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.


Telluride “Old West” Ski Town Embraces Patient Safety in Our Tenth Year Anniversary Celebration

TPSSC_Logo_v3June has always been a very exciting month for me. For the last nine years, I and many others have journeyed west to Telluride, CO, a beautiful mountain town known by many for its skiing as opposed to summer activities. For those outside CO, Telluride may be one of the best kept secrets in the United States. Many of us often choose to take the scenic six-hour journey from the Denver airport to Telluride each year, making our way up the mountain to run our annual Telluride Patient Safety Roundtable and Summer Camps. The trip provides an up close view and reminder of the silent power held within the peaceful surroundings in which we will be teaching for the next two weeks. Over the years, people have asked me “Why Telluride?” My response has always been the same – “Why not?”  Be it the “old west feel” of the town, or the “hypoxic” magic that happens at an elevation of 9,600 feet, Telluride has always been a learning mecca for everyone that joins us during these memorable weeks of high altitude education.

TSRC hosts about 30 scientific programs each summer. We have been fortunate to be one of those chosen each of the last ten years. In fact, out Patient Safety Roundtable and Summer Camps has now become the longest consecutive running meeting that TSRC has agreed to host. The smaller, roundtable format using small group breakouts and learner-centered activities is designed to foster creative thought and consensus building through lively conversation in a relaxed and informal setting. We purposely limit the use of power-point slides to ten each day so learners are fully engaged in the work but not spoon fed the information by people who like to lecture. The students and residents especially love this interactive format. This non-traditional learning environment also attracts patient safety leaders from around the world to Telluride each summer, to “break bread” and share ideas on current issues and challenges. Because of this unique venue and format, a lot of our discovery, sharing of ideas and learning happens on the walking paths, hiking on the mountain trails, in a coffee shop, or over a glass of wine.

Screen Shot 2013-06-02 at 10.46.03 PMThrough the generous support of The Doctors Company Foundation (TDCF), COPIC, Committee of Interns and Residents (CIR) and MedStar Health, about 130 health science students and resident physician leaders will be attending one of four, week-long Telluride Patient Safety Summer Camps this summer. The first two weeks will be held in Telluride and the final two weeks will be held in the Washington DC/Baltimore MD region (“Telluride East”) later this summer. In the summer of 2015, thanks to the continued support of The Doctors Company Foundation, an additional Patient Safety Summer Camp will be held in CA – our new home for “Telluride West”.

Our objectives for the Telluride Patient Safety Summer Camps are the same each year:

  1. To identify and help develop future healthcare leaders and champions in patient safety, transparency and open, honest and professional communication between patients, families and caregivers.
  2. To develop a growing number of Patient Safety Summer Camp alumni that serve as role models and mentors to (a) health science students and resident physicians at their respective medical centers and health systems, and (b) health science students and resident physicians enrolled in future Patient Safety Summer Camps.
  3. To create a social networking community where Patient Safety Summer Camp health science students, resident physicians and past alumni can interact with international leaders in patient safety, education and patient advocacy on issues pertaining to patient safety, transparency and open, honest and professional communication between patients, families and caregivers.
  4. To help create risk reduction and quality improvement collaborative projects between Patient Safety Summer Camp alumni, faculty and patient advocates that are implemented within the Patient Safety Summer Camp alum’s institution and beyond.

DSC_0684This coming weekend, many wonderful and highly committed patient safety advocates and safety leaders will once again convene in Telluride, CO to continue our mission of “Educating the Young”. Over the past 10 years, we now will have had over 400 Telluride student and resident alumni scholars attend one of our Patient Safety Summer Camps. As you have read on our ETY blog, many have done amazing work in leading change that is helping make care safer and more transparent.

Next week, we will kick off this year’s Patient Safety Summer Camps by welcoming thirty resident physicians into our Telluride Scholars club. They are future physician leaders from all across the country who will be immersed in learning about transparency, patient safety, and patient partnership. It truly is an amazing experience that always leaves me and many others energized for months to follow.

Sharing The Doctors Company Foundation 2014 Award-Winning Essays

At the National Patient Safety Foundation annual meeting in May, the sharing of patient stories was once again at the forefront of the meeting. Helen Haskell, Tanya Lord, Regina Holliday and more, provided real-life examples of why a focus on patient safety is still a much needed and continuous journey. There is also a growing awareness of the need to honor provider stories, perhaps one of the missing links in the quest for zero preventable harm across the country. The Doctors Company Foundation (TDCF) is well aware of the power of medical student and resident physician stories, and instituted the Young Physicians Patient Safety Award, which is given to the author of the best patient safety driven essays written by 3rd and 4th year medical students, and first year resident physicians. TDCF shared those essays and the award winners at this year’s NPSF, with the winners to be honored at the 6th Annual Association of American Medical Colleges’ Integrating Quality meeting June 12th & 13th.

Excerpts from the winning essays follow, but being less than two weeks away from our first 2014 Telluride Patient Safety Summer Camp–and in our 10th Anniversary year–it was with great enthusiasm that I read the 2014 Award-Winning Essays. Since 2010, our student and resident physician driven Telluride blog has seen an increase in submissions, and I can only hope it is more than the younger generation’s acculturation into blogging communities or social media. I would like to believe it has more to do with the younger generation of providers embracing the transparency that will be needed as they navigate the challenging landscape the present day career in healthcare holds. The following excerpts, like our blog posts, hold knowledge and wisdom far beyond the years of the author’s tenure, and are equally reflective of what is needed to provide the full complement of safe, patient-centered care we all want. We talk of educating the young, but far more often, they are educating and inspiring us. So in the spirit of educating the young (and old!)–Please keep writing!

…I read everything I could get my hands on about root cause analysis, the Swiss cheese model, and methods to “engineer out” potential for human error. It was not until my third-year surgery rotation, however, that I encountered the major challenge to patient safety that no number of PDSA cycles can resolve–the problem of a medical culture that is not safety conscious…


…In the case of this patient, who cannot read, more time has to be spent educating him about his medications and adverse drug reactions…emphasizing the most important points to be certain they’re understood…Some patients may not readily admit to their health care provider that they cannot read, and we should be sensitive to clues that suggest the patient may be illiterate…


TIME: 6:00AM, Surgery Morning Rounds Began: Ms. A, your MRI shows you have colorectal cancer…said my surgery attending, who rushed out of Ms. A’s room right after he dropped this shocking news…TIME 12:30pm Rounds Just Adjourned: A nurse ran into the surgery dictation room: “Who is Ms. A’s doctor? Did you know she has depression, and today is the first time she’s heard she had cancer? She just attempted suicide”…I was shocked by this…how could the whole surgery team not know Ms. A hadn’t yet been informed of her cancer status?…



Residents as Sentinels and Change Agents for Safer Care

This coming Saturday, April 26th, the Committee of Interns and Residents (CIR) will be hosting its next QIIQ Conference titled, “How to be a Lead Agent of Change: From Bedside to Transformative Care“, in NYC. Rosemary Gibson, Carole Hemmelgarn, Shelly Dierking and I have the honor of joining leaders from CIR to help facilitate the all-day interactive session. While many faculty will be attending, the major focus of this educational meeting will be on the residents, both from CIR Hospitals as well as other GME programs, and aligns with the “Educating the Young” mission.

Residents can be change agents for safer, higher quality care. There are now numerous examples across the country of this fact–residents leading important quality and safety initiatives that have reduced risk and raised the quality of care provided–and they have done this work despite internal challenges and long work weeks. Those that have followed our ETY blog for the past two years will remember my post on the work of David Leach, the former CEO for the ACGME (see The Canary in the Coal Mine…).  In one of his publications, Dr. Leach shared the most important role of graduate resident physicians was to act as the “moral agent” for their patients. Residents must be the gatekeepers for safe, high quality care–a sentinel on watch for the many unsafe conditions they might encounter while trying to provide optimal patient care, prepared to alert faculty and leadership to these unsafe conditions, and then work with their institutions to find solutions to remove risk from the patient experience. The analogy Dr. Leach used was the canary in the coal mine, taking on the role of guardian and protecting others from harm before it was too late. I loved this “moral agent” concept. It is so simple, yet so important in the quest for safer, higher quality, patient care. In academic medical centers, resident physicians spend more time in the hospital, have more direct contact with patients, and see many more unsafe conditions during days, evenings and weekends than most other caregivers, except possibly nurses. And they do it many times with little, if any, direct supervision. Resident physicians can be those sentinels and serve as excellent change agents for safer care.

We need more conferences like CIR’s QIIQ focused on our next generation of caregivers.  Please help spread the word about the conference. Below is some additional background information with the links to register. The third link is the conference brochure which has additional details.  We appreciate the support and as always, thank you!!

Background Info:
The one-day conference on How to be a Lead Agent of Change will be held Saturday, April 26th in New York City. Given the importance of the patient experience and the desire for more patient-centered care, the Committee of Interns and Residents conference is meant to empower medical residents to develop and execute high-value care projects in their hospitals and health systems, and better equip them with the competencies they need to work in a rapidly changing delivery system.

To register for this conference, please click here. There will also be a webcast, and people can sign up for that here. The agenda and conference brochure can be found here (this includes logistics on location and timing, as well as goals for the day and additional contact information). Please feel free to share this information, as well as the links to register, with your organization and networks.

*CIR has also been tweeting about the conference with the #QIIQ hashtag. Here is a sample tweet you are more than welcome to share with your followers: What’s your #QIIQ? Join @cirseiu & @EinsteinMed in NYC on 4/26 for the next #QIIQ conference. Register now! bit.ly/qiiq426

Dates Announced for 10th Annual Telluride Patient Safety Resident Summer Camps

Applications are now being accepted for the 2014 Telluride Patient Safety Resident Physician Summer Camps in Telluride, CO and Washington, DC

TPSSC_Logo_v3Resident physician leaders are now invited to apply to attend a week-long, immersive learning experience with leaders and educators in patient safety, along with patient and healthcare advocates at the 10th Annual Telluride Patient Safety Educational Roundtable and Resident Physician Summer Camps. Residency programs will be responsible for covering travel, lodging, and meeting registration fees for their attendees. MedStar Health, COPIC and CIR have been generous supporters of past Telluride Resident Summer Camps, and have sponsored many resident physician alumni, who are now change agents at their home institutions. We are again grateful for their support and participation in our 10th year!

The Telluride, CO and Washington, DC Patient Safety Resident Summer Camps are one-week, educational opportunities offering an in-depth exploration of current patient safety issues and risk reduction strategies for achieving optimal patient care. Two, one-week resident summer camps will be offered in 2014:

  • Monday, June 9th – Thursday June 13th, 2014 (to be held in Telluride, Colorado) — Arrive Sunday, June 8th for evening reception
  • Thursday, July 31st – Sunday August 3rd, 2014 (to be held in Washington, DC) — Arrive Wednesday, July 30th for evening reception

Over the last nine years, interprofessional leaders in patient safety, communication, informatics, human factors, patient advocacy and education have met in beautiful Telluride, CO to address patient safety issues. Because of the growing interest and number of resident applications, a second patient safety summer camp was added in Washington, DC in 2013.

The Telluride Roundtable Vision is to create an annual retreat where experts in patient safety come together with patients, residents and students in an informal setting to explore, develop and refine a culture of patient safety, transparency and optimal outcomes in patient care. The 2014 Patient Safety Summer Camps will again use an immersive, interactive format to examine ethical, professional, legal and economic issues around patient safety, transparency, disclosure and open and honest communication skills when medical errors and adverse events occur.

Applications and additional information can be found on the Telluride Patient Safety Summer Camp website (www.telluridesummercamp.com). Residency Programs interested in funding a resident to attend one of the patient safety summer camps will need to submit the following resident materials by March 1st, 2014:

  1. Two-page maximum CV
  2. Personal statement on your interest in patient safety and how attending the Patient Safety Summer Camp would benefit you
  3. Support letter from faculty or a mentor about your leadership and engagement in patient safety
  4. First and second choice for the summer camp weeks (Telluride CO or Washington DC)

Questions regarding the Patient Safety Resident Summer Camps can be directed to David Mayer, MD at: david.b.mayer@medstar.net

COPIC_registered_CMYK CIR PEI logoScreen Shot 2013-12-19 at 8.42.01 AM  

Resident Physicians Leading Culture Change in Healthcare

I continue to enjoy following all the quality and patient safety work being led across the country by resident physicians. Many have come into healthcare with a much different perspective regarding quality, safety and outcomes than my generation did years ago. Be it the daily focus by the media on preventable medical errors, required transparency of outcomes, or the newer reimbursement models based on quality and safety, this new generation of physicians is asking the right questions and looking for the right solutions. It is why the premise “Educate the Young” is such a critical component to any enduring culture change.

In this spirit, we want to share another wonderful example of how resident physicians are changing the landscape of quality and safety in healthcare for the better. The AAMC webinar highlighted below, The House Staff Patient Safety Council: Creating a Culture of Safety and Openness, is being led by Nate Margolis and Say Salomon, both Telluride Patient Safety Summer Camp Scholar Alums, who are helping inspire resident physicians on how to lead change in their own academic institutions. What a great example of “pushing it forward”.

Date and Time: Wednesday, October 30, 2013 3:00 pm ET

Duration:  1 Hour

Description: In support of the Best Practices for Better Care Initiative commitment area to teach quality and patient safety to the next generation of doctors, this webinar will spotlight two institutional approaches to creating a culture of safety and openness by leveraging House Staff Patient Safety Councils to improve care processes and outcomes.

House staff patient safety councils create a culture of safety, engage residents in process improvement, and help satisfy ACGME requirements. A successful resident driven project will be described in which the distribution of badge buddies, incident report guidelines, and an incident reporting presentation increased house staff adverse event reporting in a 3-hospital academic program. In addition, the Safety Council activities and outcomes from Woodhull Medical Center will be shared. Some examples of their core projects include: the triaging of critical care value from an ambulatory care clinic, standardization of hand off processes and just culture conferences to improve quality of care delivered to its patients.


–Nate Margolis, M.D., is a chief resident in Radiology and the co-chair of the House Staff Patient Safety Council at NYU, Bellevue & Manhattan VA hospitals
–Say Salomon Jr., M.D., is an Associate Chief Resident in Internal Medicine at Woodhull Medical and Mental Health Center

To register, click here.  It should be a great discussion!

New Website for Resident Physician Education @CIRSEIU

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).

CIRSEIU_Residents_TrainingIn 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.