Earlier this summer I stumbled upon an AM Rounds post, the official blog of the journal, Academic Medicine, entitled The Power of Humanities & Storytelling in Medical Education, by Daniel George, PhD, Penn State College of Medicine. I copied the link into my slush pile, noting immediately I had found a like-minded colleague who also valued the use of stories in healthcare, as I read:
Storytelling is central to the human experience. In fact, it is quite likely that our human ancestors survived, in part, because they became adept at telling stories to convey complex information about environmental threats…social group dynamics, and to transmit crucial information and practices across generations. The urge to engage in storytelling is so irrepressible that it is almost a reflex…This narrative instinct is present even in persons with dementia, a vulnerable population too often defined in our society by their deficits rather than by their remaining strengths…
The post outlines a research study by George, who has studied Alzheimer’s, as well as medical student stress, healthcare social media and medical humanities. In this particular study, Penn State medical students were part of a storytelling program for those suffering from dementia. The program, TimeSlips, was originally developed by Ann Bastings, PhD, at the University of Wisconsin-Milwaukee. TimeSlips is:
…a group-based storytelling activity for persons with dementia that is increasingly used in caregiving settings worldwide. TimeSlips involves giving persons with dementia a visual prompt (generally a staged and surreal image with no recognizable subjects) and encouraging participants to collectively tell a story about the subjects of a given picture.
While all the links above are worth exploring if you have time, the greatest takeaway for me was the fact that people with dementia, those known to have an increasingly greater struggle recalling the stories of their own lives, can create new, cohesive stories when given a visual prompt, according to findings by George and colleagues. Not only did the patients respond positively to the experience, but the medical students who participated were also found to have improved attitudes and greater empathy toward persons with dementia after participating. See An Arts-Based Intervention at a Nursing Home to Improve Medical Students’ Attitudes Toward Persons With Dementia, (Academic Medicine, June 2013) for more information.
The following video is a call put out by the National Academy of Arts & Sciences. Actor, John Lithgow, and director, George Lucas, highlight a greater need to embrace the humanities, and to recognize the integral connection between the humanities and science. Lucas states: Sciences are the how, humanities are the why…I don’t think you can have the how without the why. As the call for a greater emphasis on patient centered care is now linked to reimbursement, training healthcare students to embrace both the science and humanity of medicine, seems to be one logical solution to what the future of healthcare requires. Penn State College of Medicince appears to have a growing medical humanities program, successfully creating a medical learning environment steeped in the human experience, preparing care providers who will be ready to meet patients as people, understanding that their stories, real and imagined, can aid in the healing process for all involved.
Dr. David Leach, the former CEO of the Accreditation Council for Graduate Medical Education (ACGME), once wrote that the most important role a Resident Physician has is that of being the “moral agent” for their patients. They have the responsibility of speaking up when harm is near. I love this “moral agent” concept…it is so simple, yet so critically important in the quest for safer, higher quality, patient care. (See ETY, Canary in a Coalmine).
In academic medical centers, Resident Physicians spend more time in our hospitals, have more direct contact with our patients, and see many more unsafe conditions and near misses than most caregivers. I hope all residents will be that moral agent – the “sentinel on watch” – for your patients. Report all near misses and unsafe conditions you experience to those in charge. Then help make a difference by working with your leadership to find solutions to those problems.
Today, the Committee of Interns and Residents (CIR, @CIRSEIU) will launch a new educational website for resident physicians (www.QIGateway.org) focused on quality and safety. The QIGateway portal is the first platform of its kind that is focused on patient safety and quality improvement by, and for, medical residents.
I encourage all resident physicians to visit this site, appreciate the growing body of quality and safety work being done by resident physicians across the country, and share your own quality and safety projects with others so that together we can continue to reduce risk and make care safer for all our patients
Through this exciting new educational website, the premise “Educate the Young” now aligns with “Inspire the Young”. More and more resident physicians are becoming leaders and change agents in quality and safety – being the patient’s “moral agent” that Dr. Leach called for while helping make a difference at their home institutions. It is a brighter day for safe, high quality care at our academic medical centers thanks to the new QIGateway portal.
The Telluride student, resident and alumni reflections on our sister blog, Transparent Health, provide student perspectives on the patient safety teachings shared during their week at Patient Safety Summer Camp. For many, it is the first time they are exposed to some of the challenges found in healthcare. Matthew Waitner, M2 at Georgetown University, who attended our first Telluride East session in Washington DC, shared his thoughts after digesting some of this content in a TH post, Trust and Safety in Medicine: Part One,
Matthew’s words echo what many of us working in patient safety can feel from time to time. Those who have gone the distance, however, have learned to find like-minded colleagues to bolster a strength-in-numbers approach. Rick Boothman, JD, a regular Telluride faculty member, thought leader, and ever-present voice in support of patients, read Matthew’s post from a distance this year, and shared the following comment in response. Rick’s words continue to inspire all of us — faculty and students alike. Thanks Rick–we missed you this year!
I read with much interest the Telluride postings and I fully support Dave Mayer’s work which is deeply rooted in his conviction that though we might work hard to change the status quo toward improvement, you and your colleagues represent the very best shot we all have in making serious and durable change. We all have choices to make about how we spend the ultimate fixed resource – our time and passion; Dave has dedicated himself smartly where effort may yield the greatest benefit. His passion and commitment to the young is not misplaced and your post confirms the wisdom of Dave’s choice.
BUT . . . as we identify what is wrong and work to correct it, it is equally important not to lose our way and destroy what is right. Understandably, after a few intense days focusing on the negative, you ask “Where is the outrage?”
Patience is not always a virtue, especially where lives are at stake. Without question, we’ve been far too patient with ourselves and the problems we’ve known about for a very long time. We must move deliberately and courageously to fix what’s broken, re-orient what’s misdirected, rethink what’s no longer relevant or useful.
BUT . . . I worry that you and your colleagues will despair. That you’ll lose heart. That you’ll lose the drive and the dedication and the determination to salvage what is right while fixing what is wrong even before you get started. That you’ll give up before trying.
Do not get jaded. Do not despair at the magnitude of the problems to which you’re being introduced. Despite more than thirty years of supporting health care providers in their very worst moments, I see more miracles large and small every single day. I see the positive difference all of you make for all of us. In spite of your human frailties and imperfections. In spite of systems that are fundamentally flawed, outdated and challenged by an unbelievable array of perverse incentives.
Despite thirty years’ worth of opportunities to become cynical, I am humbled every day by all of you.
Our daughter just finished her second year in medical school and she’s in the midst of her clinical rotations – I will never forget the sense of awe I saw in her face as she excitedly described for me and her mom the first time she actually laid hands on another person and diagnosed a heart murmur. And the overwhelming sense of responsibility she also felt when that patient put her life, her hopes, her body in my daughter’s amateur hands. I hope she will never forget that either. As I lawyer, I can only imagine that every one of you has had similar moments in your training.
Self-flagellation may have its place somewhere I suppose, but I don’t think it’s very constructive in general. And being overly condemning only makes the status quo hunker down in defensiveness.
As Dr. Mayer and his colleagues introduce you to the multiplicity and magnitude of the challenges we have, never lose your sense of awe. Work consciously your whole career to hold that profound feeling in your hearts and minds no matter what. Be proud of what you’re part of. And treasure the awesome privilege you have to touch us and heal us and help us.
We are all in this together.
Executive Director of Clinical Safety
The University of Michigan Health System
Over the past few years, I have really come to enjoy reading Paul Levy’s blog, Not Running A Hospital, especially when the focus is on quality and safety. I have found it educational, thought provoking, and timely. Paul’s post last Sunday, Kill this monster, was no exception, as he starts off by saying, “The time has come to drive a stake through the heart of an oft-repeated assertion. How often have you heard something like the following when those of us in healthcare who want to stimulate quality and safety improvements draw analogies to the airline industry?”
“Well, in an airplane, the pilot has an extra incentive to be safe, because he will go down with the ship. In contrast, when a doctor hurts a patient, he gets to go home safe and sound.”
His story took me back in time, as I remembered first hearing that comment many years ago. A pilot remarked similarly to me as we walked off a stage together, having just concluded an “Ask the Experts” patient safety panel at a national medical meeting. To be honest, I was a little offended, feeling as though I had just been insulted for being a physician. He had challenged the essence of why the great majority of us enter the medical field, which is to help others and always put our patients above our own self-interests. Before I could respond and defend my chosen profession, he was off…running to catch his plane. But his comment stuck with me and forced me to think deeper into why it bothered me. While it is true that similar complexities exist in both professions–high stress, high risk, varying conditions forcing both pilots and physicians to adapt–why do we, as healthcare professionals, struggle to grasp simple elements–those repeatedly passed on by human factors engineers–that aviation seems to easily adopt and follow without push-back?
I first thought about my specialty – anesthesiology. Why is it that many surgeons will tell anyone who is willing to listen that anesthesiologists are overpaid. They complain that many of us read newspapers, answer emails on our handhelds, or talk on our cell phones with friends while a case is in progress. Would an airline pilot ever consider reading the newspaper, answering emails or using their personal cell phone while working in the cockpit?
How about the accepted practice of running our anesthesia machines through a set of safety checks before using them each morning for surgery? While the manufacturers have added many self-check features through the years, there are still a few things we as anesthesiologists are asked to do each morning. Unless things have drastically changed in recent years, this “recommended safety practice” is not being followed regularly, the assumption being the machine worked fine yesterday so it should be ok today. Would an airline pilot ever think of not doing a pre-flight, airplane walk-around, checking the plane he or she is about to fly, and instead say, “Lets skip the pre-flight walk-around this afternoon…the plane was flown earlier today and I am sure nothing happened during the previous flight”.
Wrong-sided anesthesia blocks have seen significant increases in the past few years as regional anesthesia has become an important element for pain management supplementation in the post-operative recovery period. With the Joint Commission mandating the use of human factor tools like pre-procedure site markings, time-outs, and the use of checklists designed to help eliminate the “humans will be humans and forget at times” factor, we still see over 90% of these wrong-sided, wrong-site, wrong patient procedures attributed to a lack of following Universal Protocol and the use of a checklist. Would a pilot ever think of saying “Let’s not do the pre-flight checklist today. The extra two minutes it takes to do it just kills my day”?
The same figures hold true for surgeons. Many refuse to use timeouts and checklists. They will be quick to point out they have never had a wrong-sided surgery in their ‘fifteen or twenty years of practice’ and don’t need to use these safety tools. As John Nance says, those are the physicians that scare him the most. They believe they are, and will always be, better than the rest of us who will under the right circumstances make a mistake when the holes of James Reason’s Swiss cheese all line up. Having interviewed a number of surgeons and anesthesiologists who were involved in a wrong-sided procedure, every single one of them said the same two things right after the event: (a) They never thought this could happened to them, and (b) They are always so careful. But after the event, they realize we are all human. So why do some physicians still choose not to adopt the same mindset as pilots, before a patient gets harmed?
If you believe Paul’s premise–that it isn’t because pilots have more personal “skin in the game” than physicians do (see More Skin in the Game…)–maybe it could be one, or a combination of, three of the following reasons why we see differences in safety adoption between pilots and physicians: (1) Physician autonomy, (2) Financial incentives, and (3) A lack of accountability by leadership in the face of less than “reckless” behaviors.
To be continued….
One of the most significant takeaways from the Telluride Patient Safety Educational Roundtables & Student/Resident Summer Camps has always been the new connections made with some truly amazing people from around the world. This year, we all were so very fortunate to meet Dr. Sarah Dalton, a pediatric emergency physician from Australia, visiting the U.S. on a Fulbright Scholarship. Sarah lives patient centered care in her daily work, and is here to study Clinical Leadership Development Programs.
As many following ETY and Transparent Health blogs may know, Paul Levy (Not Running A Hospital) has been on the TPSER faculty the past two years, and is also one of those amazing people working in the best interest of patients. Following is a link to his recent post, Monkeys and Bananas, which includes the following short video our new TPSER connection, Sarah, shared with him — highlighting why “we’ve-always-done-it-this-way-thinking” is for monkeys — not the new leaders of healthcare!
The concept of “mindfulness” dates back more than 2500 years. In Sanskrit, it means awareness that, according to the teaching of the Buddha, is considered to be of great importance in the path to enlightenment. It is said that when we are enlightened, “greed, hatred and delusion have been overcome, abandoned and are absent from our mind and we are focused on the present moment and the reality of things around us”.
With the increased focus on High Reliability in healthcare over the past few years, we continue to hear more about the importance of mindfulness as a patient safety tool. I always thought of myself as being “mindful”. Anesthesiologists have to be “in the moment”, aware of the different cues happening around us in the operating room. However, through two simple examples recently, I learned a very important lesson from a longtime friend and mentor, Cliff Hughes MD, — that being mindful and aware of our surroundings is only half of the equation when applying mindfulness to safety.
For many years, I have had the great fortune of being a close friend and student of Professor Cliff Hughes. Cliff was a cardiothoracic surgeon for 25 plus years in Sydney, Australia before being elected CEO of the Clinical Excellence Commission (CEC) in New South Wales, Australia. From the CEC website:
(Cliff)…has been chair or a member of numerous State and federal committees associated with quality, safety and research in clinical practice for health care services. Prof Hughes has held various positions in the Royal Australasian College of Surgeons–including Senior Examiner in Cardiothoracic Surgery and member of the College Council. He has been a member of four editorial boards and has published widely in books, journals and conference proceedings on cardiothoracic surgery, quality and safety. Prof Hughes has a particular passion for patient-driven care, better incident management, quality improvement programs and development of clinical leaders.
Cliff, and his lovely wife Liz, were visiting from Australia this month, in part to attend our Telluride East Patient Safety Roundtable and Summer Camp in Washington, DC. As a result, my wife Cathy and I were able to spend some social time with Cliff and LIz, and with a consummate teacher like Cliff in the mix, the learning does not stop outside the four walls of a classroom or hospital. I share the following stories because they left such an impression on me, showing me that Cliff’s wisdom comes through living that which he teaches on a daily basis…
As we were walking through a local grocery store, we came across a small puddle of water on the floor in the produce section. I walked around the puddle, pointing out the potential safety hazard to Cliff following behind me. I continued walking, and it took about twenty more steps before I realized Cliff was no longer behind me. Instead of walking around the puddle like I had, Cliff had detoured to find the produce manager and show him the puddle so the safety hazard could be cleaned up. While I was mindful of Cliff’s safety in pointing out the puddle, Cliff was mindful of all others who would be following our same path and could suffer harm by slipping on the wet floor. Cliff acted on his mindfulness, and by reporting the event, helped prevent possible harm to others. I was mindful but didn’t act.
The very next day, Cliff and I were walking through a parking lot after a quick stop at a local Starbucks. I was in deep thought about our upcoming meeting. As we walked, we passed a parked car which I vaguely noticed had a back tire that was quite low…not completely flat, but would most likely soon be so with some extended driving. Momentarily noting the car, I kept walking, thinking about our upcoming meeting, Once again, Cliff disappeared and was no longer behind me. Instead, he was standing by the side of the car with the low tire, writing on a piece of paper. I walked back to where he was standing, and asked what he was doing. He said he was writing a note to the car’s owner, alerting the driver of the possible safety concern. Finishing the note, he placed it under the windshield wiper, clearly visible to the driver. Again, I noticed the potential safety hazard but was distracted by my own thoughts and priorities, and kept walking. I wasn’t fully “in the moment”, a prerequisite of mindfulness. Cliff, however, was fully in the moment. As such, he was able to not only notice potential safety risks, but also to report each incident and act to prevent possible harm to the driver and grocery shoppers.
Two simple, but thoughtful, actions became perfect learning moments for me, role-modeled by a masterful safety “Sensui”. Mindfulness without action is stasis.
Healthcare needs more Cliff Hughes’…
A Day 3 tradition during the Telluride Patient Safety Educational Roundtable & Student/Resident Summer Camps has been for students and faculty to join in a team building trek up the Bear Creek trail in the San Juan mountain range of Colorado. The hike has always played an important part in the week, allowing students and faculty to collectively reflect in a relaxed, awe-inspiring environment on the conversations and concepts around patient centered care, new to some and a career choice for all. This week, the Telluride experience moved east to Washington DC, and the Bear Creek hike transformed into a crosstown journey from the Georgetown University campus on foot and Metra to the Arlington National Cemetery. While the threat of bears and the physical challenges of altitude and mountain terrain were absent, the group was left to navigate east coast summer drizzle, a big-city subway system and an unfamiliar routine to overcome together.
As we made our way across Washington DC, organic conversations between students and faculty grew throughout the largest Telluride gathering in nine years. I was fortunate to get to know a number of students on the walk to and from this national landmark, many of those conversations each deserving a blog post all their own. Like Rose Ngishu for example–a nurse and mother of four from Kenya now in Galveston, TX, and in her third year of medical school. Rose shared how she knew at 7 years old, living in a country where any healthcare was a luxury, that she wanted to become a doctor and change the conditions in her country of origin. A woman, who despite many personal obligations, continues to push stubbornly toward her goal of improving the lives of those less fortunate and become a physician.
Saturday’s hike culminated on the hill beneath Robert E. Lee’s house with Dave Mayer and Rosemary Gibson centering the group around the fact that it would take less than two years to fill Arlington National Cemetery with the victims of medical harm. Less than two years to fill a cemetery that holds over 100 years worth of US Military casualties and their family members. Rosemary then encouraged us to break up into groups of 3-4 and remember by name, if possible, patients or family members that we personally knew affected by medical harm. The group then came back together and honored those we had discussed in our smaller groups. A new Telluride tradition began this week–one that connected the head with the heart, patient with provider.
Following are a few of the names remembered on Saturday. I can only hope that the efforts of our group, all the Telluride alumni, and healthcare stakeholders working in the best interest of patients, will result in the ability to recall fewer names in the future.