John Nance Reflects on The Telluride Experience and Need for Patient Safety Immersive Learning

Today’s post is by Guest Author, John Nance, Telluride Experience Faculty, Author and ABC Aviation Consultant


Having had the delightful experience of attending and working with all of the sessions of the Telluride Experience this summer,  I’ve spent some time since returning from Napa thinking through the scope and the effectiveness of what we all came together to advance: The goal of never again losing a patient to a medical mistake or nosocomial infection.

It may well sound hackneyed, but in fact I think all of us as faculty mean it to the depth of our beings when we say that the medical students and residents and nurses – all of those who joined us – are truly the best hope of changing the course of a noble but tattered non-system that slaughters people at the rate of 50 per hour.  That does not mean that existing healthcare professionals cannot or will not embrace the dramatic changes that are required to keep patients safe, because, indeed, thousands are passionately involved in just such efforts.   It does mean, however that the opportunity for leadership from the newer members of this profession will be critical, from the small and subtle gestures, to the grand and sweeping reforms.

And the potential for meaningful  leadership, of course, is why those who joined us were selected in the first place, and what we expect of them from here on:  Courageous leadership steeled against the oppressive influence of the status quo.

Having participated in this battle for patient safety for nearly a quarter of a century, I can say with some degree of authority that no matter how many presentations, discussions, articles, consulting hours, or other efforts are thrown at the problem nationally, creating a major cultural change is perhaps an order of magnitude more difficult when you’re surrounded by the very environment you’re needing to alter.  Coming together at a distance – especially in a resort atmosphere, or in the incredible beauty of Telluride itself – is an important element in achieving transference of ideas, concepts, goals, and determination as free of dogmatic and traditional thinking as possible.  And, of course, catching people at the beginning of their careers before the insidious influence of cultural rigidity has been allowed to take root and oppose change,  is an equally important key.  I know of no better forum than this, and I’m truly honored to be a part of it.

John Nance BooksAnd so we came together and told you horrifying stories that made us all cry, exposed young learners to the realities and predictability of professional human failure,  and rubbed all our noses in the reality that a profession whose routine operations count as the third leading cause of death in America does not possess the ethical choice to resist meaningful change.

But at the end of the day – and our time together – it all comes down to taking those small sparks of understanding and recognition and fanning them into flames back home,  never forgetting that every hospital room,  scheduled surgery, ambulance arrival,  admission, or diagnostic test involves a fellow human who is as entitled to the highest standard of care and caring as your own family.

From a very personal POV, I thoroughly enjoyed meeting each of our participants this season and pushing the quest forward, and I look forward not just to next year, but to hearing how the seeds we all helped sow will sprout and change the landscape of American healthcare.

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.


Graduate Medical Education: Value-Based Reimbursement Models Heading Our Way?

Courtesy of the Institute of Medicine

Courtesy of the Institute of Medicine

As an educator, there are few things more rewarding than watching the transformation our new interns experience from the time they come into our programs on July 1st  until the day they finally graduate residency a number of years later. It is like an abbreviated version of watching your children grow up…many enjoyable memories that make you smile, a few challenging bumps in the road that remind you they are still young, and like all of us no matter how old we are, still have more learning yet to experience. But at the completion of that journey we share with our residents, we feel good about what they have accomplished and send them off on their own.

The purpose of graduate medical education (GME) in the United States is to do just that – to prepare medical school graduates for the independent and unsupervised practice of medicine. Over the last few years, there has been considerable debate on whether we have been meeting our GME mission. Many, including organizations like CMS and HRSA that help fund GME to the tune of around $9.1 billion a year, would not call it a debate but a fact that we have been failing. The competencies and skills necessary to provide safe, high quality care at good value are not ones found in most GME curricula of today. Healthcare continues to change dramatically and medical education has not kept pace. In December, 2008, the Institute of Medicine (IOM) issued a report titled “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety”. In the report, the IOM asserted that revisions to medical resident workload and duty hours are necessary to better protect patients against fatigue-related errors, and to improve the learning environment for doctors in training. While the report made recommendations on duty hours, patient care handovers and patient case loads, a significant portion of the report focused on current GME patient safety related deficiencies. Aligned with David Leach’s writings, the IOM recommended the use of near misses and unsafe conditions as opportunities for both resident education and institutional patient care improvement purposes.

The Accreditation Council for Graduate Medical Education (ACGME) responded quickly to these recommendations. Dr. Tom Nasca, the current CEO for the ACGME, sent a letter to all residency programs on June 23rd, 2010 in which he outlined a new cohesive and comprehensive package of interrelated standards that were designed to accomplish three goals:

  1. To assure the safety and quality of care rendered to patients in our teaching hospitals today;
  2. To assure the safety and quality of care rendered to patients of our current residents in their future independent clinical practice; and
  3. To assure the provision of a safe and humanistic educational environment for our residents to learn and demonstrate professionalism and effacement of self-interest.

On September 28, 2010, the ACGME Board of Directors approved new requirements for residency programs, including updated standards for resident duty hours, education, and supervision. ACGME’s press release at the time stated: “The standards are based on recommendations made by the IOM in 2008 and evidence collected during a 16-month review of the scientific literature on sleep issues, patient safety and resident training.” The new standards were implemented on July 1, 2011.

All of us in healthcare are experiencing the escalating demands for transparency of outcomes, greater accountability, and quality based reimbursement models as they relate to patient care. Many say, “It’s about time,” because this newer value-based model has finally garnered the attention of hospital boards and C-Suites. If the model has successfully created urgency around the provision of safe, high quality patient care, don’t look now but that same model might be just around the corner for the provision of safe, high quality GME where academic medical centers will be paid on value with penalties for lapses in safety and quality education. A reimbursement model based on Value-Based Education and HCAHPS for graduate medical education…is it déjà vu all over again?

More to come on these new ACGME standards…