Are Interns Really Willing To Disclose Medical Errors?

In a recent email conversation with Paul Levy, he shared with me a very exciting study, Changes in intern attitudes toward medical error and disclosure. I mentioned that the results of the study, while encouraging on one level, need to be looked at with a cautious mindset. The actual act of disclosing an error to a patient (behavior) is much different from a belief about doing the same (attitude). In our hearts, we all want to do the right thing–but it is our actions or behaviors that define the ultimate outcome. More of our conversation can be found in Paul’s post, Attitudes are one thing, behavior is another.

We believe that disclosure and apology in the face of a medical error is the right thing to do, but in actuality, how many of us really do so? In my personal experience with UIC’s disclosure and rapid remedy program (The Seven Pillars), caregivers don’t disclose – organizations disclose.  Without leadership/board buy-in and medical malpractice carrier support, the right attitude about disclosing doesn’t become behavior. In a previous post, Can We Be Honest When Medical Errors Occur, Part 2, I share a medical error case I was involved in many years ago and mention the very real barriers that prevent caregivers (who believe it is the right thing to do) from being open and honest when care unintentionally causes harm (the behavior), such as:

  1. Damage to one’s reputation
  2. Loss of license or career
  3. Fear of litigation
  4. Culture that blames individuals when system errors occur (“Shame and Blame”)
  5. Loss of control
  6. Lack of training on how best to handle these difficult conversations
  7. Uncertainty/Unknown

These barriers have prevented very good people from doing what they believed was the right thing to do. Today, a growing number of health systems across the country are slowly putting programs in place that encourage residents and interns to act on the changing attitudes Varjavand et al mention in their study above. But it is a systems effort, and the conflict between attitude and behavior will continue to exist until more health systems realize that disclosure, and programs that teach how to do so in the best interest of both patient and caregiver, become widespread.

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The Changing Educational Paradigm

One of the greatest challenges for the future of education is that 65% of today’s grade school kids will end up working in a job that hasn’t even been invented yet, according to the U.S. Department of Labor. How do you prepare students, medical or otherwise, to use technology yet to be invented for jobs yet to be defined? How do you move academic deans of colleges, principals of grade, middle and high schools to change curriculum in line with current educational delivery platforms, yet alone those of the future?

White-boarding presentations is one new educational delivery format. Purely for entertainment and comment, included below is a RSAnimate on the Changing Education Paradigms taken from a speech by Sir Kenneth Robinson, presented by the RSA (Royal Society for the encouragement of Arts, Manufacturers and Commerce), an English charity whose mission includes a multi-disciplinary approach to generate research based innovation and change. Among other things, the group provides speeches by thought leaders and distills them into compact messages creatively cartooned on a white board and can be viewed in less than 12 minutes.

How will the changing workforce and demands on education affect medicine? And are we prepared to keep up, open enough to welcome the change that is needed? Simulation, gaming, technological advances in delivery of care, mobile technology, data collection–all have capabilities expanding at exponential rates–rates must faster than any curriculum is being changed to meet those capabilities. How quickly will medicine, and those that lead it, be able to adapt?

An excellent projection as to what the future may hold for education is to the left. Michell Zappa at Envisioning Technologies provides a snapshot of what education may look like into 2040. Digitized classrooms allowing students in Chicago to collaborate with students in Madrid, gamification of learning that provides instant feedback on skill acquisition, on into immersive virtual reality, retinal screens and neuro-informatics–it seems our ability to adapt will be the rate limiting step as compared to our ability to create new ways of learning.

The massive open online course (MOOC) from Coursera that I signed on to experience one of these new educational formats for myself is an amazing thing. Students from around the world are discussing literary works through an active Discussion Forum, and forming local study groups. People innately want to learn and when good content is made accessible it is apparent they show up in droves–thirsty for knowledge. Try one out for yourself and share what you learn.


One more example of Mindlessness vs Mindfulness

Speaking of checklists and routine, Atul Gawande and colleagues put out an excellent example of a mindless execution of a surgical checklist on You Tube. As they say, a picture is worth a 1,000 words–in this case, a video of “how not to do it” eloquently makes the case for ‘how to do it’ correctly. Thanks Atul, for providing yet another example of true north to patient centered care.

And a more mindful, creative method of performing a surgical checklist follows. If you have a few minutes, it’s well worth it to watch this one–at least until the Remix portion:

In Gawande’s piece, The Velluvial Matrix, for the New Yorker in July of 2010, he writes:

…Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society…

Without mindfulness applied to daily practice, including routines that may seem to have little effect on outcomes, health systems will fail to reach the high reliability that will deliver the Triple Aim–better care, better population health at the lowest possible cost. It is imperative we start teaching these newer concepts of high reliability, mindfulness, teamwork, human factors and transparency to our students and residents. Our future caregivers should not have to struggle trying to provide care that is safe and low risk.


Mindlessness versus Mindfulness

As mentioned, high reliability organizations (HROs) are built upon a state of mindfulness. The enemy of mindfulness is mindlessness, and in a dynamic environment like a hospital there are still many routine tasks that are done with every patient. The potential to perform the routine tasks mindlessly is something HROs successfully avoid. Instead, every task is approached with mindful questioning, “What’s the big picture here, and what is the worst thing that can happen?” As Weick & Sutcliffe point out in Managing the Unexpected:

…When operators execute operations mindfully, they tend to rework the routine to fit changed conditions and to update the routine when there is new learning. These small adjustments are the bane of a command-and-control system. But those same adjustments keep the system going even as they sustain the illusion that it is commands and rule compliance, not continuing
adjustments, that keep it going.

From Mindful Practice in JAMA 1999 by Ronald Epstein MD

In the healthcare setting, checklists and surgical debriefs are two ways to introduce and incorporate mindful practice into daily routine. Ronald Epstein MD penned a must read article on Mindful Practice in JAMA in 1999, showing how mindfulness can further be applied to medicine. The table to the right itemizes characteristics of mindful practice, not currently taught in medical schools or tested on boards, but skills very necessary to complete a healthcare providers training in order to provide true patient-centered care. As Epstein writes:

…consider what a resident in a busy pediatric emergency department might do when he is unable to determine whether an ear examination is normal or abnormal and the attending physician is not immediately available…(s/he) weighs the consequences of misdiagnosis for the patient, the humiliation of having to call the otolaryngology resident…loss of self-esteem by having to admit incompetence…

…A mindful conscious approach would be to cultivate awareness not only of the correct course of action but also of the factors that cloud the decision-making process. The mindful practitioner is mentally and technically better prepared for the next situation.

Mindfulness shares a number of qualities embedded in emotional intelligence.  Developed by Daniel Goleman, emotional intelligence embraces and draws from numerous branches of behavioral, emotional and communications theories. Forbes.com interviewed Goleman in September of last year, and provides an overview of his work in their piece, Daniel Goleman on Leadership and the Power of Emotional IntelligenceKey to his work are the identification of five emotional intelligence domains:

  1. Knowing your emotions.
  2. Managing your own emotions.
  3. Motivating yourself.
  4. Recognizing and understanding other people’s emotions.
  5. Managing the emotions of others in building strong relationships.

High emotional intelligence requires awareness and control of our own emotions, values, preferences and goals as well as those around us – for caregivers that includes not only our colleagues and peers, but most importantly our patients. Understanding and being mindful of a patient’s emotions, values, preferences and goals is critical to the provision of high quality, safe healthcare.


High Reliability Series: On Collective Mindfulness

Reprinted with permission of the Agency for Healthcare Research and Quality. Source: Hines S, Luna, K, Lofthus J, et al. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. AHRQ Publication No. 08-0022. Rockville, MD: Agency for Healthcare Research and Quality. April 2008. (http://www.ahrq.gov/qual/hroadvice/).”

Throughout our series on High Reliability Organizations (HROs), we have been discussing the five defining principles Weick & Sutcliffe have described HROs to possess: 1) Sensitivity to Operations; 2) Preoccupation with Failure; 3) Deference to Expertise; 4) Resilience; and 5) Reluctance to Simplify. The five principles are interrelated and do not exist unless they are built upon an organizational “collective mindfulness,” which describes the way in which the scarce commodity of individual attention is applied to the health of the overall organization. They use Langer’s model of a mindful state at the individual level and then apply it to the group based on its application and interplay within the five principles above. According to Langer:

“…a mindful state is expressed at the individual level in at least three ways: active differentiation and refinement of existing categories and distinctions; creation of new discontinuous categories out of the continuous streams of events that flow through activities; and a more nuanced appreciation of context and of alternative ways to deal with it…”

But mindfulness for the sake of mindfulness will not transform an organization into a HRO. Awareness and vigilance without action will not keep patients safe in our hospitals. It is the ability of all within an organization to consistently focus awareness to that which has the potential to cause harm without losing the forest through the trees as they say, and then effectively act upon the data taken in that will effectively transform an organization. As Weick, et al share:

“…To grasp the role of collective mindfulness in HROs, it is important to recognize that awareness is more than simply an issue of “the way in which scarce attention is allocated” (March, 1994, p. 10). Mindfulness is as much about the quality of attention as it is about the conservation of attention. It is as much about what people do with what they notice as it is about the activity of noticing itself…”

Mindfulness empowers action that prevents potential harm, and can be appreciated with the high reliability mindset of crews on aircraft carriers. Stephen Muething, MD, Vice President of Safety at Cincinnati Children’s Hospital illustrated one such example of action in his post, Lessons From An Aircraft Carrier:

“A piece a paper floated up onto the deck. A young trainee raised his hand immediately, dozens of other hands went up on deck when they saw his, and the landing was aborted. During the commanding officer’s daily address that evening he called out the sailor by name and thanked him.

The chart at the top of this post is adapted from Weick, Sutcliffe & Obstfeld, 1999 and was found in the AHRQ publication “Becoming a High Reliability Organization: Operational Advice for Hospital Leaders.” The visual further reinforces that without a constant state of mindfulness, an organization will not achieve high reliability, or if they do so, the accomplishment will be fleeting. How can organizations develop and institute a state of collective mindfulness within their organization? With practice, intention and a culture steeped in transparency and an openness to learning. More on mindfulness to follow. Please share your thoughts–

References:

Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: Processes of collective mindfulness. Research in Organizational Behavior. 1999;21:81-123.

Weick KE & Sutcliffe KM. (2007). Managing the Unexpected: Resilient Performance in an Age of Uncertainty. San Francisco: Jossey-Bass.


The Future of Education: Only The Mind Is the Limit

“Everyone is both a learner and a teacher,” states Peter Norvig, Director of Research at Google, and an expert on Artificial Intelligence (AI), during his February 2012 TED.com talk on the 100,000-student classroom. Norvig, and his partner, Sebastian Thrun, taught a 10-week course on AI to a virtual class of over 100,000 students from around the globe. Drawing on what others have already accomplished, such as Salman Khan at Kahn Academy, Norvig and Thrun knew that shorter videos work best, and that typical educational deadlines were also a necessity to move the learning forward. Through their experience, the pair has gathered billions of interactions and data points from students on the future of learning, which they plan to analyze and share, as well as use to reshape future offerings.

From flipping the classroom to creating a global classroom, what Khan, Norvig and Thrun have begun, others have picked up and expanded upon. Coursera, the group garnering current attention, is ready to roll with over 100 MOOCs, or Massive Open Online Courses, which include courses in medicine, biology and health, society & medical ethics. Original Coursera partners (University of Michigan, Princeton, Stanford and University of Pennsylvania) offered 43 courses and registered 680,000 students. This week the company announced that 12 major research universities (listed below) will now also offer courses. Both Forbes (“Is Coursera the Beginning of the End for Traditional Higher Education?“) and the New York Times (“Universities Reshaping Education on the Web“) picked up the story, as interest in the changing educational paradigm grows. Whether or not MOOCs will replace traditional education is yet to be seen, but the number of course offerings at Coursera has now more than doubled, as will the number of expected students from around the world. New Coursera partners include:

  1. California Institute of Technology
  2. Duke University
  3. Georgia Institute of Technology
  4. Johns Hopkins
  5. Rice University
  6. University of California at San Francisco
  7. University of Illinois – Champaign-Urbana
  8. University of Washington
  9. University of Virginia
  10. University of Edinburgh-Scotland
  11. University of Toronto
  12. EPF Lausanne (a technical college in Switzerland)

The inclusiveness and ability to reach less traditional students are just two impressive benefits of these MOOCs. All a learner needs is access to the internet, which they can get in any internet cafe or Starbucks around the world. Suddenly someone living on the south side of Chicago, or as Khan points out–in Kolkata, without the means for higher education, has one more option. Not to mention the collaboration that can occur across oceans. As knowledge spreads through these novel means with greater openness and transparency, think of the accelerated rate at which problems, medical or otherwise, can potentially be solved.

I just signed on for a course offered by University of Michigan Professor Eric Rabkin on Fantasy & Science Fiction: The Human Mind, Our World, which focuses on how we understand ourselves and our world through stories. As we look to better understand patients through narrative, what better way than to get grounded in the classics and character archetypes once again? And as a perpetual student, what an incredible opportunity to take a course of this caliber in the moments I can spare throughout a full work week! I will be sure to report back on the experience along the way. Please share your own experience with anything educationally innovative–as Norvig so astutely stated, “everyone is both a learner and a teacher.”


Transparency Begins With Informed Consent and Shared Decision-Making

In the trailer for The Story of Michael Skolnik, Rick Boothman, Chief Risk Officer for the University of Michigan Health System, introduces the film by saying:

I think it’s absolutely critical to understand that transparency begins with the informed consent concept…with a committment to reach a patient on every level and that disclosure…is simply nothing more than a committment to be honest with patients from the beginning and throughout that therapeutic relationship.

Harlan Krumholz, MD, Harold Hines Jr. Professor of Medicine (Cardiology) at Yale University continues the conversation in the trailer by sharing:

We have many patients who are having prescriptions or procedures or large surgeries that they would not necessarily choose if they understood all the facts. And that’s what we’ve got to fix in medicine. We’ve got to make sure that the choices that are being made are completely aligned with the patient’s needs, values, preferences and goals, and they are making the choice. So it’s not a matter of someone coming in and giving them a choice, which wouldn’t be what they would choose if they knew all the facts. We’ve got to give them the facts, and make sure we’re making the choices together that are right for them.

Both Rick and Harlan touch on two key components of Transparency, a foundational concept for high reliability organizations. Issues related to informed consent and shared decision-making are fundamental to any efforts focused on open and honest communication in healthcare. Is there any strength or quality to a therapeutic relationship if it lacks an informed consent process built upon transparency–one that reveals all risks, benefits and alternatives to the proposed procedure or treatment–or fails to have the patient share in the final decision?

True informed consent is a process that begins with a transparent sharing of information – an effective and honest communication between patient and caregiver. Patients should know how many similar procedures their surgeon or proceduralist has performed as well as information on outcomes like infection rates and other complications that have occurred. They should understand what risks are inherent to the procedure and are augmented or reduced by the patient’s current comorbidities and overall health. The provider should understand what risks the patient is willing to take versus attributing his or her own risk tolerance to the patient. But this does not occur as often as it should in the current healthcare system, and it would be interesting to prospectively evaluate how improving the informed consent process would affect outcomes. For example, in Harlan’s JAMA commentary from March 2010 on Informed Consent and Patient Centered Care, he suggests a new and improved informed consent which provides the patient with:

  1. An explanation of the procedure or test
  2. Potential Benefits
  3. Potential Risks
  4. Other Available Treatment
  5. Experience of Your Health Care Team
  6. Cost

What would you hypothesize the results of a prospective study to look like if greater care was taken upfront to ensure the patient understood all of the above, and shared in the decision-making? How would a stronger partnership between provider and patient affect outcomes? Patient satisfaction? Patient engagement? Readmissions?

The lack of training in informed consent and shared decision-making was made apparent during this year’s Telluride Patient Safety Student Summer Camps. Both skills need to be taught to medical students early on in their training and incorporated into the new culture of medicine. More on the state of medical education around this skill set later, but until then, a number of tools and resources are being made available to help patients and providers better understand how they can increase their knowledge in both areas. Dartmouth-Hitchcock is one such resource, and has a Center for Shared Decision-Making which provides information for providers and patients alike. Take a look, share additional resources–we’re in this together after all.