Staying True to the Mission: One Key to Good Storytelling

Last week at the National Quality Colloquium, I had the opportunity to share research and ideas around the use of stories and storytelling to change behavior. The audience’s engagement and the lively discussion that followed gave evidence to the growing number of healthcare professionals openly looking to embrace the power of stories in their daily work. As a result, many are looking to learn how to share stories in a meaningful way, so that their healthcare improvement missions become contagious. One way to accomplish this is to borrow the secrets used by successful CEOs and filmmakers, and apply the intentional structure they use to weave what often feels like magic beneath their words. Peter Guber, film producer (Rain Man, The Color Purple) and author of Tell to Win, lays out a simple plan to craft stories that both move and captivate listeners in a Harvard Business Review article from 2007, “The Four Truths of the Storyteller“. Simply put, good storytelling requires:

  1. Staying true to the teller
  2. Staying true to the audience
  3. Staying true to the moment
  4. Staying true to the mission

Following is a video example of how TOMS CEO & Chief Shoe Giver, Blake Mycoskie, not only thanks his customers, but shares his mission in a way that captures the heart. For those who don’t know TOMS, it is a philanthropic-driven, hip shoe company that matches every pair of shoes purchased with a pair of new shoes given to a child in need. Storytelling is so important to TOMS mission that they have an entire section dedicated to their stories on their website. Click here for more examples of stories that stay true to the TOMS mission.

Healthcare providers have been traditionally trained to distance themselves from the potential heartache of delving too deeply into each patient’s story, but that appears to be changing as medical humanities and narrative programs are growing across the country. As we search for ways to make the culture of medicine more inclusive, inviting patients to partner in their care includes a better understanding of their stories–who they are and what matters to them–as well as a willingness to step outside the comfort zone for some. Writers and filmmakers understand all too well where our comfort zones lie, and push us to those limits in ways that often leave us begging for more. Whether or not you saw the 1998 movie, Patch Adams starring Robin Williams, based on the experience of physician, Hunter “Patch” Adams, MD, the screenwriters deliver a fitting line of dialogue for this storyline:

You treat a disease, you win, you lose. You treat a person, I guarantee you, you’ll win, no matter what the outcome.

Interesting to note that the real Patch Adams was seen as an outlier for staying true to his mission–patient-centered care–long before its time.

Palindromes and Patient Safety

I have been very fortunate through my career to have met, learned from, and become friends with many patient advocates from across the country.  People like Helen Haskell, Patty Skolnik, Linda Kenney, Sorrel King, and Carole Hemmelgarn to name just a few. Their ability and willingness to turn personal loss into a life-long commitment to make care safer and of higher quality is quite inspiring…they are the true heroes of this mission.

The same holds true for Victoria and Armando Nahum who I was so fortunate to meet about two years ago. Over a period of 10 months in 2006, the Nahums had three family members stricken by hospital acquired infections, at three different hospitals in three different states, culminating in the death of their 27-year-old son, Josh. Like the families I mentioned above, they also turned their own personal loss into a crusade to reduce and hopefully eliminate hospital acquired infections by starting the Safe Care Campaign.

Screen Shot 2013-09-22 at 1.54.18 PMLast week at the Quality Colloquium, I moderated a morning long session on quality and safety at the bedside. Because patient partnership is a critical piece to any quality and safety mission, I asked Victoria and Rosemary Gibson, author and healthcare advocate, to be part of the panel and lead a patient partnership discussion with the audience. Both Victoria and Rosemary (as usual) were outstanding speakers, and had the audience fully engaged. However, during Victoria’s presentation, something truly special happened. Victoria shared the following video that she and her husband Armando created. Lke most in the auditorium, I had not seen the film before. The video delivered its message that morning in a unique and quite remarkable manner. Few times have I seen an audience as captivated at a medical meeting as they were last Thursday while we watched the Nahum’s two-minute film. The audience burst into spontaneous applause at the conclusion of the video, even though Victoria was still in the middle of her talk.  It was an inspiring moment. The Nahum’s creativity and message captured us all that morning. Take a look for yourself:

The Nahum’s courage is powerful, and their message so very important if we are to escalate the fight to reduce risk and improve the quality of care providing to our patients. We need a greater sense of urgency around all of these efforts, especially at a time in the evolution of healthcare when competing agendas vie for attention and funding. Like Don Berwick, Carolyn Clancy and other healthcare quality and safety leaders who have inspired us to do better, patient advocates like Victoria, Rosemary, Helen, Patty, LInda and Sorrel are leaders who inspire us with their passion and commitment to help us get it right. It is encouraging to see them with a seat at the hospital conference or board room, as keynote speakers at national conferences, and included in hospital quality and safety improvement committees.  How we thought we could do this important work without them still befuddles me.

Infectious Innovations in Medical Education

In May of 2012, Chip Heath (Made to Stick) and Charles Prober MD at Stanford University School of Medicine co-authored a NEJM perspective, Lecture Halls Without Lectures–A Proposal for Medical Education, positing that lecture time is wasted time, and that a more dynamic content delivery medium should be explored. Today, Prober and Sal Kahn, of Khan Academy, are now teaming up to experiment with exactly that concept by “flipping” the med school classroom, according to a September 9, 2013 Inside Higher Ed blog post, Flipping Med Ed:

Khan and Prober present a three-step road map: First, identifying a core curriculum with concepts and lessons that can be taught through…short, focused video clips…then, changing static and poorly attended lectures into interactive sessions where students can practice that curriculum; and finally, letting students explore their passion…early on in their med school careers.

As Khan Academy moves toward delivering lessons for medical students, Khan is engaging experts in the field to help create content. He believes that a ratio of 1:299, lecturer to student, only captures the knowledge of one person in the room. When everyone in the classroom is allowed to weigh in, the content, and learning, take on new life. An example of a Khan Academy lesson on antibiotics follows:

Stanford is also working on interactive learning initiatives to support medical educators who would like to explore new ways of delivering traditional curriculum. See more at Stanford Medicine Interactive Learning Initiatives, and stay tuned, as we will continue to share more on the innovations coming your way in medical education.

Medical Students Use Music to Share Patient Voice

In a recent AM Rounds post, Not the Story: Medical Students’ Reflections on the Patient-Doctor Relationship, author/singer/medical student Jessica Bloom, shares a clip of an original song inspired by the patients and families visited during M1 and M2 years in the University of Michigan Family Centered Experience Program, run by Dr. Arno Kumagai. The trio of songwriters/performers/medical students, as well as their 1st & 2nd year medical school colleagues, came to better understand the needs and desires of patients and families dealing with chronic conditions by spending time in the homes of volunteer families, learning more about their patients as people in order to better understand what it is like to experience illness. At the end of their second year, the medical students are required to create an interpretive project of this experience, and many turn to the arts to not only express the voice of their patients, but also their new-found understanding of medicine from the patient’s point-of-view.

It’s worth a quick click to hear the clip — poetry unintended.

Stay tuned for more information to come on the growing number of medical humanities programs across the country…

Experiencing Both Sides of the Quality and Safety Chasm

For more than 25 years I have had the pleasure of calling Jerod Loeb my friend. We lived down the block from one another as our families “grew up” together. Many who read this blog also know Jerod, or have worked with him at some point during his illustrious career. He has been a leading international expert in healthcare quality and safety for decades, and he has taught me much through his leadership. His wife Sherri is also a good friend of ours. She too has spent her entire professional career in healthcare as a registered nurse.  I wanted to share part of a recent article about the Loeb family’s personal journey through the healthcare system. Many of Jerod’s academic writings can be found in leading healthcare journals, however this piece, was published in their community newspaper.

Ironically, they will now tell you it wasn’t until Jerod was diagnosed with cancer that they both realized how much they did NOT know about healthcare. The Loeb’s personal experience has made them realize that drastic changes need to be made in healthcare administration. To that end, Jerod and Sherri are making it their personal challenge to educate others on how to best navigate the healthcare system as patients. Below Sherri describes some of her thoughts in relation to this dreadful disease:

“How do you ever start to explain the changes in your family’s life when someone is diagnosed with stage IV metastatic cancer? What was a perfectly normal life, changed on a single blood draw two years ago. From a PSA of 1.2 to 535 in one year. The prostate cancer had already spread out of the prostate and throughout the bones. It was too late for surgery. Two highly educated health care individuals were suddenly thrust into the sharp edge of the medical system. Through standard treatment, clinical trials, having to travel 1000 miles for care that looked beyond the “standard of care”, we have done it all. Throughout this journey we have learned many things:

1. Diseases don’t read textbooks – thus what may be appropriate care for some is not for others.

2. Although you may be extremely bright and knowledgeable once you enter the health care system as a patient you tend to become deaf, dumb and blind.

3. The need for patient advocacy and family engagement is crucial for the best care possible

4. Communication is vital. Without it everything else is lost.

5. Epidemiologists who decide that PSA screening is not important need to look at patients individually and not make a generalized statement.

6. Shared decision-making is the only way to appropriately approach care.

7. Stop treating patients like they are simply an icon on the computer and remember they are a person, with hopes, dreams and families.

8. Patient safety is not something to take haphazardly. Without it patients die or are harmed unnecessarily.

Many times, the most important educational messages we need to share in our teachings are not found in the traditional p-valued, statistically significant healthcare research articles we like to reference. The best learnings can be found in a neighborhood journal that incorporates the patient’s perspectives and needs into the educational moment.

Would These Physicians Do a Time Out Before a Procedure?

My wife, Cathy, is extremely knowledgeable in safety, quality and accreditation for the non-acute healthcare arena which can make for very interesting dinner conversation. Recently one evening, she shared that after entering “Medicare fraud” in the website search engine of her favorite journal, Outpatient Surgery, the site returned 1178 hits. 1178 hits? You mean 178 hits, I had replied–or maybe, hoped. Unfortunately, 1178 was the correct number. I had to go online and read a few of the stories returned in the search. Following are just two examples from their site:

Spine Surgeon Charged With Medicare Fraud …Atiq Durrani, MD, billed Medicare for $11 million worth of anterior lumbar fusion surgeries between February 2010 and January 2013. According to federal prosecutors, those cases were medically unnecessary for his patients. They’ve charged him with healthcare fraud and making false statements. According to published reports, he has been named as a defendant in 150 medical malpractice cases filed by former back and neck pain patients, and no longer has privileges at the 4 Cincinnati-area hospitals at which he performed surgery.

Oakland County Doctor and Owner of Michigan Hematology and Oncology Centers Charged in $35 Million Medicare Fraud Scheme Dr. Farid Fata, 48, of Oakland Township, MI, was arrested and charged in a criminal complaint for his role in a health care fraud scheme…submitting false claims to Medicare for services that were medically unnecessary, including chemotherapy treatments….positron emission tomograph (PET) scans, and a variety of cancer and hematology treatments for patients who did not need them…Fata falsified and directed others to falsify documents. MHO billed Medicare for approximately $35 million dollars over a two-year period, approximately $25 million of which is attributable to Dr. Fata…The complaint further alleges that Dr. Fata directed the administration of unnecessary chemotherapy to patients in remission; deliberate misdiagnosis of patients as having cancer to justify unnecessary cancer treatment; administration of chemotherapy to end-of-life patients who would not benefit from the treatment; deliberate misdiagnosis of patients without cancer to justify expensive testing; fabrication of other diagnoses such as anemia and fatigue to justify unnecessary hematology treatments; and distribution of controlled substances to patients without medical necessity or administered them at dangerous levels.

About two weeks ago, Paul Levy posted in Kill This Monster, that 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.

I felt compelled to respond to Paul in Pilots and Physicians…Skin in the Game, expressing that, if you don’t believe the reason physicians are slower to adopt proven safety tools than pilots are because pilots have more personal “skin in the game” than physicians do, than perhaps the difference between pilots and physicians might be one, or a combination of, three other reasons: (1) misaligned financial incentives, (2) physician autonomy, and (3) a lack of medical accountability and oversight.

Screen Shot 2013-09-01 at 8.33.40 AMI am, and have always been, a big believer in Just Culture. Be it James Reason or David Marx, the concept is critical to achieving any true culture of safety. Over the last few years, I have followed the work of Sidney Dekker, Professor of Humanities at Griffith University in Brisbane Australia where great quality and safety work originates from (See Living Mindfulness). Dr. Dekker has a PhD in Cognitive Systems Engineering and is the author of  Just Culture: Balancing Safety and Accountability, a book I highly recommend, as he encourages us to ask:

What is responsible, not who is responsible. The aim of safety work is not to judge people for not doing things safely, but to try to understand why it made sense for people to do what they did – against the background of their engineered and psychological work environment. If it made sense to them, it will for others too.

After reading about the two physicians via the Outpatient Surgery website, I really struggle to understand how these actions made sense to any physician. The only answers I can come up with are: 1) These physicians had little, if any, regard for the patients who put their trust in them, or; 2) Believed the chance of getting caught for the alleged crimes committed was very slim. The perceived risk-benefit profile was heavily weighted towards personal financial gain, versus the consequences of inflicting significant patient harm. And if these physicians (and the many others referenced in my search) seem to have no fear of the law and possible legal repercussions, what chance do we, as safety leaders, have in getting them to perform Universal Protocol or employ risk reductions strategies before any procedure?

Like Dr. Dekker I believe that a Just Culture is all about balancing safety and accountability. Accountability in healthcare should never be lost.  If we as physicians don’t take personal responsibility and hold others professionally accountable, who will?  When we don’t, we lose the most important element of any patient-physician relationship, which is trust. As Dr. Dekker says:

Calls for accountability themselves are, in essence, about trust.  Accountability is fundamental to human relationships. If we cannot be asked to explain why we did what we did, then we somehow break the pact that all people are locked into. Being able to offer an account for our actions is the basis for a decent, open, functioning society.

To this I say “Amen”.

And…that I am happy my pilot has similar “skin in the game” (aligned outcomes) as I do when I board his/her airplane.