Disclosure of Medical Errors as Part of a Patient Safety Medical School Curriculum – Third Year

In my previous posts this past week, I described the first two years of the medical error disclosure educational track that was part of our four-year patient safety medical school curriculum at UIC. The goal for the first two years was to engage our students in readings, discussions and case-based learning so they were aware of, and appreciated, the medical error crisis, understood the deny and defend approaches previously used, and gained insights on newer disclosure, apology and rapid compensation models being adopted by a growing number of hospitals across the country.

In the third year of medical school, we brought additional case-based learning to our educational efforts. We had a number of historic internal cases that were used as examples on how we did it wrong – causing an additional “harm after harm” – by not being honest, having our lawyers “defend the indefensible” and hoping patients and families who had been harmed by our care would just give up trying to get the answers and remedies they deserved.

In addition, we spent significant time in the third year of medical school addressing informed consent with our students who now were engaged in their clinical care rotations. Open and honest communication is critical to any successful informed consent or true “shared decision-making”. The patient safety film “The Faces of Medical Error…From Tears to Transparency: The Story of Michael Skolnik is an excellent educational tool to begin this discussion. In the film, 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 commitment to reach a patient on every level and that disclosure…is simply nothing more than a commitment 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 film 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…We’ve got to give them the facts, and make sure we’re making the choices together that are right for them.

Issues related to informed consent and shared decision-making are fundamental to any efforts focused on open and honest communication in healthcare. True informed consent is a process that begins with a transparent sharing of information – an effective and honest communication between patient and caregiver. To support the educational messaging of the film, we shared with students related critical readings. One of the best overviews was Harlan’s JAMA commentary from March 2010 on Informed Consent and Patient Centered Care, in which he suggests a new and improved informed consent process 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

The students enjoyed these discussions and shared their concerns about what they saw role-modeled by some physicians and residents. They also understood why these meaningful conversations around procedures and treatment options were an important foundation for any true patient-centered care model. We knew our curriculum was quite different from other medical school and residency trainings programs, and the lack of training in informed consent and shared decision-making was especially evident during this year’s Telluride Patient Safety Student and Resident Summer Camps. (See post by Paul Levy, Telluride Day 2 – Informing Consent).

In my next post, I will share the final component – the capstone – of our four-year medical school curriculum on disclosure of medical errors. It is our belief that educating future physicians about the importance of open and honest communication when patient care causes unintentional harm is most certainly more than a 50 minute, one-time plenary.

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5 Comments on “Disclosure of Medical Errors as Part of a Patient Safety Medical School Curriculum – Third Year”

  1. Jason Newland says:

    Excellent posts about patient safety and I am very interested in what you have done in establishing this curriculum for medical students. I am assuming you have done it for your residents as well. If so, any chance you would share how you have incorporated disclosure into resident/fellow education. Thanks for sharing this.

    Jason

    • Jason,
      Yes – we did introduce disclosure training at the resident level but it was more challenging for us because of multiple residency programs, different program directors and different specialty curricula and focus. With the students, we had them all together and as educational dean I had more control over the medical school curriculum. Plus it was myself and Tim McDonald who did almost all the safety and disclosure training – both large and small group sessions – so we were able to control and focus the educational message better.
      What did make disclosure training much easier on the resident level is that our medical center created the “Seven Pillars” model in handling medical errors – disclosure, apology and rapid remediation. All the teachings I have been describing in my posts on disclosure are based on our expereinces with using the Seven Pillars in our system – one of my previous posts had a link to a paper on the Seven Pillars. Thus any resident within the UIC program was educated on the Seven Pillars model, knew when to activate the system if needed, and understood the process we would implement when unintentional harm from a possible medical error had occurred to one of our patients.
      The main focus of UIC’s safety training for residents was getting them to report near misses and unsafe conditions within the system and then eduating them on how those reports were used to improve the quality and efficiency of patient care. We called these reports “gifts” becaus we could act on them before harm occurred. Through this approach, the near miss and unsafe condition occurence reports went from zero to over 1000/year submitted by the residents in a three year period.
      I am no longer at UIC having recently moved to MedStar Health in the DC/MD area to be their Corporate VP for Safety and Quality – one of the larger integrated health systems in the country. We are going to bring these curricular programs to the students and residents in the MedStar program.
      Thanks for your question.
      Regards,
      Dave

    • Jason,
      Also saw you are from U of Michigan. A lot of our educational programs and the Seven Pillars are based on the great work being done at Michigan by Rick Boothman, Susan Anderson and Skip Campbell – good freinds and mentors of mine.

  2. Jason Newland says:

    Thanks so much for your reply. I am a Pediatric ID doctor by training and am now the medical director of patient safety and Children’s Mercy Hospital in Kansas City. The Seven Pillars model sounds great and I am definitely going to be learning more about this. We struggle getting people, especially docs, to report unsafe practices which I think is essential. I am just learning and realizing we have to change the culture of the institution to realize we need to create safe systems.

    Your blog is fantastic and a great way to get this out. I wish you a ton of success and expect some frequent questions from me as we proceed with implementing this type of curriculum. Have a great day

    Jason

    • Jason,
      Thanks for your reply and nice comments. Glad the information has been helpful. Getting buy-in for these initiatives is challenging – it takes strong hospital leadership that believes it is the right thing to do and a board that will stand behind that leadership team when the going gets tough such as pushback from key MD’s in the program. I encourage you to read the book Transforming Health Care by Charles Kenney. It is the story about Virginia Mason’s pursuit of the perfect patient experience. Great example of leading in the face of pushback from many fronts and keeping with your convictions even when things don’t always go the way you hoped. Gary Kaplan’s board support was a key piece that allowed leadership to stay the course.
      Regards,
      Dave


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