I couldn’t
wait to get back to my institution and start implementing change.
However, as I returned to the hospital today, I was quickly reminded of
the main reason why this goal will be so difficult. Not only does
cultural change need to occur in the hospital, but I would argue that
even more importantly, cultural change needs to occur in the education
of students in the health professions.”
There are steps in the education of young doctors that are our
obligation if we are associated with health care institutions. As David
Mayer notes: “The day has now come for greater accountability in medical
education around safety and quality.” In a series of blog posts, he has
set out the elements of an education program characterized by rigor,
thoughtfulness, and pedagogical excellence. If you are in a position to
influence the education program in your hospital, please read David’s
three posts by clicking the following:
part one;
part two;
part three.
Then, use your leadership position to move your institution forward in
designing and implementing this kind of educational program for your
medical students and residents.
There is a potential bonus in all of this for hospital
administrators. It is well-documented that the incidence and size of
medical malpractice claims are reduced when physicians show empathy and
apologize after errors are made; when they accurately portray the nature
of what occurred; and, when they demonstrate that the hospital will
learn from the experience so that future patients might be spared the
same type of harm. Many older doctors are not adept at carrying out such
a disclosure and apology. Raising a new generation of doctors who are
skilled at this might therefore produce ancillary benefits for
hospitals.
