Wednesday, August 12, 2015

Disclosure and Apology Must Be Taught Before They Can Be Learned

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.

1 comment:

Peter said...

Kudos, Mr. Levy!

For us old folks, this is called “taking responsibility for one’s actions."

But it’s a tougher subject for young men and women of twenty years.

Whatever their ultimate paths, new medical students have “something” which drives them to welcome and relish their apprenticeships and all they entail. ‘Empathy’ is the usual label, but it is not really encompassing enough. During my 50 yrs. learning, practicing, and expanding my skill set, I had the good fortune to have learned medicine at a time when Big Pharma, Academic intrigues, and other special interests were beyond my ken. It was a wild ride! And I would come to need every minute of it.

Any effort which reinforces, validates, and strengthens the qualities which brought these young people into medicine in the first place is not only heroic, it’s crucial! Deep in their core, they are attracted to medicine because they possess one quality that a computer cannot duplicate; to provide succor to the expectations, fears, and insecurities of a sick patient.

As physicians, it sustains us in our work, and keeps us striving to do it better.

It is the quality which cannot be legislated, cannot be short-shrifted by streamlined curricula, and definitely cannot be ignored as the central force in the physician-patient relationship. It must be encouraged, fostered, nurtured, and kept alive like a small flame on a dark, rainy night, when the wind uses all its guile to snuff even a tiny spark.

Simply put, it’s a sine qua non of Real Healthcare.