Judgment, Fact and Anxiety

20140617_091709During the Resident Patient Safety Summer Camp in Telluride two weeks ago, the group joined in an emotional discussion led by one of our patient advocates, Carole Hemmelgarn, also a graduate and educator for the University of Illinois Medical Center’s MS in Patient Safety Leadership. Carole’s talk centered around communication, and the power words hold within the healthcare environment–a lesson gleaned from her own family’s story that began with their young daughter, newly diagnosed with cancer, and almost in the same instant, also misdiagnosed and labeled as anxious.

I’ve heard Carole fight through tears of grief more than once as she has shared her family’s story, imploring the medical profession be careful in the words they choose to describe and label patients – both formally in a chart, and informally among colleagues. This time, however, I had a flashback to my own graduate training in sport psychology, where we studied in detail the differences between state and trait anxiety, two very different states of arousal, and different still from a full-blown DSM-V diagnosis of a generalized anxiety disorder. I asked the group if they understood the difference between state and trait anxiety, would they treat each of the two the same, and what assumption would they make if they came across the word “anxious” in a patient’s chart. The answers I received from a few in the group were confident, but unconvincing, and I wondered silently at the depth and type of training medical students receive around the nuances of mental health.

Reflecting on what I had learned years ago, it dawned on me that Carole’s little girl most likely had not been properly assessed to have had this label attributed to her upon a first meeting–something the family knew but no one was listening. To my knowledge, she was not seen by a mental health professional, or given a formal assessment for anxiety. However she was a child newly diagnosed with a disease other people in her life had left her world as a result of, and she was an intelligent, sensitive, thoughtful young person who put two and two together–easily becoming state anxious, if she was truly anxious, or just attributed so by someone lacking the knowledge, empathy or time to understand the power one word can carry when recklessly placed into a medical chart in judgment.

Carole’s story always leaves a lasting impression with her audience, and one of our Telluride Scholars, resident physician Lakshman Swamy MD, shared the following reflection on our Telluride blog in, Thinking About the Medical Language:

…We heard a powerful story about the impact of a casual word thrown into a patient’s chart and how that created an anchoring bias that ultimately cost a child’s life — unnecessarily…

…I’ve been thinking in particular about how many normal colloquial words — like anxious, delusional, confused — have a distinct meaning in medicine. When my patient’s nurse tells me that he is confused, it doesn’t mean he isn’t understanding something and needs clarity. It doesn’t mean that there is a misunderstanding. It means he is not thinking straight because of underlying illness. This gets interesting and tricky when we translate medical English to colloquial English. What is worrisome, however, is when we are flippant with these words. I hadn’t realized the impact that the language I use can have on patients, families, and ultimately the course of a patient’s care.

For example, during transitions of care — handoffs between inpatient providers in particular — the new team has a strong inclination to believe what the old team says in their signout. A casual word in that signout — such as “anxious” when you mean that the patient is fearful, or “confused” when you mean that the patient is unaware of the treatment plan, or “delusional” when the patient might just be hopeful — can have an intense impact on the new team’s perception of that patient. We should be aware of the impact of our language but also more clearly train our students about the potency of what we write in a chart.

At the end of that paradigm-shifting session for many, Kim Oates, MD (@KimRKO), a tenured pediatrician and regular Telluride faculty coming all the way from Australia, brilliantly summarized the challenging conversations. I had sat behind him most of the meeting that week and watched on more than one occasion the emotion stories like that of Carole and her daughter triggered for him. In his soft, Aussie accent, his summary gently but firmly suggested to all young healthcare providers in the audience to be certain to understand and recognize when making a judgment versus conveying facts, and to be very careful not to confuse the two. And to make sure that what actually lands in a patient’s chart is fact.


Follow Telluride 2013 Resident Summer Camp Reflections at Transparent Health Blog

IMG_0188Please join us in Telluride this week!

We are well into day two with our resident scholars in Telluride, where the topic for 2013 is Change Agents: Teaching Caregivers Effective Communication Skills to Overcome Patient Safety Barriers in Healthcare.

This amazing group is engaging in some truly moving conversations around patient centered care, shared decision-making, personal experiences with near misses and the dangers that exist within medical education. Their bravery, knowledge and commitment to their patient is so very evident — it is inspiring, and gives hope of a very bright future for healthcare.

We will be posting summaries of the days events for the next two weeks here on ETY, but please also join us this week at our Transparent Health blog, (found here). Today’s post on the TH blog shares a number of resident reflections and can be linked to here.

Paul Levy, Not Running A Hospital, has joined us in Telluride to teach negotiation skills to our resident physicians and is also blogging about the experience. You can find his reflections here.

The Future of Health Is Social

I recently came across an old blog post by Lee Aase, Director, Mayo Clinic Center for Social Media, Move over Dr. Google, the future of health is social. Aase, a long-time communicator in the political arena, has seemingly picked up the new tools of the trade with a flair all his own for healthcare. This particular post from 2011, alludes to the fact that Google may not have been hitting at the core of how individuals will utilize health information in the future. His post significantly precedes Google folding their health business for good in January of this year.

Already a student and believer of the power of social media to change the way we experience health and illness myself, it’s always nice to have other expert communicators confirm those beliefs. For me, healthcare social media use (or #hcsm on Twitter) is less about the social support that traditional social media tools offer–such as people sharing the same illness connecting–which has tremendous value in and of itself. It is more about the reach, and the following opportunities, social media can provide healthcare stakeholders on the whole. For example, social media tools offer:

For Patients:

  • The ability to gather information in a relaxed setting
  • Access to, and information on, research studies
  • Connections to new resources (peers, providers, educators)
  • Access to answers 24/7
  • Greater transparency to the care they are seeking
  • Behavior change options (see ETY post, The Power of Social Networks to Change Health Behavior)

For Providers:

  • Inspiration
  • Training/Education
  • Support networks of their own
  • Ability to meet patients where they are and stay connected
  • Disease and outbreak tracking

It was, however, the following video in Aase’s old post that was my muse for this post. I can’t help but applaud the growing value of YouTube as a tool for patient education and provider inspiration.

In February 2013, Aase posted an article on Mayo Clinic’s Social Media Health Network, The “Right” Length for Health Videos, which summarizes a Google chat facilitated by Kathi Browne, a healthcare social media consultant. This is a timely discussion, as we are currently at work developing videos that convey patient safety information to associates without overwhelming their already overflowing inboxes. With so much competition for the attention of healthcare associates, what is the best way to get your message heard? We have chosen to go with short, sweet and humorous videos for internal education when possible. What successful strategies and tactics have you employed, beyond the traditional healthcare communication Tool Kits or inservices? Please share!

Here are some related tips gleaned from experience and reading of late!

  • Know your audience!
    According to Aase patients, will pay attention to longer videos, especially if it’s about a rare disease, as there is likely little information available. Overloaded associates will not have time to digest lengthy content. Give them meaningful highlights that both engage and educate.
  • Humor works!
    Make ’em laugh, or make ’em cry…
  • Tell a story that touches the heart!
    People will remember a story told from the heart much longer than slides from a PowerPoint deck. Talk to patients and providers about their experiences in healthcare and share those stories when appropriate.

How the Stories of Our Lives Can Change Healthcare

If you’re interested in how to use stories to change your healthcare work, please watch this two-minute video before reading.

In my new favorite magazine, Fast Company, a Co.Create section article, The Heart of Storytelling… recently highlighted how the American Red Cross is using stories of those who have received their services to help share their message and provide information about the work they do. To the credit of both the Red Cross and their ad agency, BBDO New York, the two groups recognized that their original ad campaign using storytelling lacked authenticity and felt forced. So instead, they mailed video cameras to those who could tell the story first hand, and then edited the content to share the words of those who had lived these life-changing events, such as:

Maybe putting a camera, or tools like social media, blogs, email, or good old-fashioned pen and paper in the hands of more patients, allowing them to tell the world about authentic experiences of care will leave a greater impact on those providing care, as well as their peers and consumers of healthcare. We’ve been told by many expert storytellers to share stories that touch the heart to create the change we need. But how long do emotions need to stay charged in order to equal action? And what is it that finally flips the switch to act? Is it unwavering social support or is it that the “character” within the story moves us to action? The suspension of disbelief created in a movie theater is fleeting, and the change needed in healthcare is lasting and challenging. Do we need to be reminded of these patient stories over and over, or will we become desensitized over time?

In an April 2012 Social Science & Medicine article, Aspirin Use and Cardiovascular Events, Strully & Fowler et al showed again how social networks influence health behavior–specifically cardiovascular health in this study. Their research showed that the cardiovascular event of a same sex friend or family member–i.e. a woman’s female friend or a man’s brother–was shown to increase the likelihood that each would adopt aspirin therapy to prevent cardiovascular disease. Their research also considered the confounding factor that those who actually took aspirin might be influenced by the same well-meaning physician–however this turned out not to be the case. The story this data could be telling us is that health behavior is influenced more so by the story lines of the lives of friends and family than the prescriptions given by healthcare professionals for non-acute care. At least for me, this research implies my health behavior will change when one of my girlfriends has a stroke. This research also implies that maybe we don’t have to wait for someone “like us” to have a cardiovascular event before we change the story. Rather, perhaps health prevention of the future is creating a new story altogether and targeting influential people within a social network to make treatment, or positive health behavior, spread like good gossip or a bad virus.

Creating Stories That Matter to Patients and Providers

Shekhar Kapur, the Hollywood/Bollywood director who directed Elizabeth and Mr. India, gives an excellent TED talk below that examines how valuable stories are to the expression of the self. He claims that we are the stories we tell–that without the ability to tell stories we would “go mad”. When he evaluates a script, he looks at the story from the psychological level, the plot line, the political level, and the mythological level to find the truth the story is trying to convey. This truth is what he believes will ultimately move an audience and it is up to him to convey this truth visually. Storytelling ultimately is the search for harmony, he says, which is greater than just a fleeting moment of resolution.

How does this apply to medicine and medical education? Because engaging patients will require a type of harmony, or at the very least a deeper connection, that good stories–the ones that stir the heart or hit like a punch to the gut–inspire to create the real change needed in healthcare.

So how do non-English majors or filmmakers like Kapur learn to tell good stories in healthcare environments in order to move colleagues and patients? Ryan Biggs offers some simple techniques to exercise your storytelling muscles in the blog post, A Quirky Experiment Proves the Value of Story Driven Content. Substitute “marketing” with “healthcare” and see how good storytelling might be implemented in your own health system:

  1. Brainstorm a new marketing campaign by starting with the phrase “Once upon a time…” and conclude with “and so customers lived happily ever after.” You’ll be pleasantly surprised at the story you end up creating.
  2. Write a letter to a friend about your product, service, or brand. The letter format encourages a more natural narrative and eliminates buzzwords.
  3. Distill your marketing story down to 140 characters. All strong stories can be condensed to a single sentence. Stuck? Start by creating a message map.
  4. Create an Aesop’s Fable that uses your brand or product as the protagonist. Don’t forget to include a moral.

A previous ETY post, The Power of Storytelling in Medicine, which references Jonathan Gottschall’s, The Storytelling Animal: How Stories Make Us Human is also a good foundational read on storytelling.

Follow ETY for more tips on incorporating storytelling into your healthcare improvement projects! And please tell us how you have used story in your own piece of the world to get your message across.

The Need For Better Communication in Medicine

“If they haven’t learned it, you haven’t taught it.”

I love this John Wooden quote–and John Wooden for that matter. Both Dave Mayer and I have blogged about Wooden’s leadership on and off the basketball court, and how medicine could benefit from his example of leadership. I was again reminded of this Woodism, last week after following a Tweet to Dr. Tyeese Gaines’ post, “Doctors and moms: Speaking Different Languages”  in Health on TODAY. In her post, Dr. Gaines speaks to the need for better communication skills among care providers. This same need was voiced by the American Hospital Association’s Physician Leadership Forum, and highlighted in a July 2012 white paper on: “the core competencies needed to deliver coordinated, team-based, value-driven care and recommendations for how hospitals and physician-associated organizations can develop these skills in the next generation of physicians.” In the white paper, core competency #6 was defined as Interpersonal & communication skills where physicians should be able to:

  1. Demonstrate skills that result in effective information exchange
  2. Work effectively with other members of the health care team

The gap in the need for good communication skills among medical professionals and the existing skill set around the same was named as a strategic imperative by the Physician Leadership Forum moving forward–a positive step toward thwarting the miscommunication among care providers thought to play a major role in medical error.

Returning to Dr. Gaines’ post, I can’t help but once again think of John Wooden. Physicians and patients, including Moms–unless they’re involved in medicine, often do speak different languages. When you add a sick child to the equation, you amp up the stakes and the ability to comprehend the information shared by a care provider decreases significantly. Education level, anxiety level, previous experiences with healthcare providers, frame of reference–all factor into that complex social interaction. And I can’t help but return to a health psychology class, many years ago, where the one statistic that has stayed with me over time is that patients comprehend 30% of what is said in any given conversation with a healthcare provider. If “they haven’t learned it”, maybe the information has yet to be taught in a way that bridges that expansive 70% gap? Wooden had practice time with his players daily, and it still took time for them to acquire a new skill. A 20 minute appointment on a new health topic under stress without “practice” time is a challenging learning environment for both teacher and student.

Even when the news communicated was positive, Dr. Gaines shared her frustration with the story of a Mom who refused to believe her child was healthy and ready to leave the ER. Rory Staunton, the young boy whose death was attributed to sepsis missed in an ER, and cases like this, may contribute to communication challenges even around positive results. With social media and the intensified scrutiny on all aspects of healthcare, every miss of magnitude is brought to the public for evaluation. “It’s just a rash” or “it’s just a virus” uttered by care providers no longer commands the same level of trust it once did, and as such, those conveying the positive findings may still have to battle against medical errors of their peers to gain the trust of patients once given without question. How can care providers most effectively convey this complex, sometimes charged, information in a way that makes sense and sticks with patient and family? Please share your thoughts!

Medicine has indeed become a team sport, and everyone on the care team has to be on board–fully aware of their contribution to a successful outcome.

Can We Be Honest When Medical Error Occurs? Part 2

In my last post, I shared the story of a wrong-sided surgery case I was a part of while a resident. It is a case that has stayed with me throughout my career, shaping my career as a caregiver. To this day, I wish I had chosen to be courageous, and been truthful with that patient instead of taking the easy road–a road well-paved by medical educators of my generation. Resident physicians, however, were and still are, very low on the healthcare power gradient. Everything they do is scrutinized and evaluated. One mistake, one incorrect decision, one slip of the tongue can keep a resident from a top fellowship choice, or a first attending physician position at their favorite hospital. I am fully aware, as my intuition told me so many years ago, that had I been honest with this particular patient at that point in my career with the defining culture present at the time, it is unlikely that I would be writing this post reflecting on a lengthy career in medicine. The culture was, and still is in many places, to deny and defend if necessary.

Like many medical educators with this type of experience behind us, we now hope to create a healthcare system that allows us to be open and honest with patients when unintentional harm occurs. Not only is this the right thing to do, it prevents current and future medical students and resident physicians from being put in this untenable position.  Caregivers want to be honest with their patients but are limited by the prevailing culture of medicine–scared of the consequences and the unknowns painted by others. Many legal consultants advise us that, “It is a mistake to admit a mistake.”  For the past thirty years, caregivers have been told to stay quiet and let others use these tactics to best defend the hospital, however there is no rational data to support this unprofessional and seedy approach.

The following are still very real barriers that prevent caregivers from being open and honest when care unintentionally causes harm:

  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

However, a growing body of research now shows the following benefits can occur when caregivers are open and honest:

  1. Maintain patient/family trust
  2. Reach remedy agreements in less time without having to use court system
  3. Higher percentage of remedy going to patient and families
  4. Lower number of claims
  5. Learning from mistakes
  6. Improving safety for future patients
  7. Increased employee/staff morale
  8. Psychological well-being of caregivers
  9. Accountability for those caregivers who are reckless
  10. Financial savings (e.g. decreased legal and administrative fees, malpractice costs)

More and more data continues to be published demonstrating the many benefits that can come from an open and honest approach to patient harm.* Through transparency and adoption of just culture principles, health systems are now learning from these unfortunate events and in turn, making care safer so that others will not experience similar harm. This is the hallmark of any high reliability industry mindset, and long overdue in medicine.

These new results allow healthcare professionals to educate the young, our next generation of caregivers, in every sense of the word. It allows us to be role models  that set an example of what it means to be a true professional caregiver and healer–one who is caring, compassionate and patient-centered at all times, not just when it is convenient. It moves healthcare away from the decades of deceit experienced by patients and families at critical times of need. It moves us away from a culture that built a “Wall of Silence”** between us and our patients when unintentional harm occurred. We can now educate and train future caregivers about the benefits that come from true transparency and the power of open, honest and professional communication with our patients and families. That has been our mission for the past four years at the Telluride Patient Safety Summer Camps.

*For more information see: Liability claims and costs before and after implementation of medical error disclosure program. Kachalia et al, Ann of Int Med, August 2010 and Responding to patient safety incidents: the seven pillars. McDonald et al, Qual Saf Health Care, Dec 2010).

** by Rosemary Gibson