Disclosure: Moving From “Unconsciously Incompetent” to “Consciously Incompetent”

The goals around medical error disclosure training for our UIC students over the first two and half years of their medical education were to:

  1. Engage them in readings, discussions and case-based learning
  2. Make them aware, and appreciative of, the medical error crisis
  3. Gain an understanding of the deny and defend approach previously used
  4. Gain insight into the newer disclosure, apology and rapid compensation models gaining acceptance across the country

During the second half of the third year, we now felt it important to give them a dose of reality around real world situations they would soon face as caregivers. It is one thing to “want to” do the right thing, to move from organization-centered to patient-centered care, to tell the truth and not resort to “deny and defend” approaches to medical harm. It is another thing altogether to execute all the “want to’s” successfully.

As an educator, I have learned to appreciate different knowledge acquisition models. One of my favorites was taught by Dr. Rachel Yudkowsky, a great medical educator and standardized patient (SP) simulation expert in UIC’s Department of Medical Education. The model described the following four levels of learning:

  1. Unconsciously Incompetent
  2. Consciously Incompetent
  3. Consciously Competent
  4. Unconsciously Competent.

The last goal of our disclosure training was to take students and residents from the “unconsciously incompetent” phase to the “consciously incompetent” phase of learning. Simply put–we wanted to move them from “don’t know what I don’t know” to “knows what I don’t know”. Rachel used learning to drive a car as an example of this progression. Many new, 16-year-old drivers believe driving a car is simple–a steering wheel, a pedal to accelerate, another one that serves as a brake–what is so tough about that? These new drivers are in the “unconsciously incompetent” phase, or the “don’t know what we don’t know” phase. It is only when they get behind the wheel for the first time that they realize just how much more difficult it is to drive. That is also the point at which they move to the “consciously incompetent” phase – they now know driving is tougher than they thought and requires training and practice to acquire the necessary skills to be successful.

We took this same approach with our students when it came to our disclosure training. Using standardized patients (SP), professional actors that played the roles of patients and family members, I created a disclosure simulation for our students. I am not sure if UIC still does this, but when I was there, we would present each student with a medical error case. They would have five minutes to read the case and think through what they were going to tell the patient (the SP) about the medical error and subsequent harm that had occurred. This was their chance to see what it was like to disclose a medical error to a patient–something almost all of them thought would be pretty easy. By the time they had finished and we had debriefed after the encounter, they had moved into the consciously incompetent phase, now appreciating how difficult these conversations can be. They also realized that a bad disclosure can be worse than no disclosure at all.

The simulation was complimented with additional doses of reality. Tim McDonald, being both an MD and JD, was able to provide excellent insight into the real world, and would make sure students and residents understood they should never disclose a medical error on their own. A true disclosure, apology and rapid remedy approach to medical error is a thoughtful process that requires a team approach driven by supportive leadership and buy-in by the hospital board. That process also includes knowledge of the hospital’s bylaws, support of the medical malpractice carrier, knowledge of the state’s apology laws, and then coaching and mentoring from the safety and risk department, if they work for an organization with a disclosure program in place.

By the end of the third year, the goal was always to have students understand we have not been patient-centered in our care. That we have not always been honest, and that there are newer, and we believe better, approaches to handling unintentional medical harm. We wanted our students to appreciate how difficult disclosure conversations are, and understand there are still many barriers in place which keep us from doing the right thing when harm occurs.

In the final post on disclosure training, I will share information on the four-week, online, patient safety elective we offered our fourth year medical students. This elective course continued the discussions on disclosure and medical liability, as well as care-for-the-caregiver approaches to medical harm.

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