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.

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.

Disclosure Training is a Process, Not a Fifty Minute Lecture

Since Paul Levy’s post,  Attitudes are one thing, behavior is another, and my follow-up post, Are Interns Really Willing to Disclose Medical Errors? generated much interest on the topic of resident physician and medical student attitudes and education related to medical error disclosure , I’d like to continue with this important patient safety educational theme.

When I was academic dean at the University of Illinois College of Medicine in Chicago, a number of us designed and implemented a four-year patient safety curriculum for our medical students. In 2006, this was one of the first (if not, the first) four-year, longitudinal patient safety curriculum for medical students in the country. Our curricular work was supported by grant funding provided by the Foundation for Improvement in Post Secondary Education (FIPSE).

One educational component of the four-year patient safety curriculum was dedicated to disclosure and apology related to medical errors. The disclosure training was based on our “Seven Pillars” model that the University had put in place. The “Seven Pillars” model includes: a rapid response to all unanticipated outcomes, full disclosure related to the care, apology and early compensation if warranted, and using transparency and disclosure to learn from all our mistakes so that we implemented the necessary changes to our system to reduce risk to others. This model has become well-known throughout the country, and was recently referenced by Dr. Carolyn Clancy, the Director of AHRQ, in her July 12th consumer article, Revealing Medical Errors Helps Chicago Hospitals Build a Safer Health System.  The “Seven Pillars” approach uses the court system as a last resort (versus the first thing we historically ran to, or hid behind) in bringing closure to patients, families and caregivers.

The disclosure training programs for students put in place while I was at UIC had a number of core elements to it. We started the very first day of school at 8:30am with a patient safety conversation with our students. Before they received their first biochemistry lecture, I led an interactive, one-hour session with our new students on their “expectations” related to medical school. I did this session for five years, and every year it was a very rewarding and informative session for me as an academic dean. I really enjoyed connecting with the students on the first day of their four years with us, and hearing their thoughts on what they perceived the next four years of their lives would be like.

During the first half of the hour-long session, I always asked the students to share with me the fears they had on this first day of school, the starting point on their journey to becoming a physician.  Each year I did this, two fears rose to the top – the fear of failure and the fear of hurting a patient. Students read the newspapers that share personal stories of harm or talk about the medical error crisis; many students had a family member harmed from a medical mistake. As an educator, it was a great teaching moment to start the safety conversation, and the reason why we started the conversation on the very first day of school. More on the safety curriculum and disclosure training we created for our students and residents tomorrow.

Are Interns Really Willing To Disclose Medical Errors?

In a recent email conversation with Paul Levy, he shared with me a very exciting study, Changes in intern attitudes toward medical error and disclosure. I mentioned that the results of the study, while encouraging on one level, need to be looked at with a cautious mindset. The actual act of disclosing an error to a patient (behavior) is much different from a belief about doing the same (attitude). In our hearts, we all want to do the right thing–but it is our actions or behaviors that define the ultimate outcome. More of our conversation can be found in Paul’s post, Attitudes are one thing, behavior is another.

We believe that disclosure and apology in the face of a medical error is the right thing to do, but in actuality, how many of us really do so? In my personal experience with UIC’s disclosure and rapid remedy program (The Seven Pillars), caregivers don’t disclose – organizations disclose.  Without leadership/board buy-in and medical malpractice carrier support, the right attitude about disclosing doesn’t become behavior. In a previous post, Can We Be Honest When Medical Errors Occur, Part 2, I share a medical error case I was involved in many years ago and mention the very real barriers that prevent caregivers (who believe it is the right thing to do) from being open and honest when care unintentionally causes harm (the behavior), such as:

  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

These barriers have prevented very good people from doing what they believed was the right thing to do. Today, a growing number of health systems across the country are slowly putting programs in place that encourage residents and interns to act on the changing attitudes Varjavand et al mention in their study above. But it is a systems effort, and the conflict between attitude and behavior will continue to exist until more health systems realize that disclosure, and programs that teach how to do so in the best interest of both patient and caregiver, become widespread.