Shared decision-making, choice and compassion are three key takeaways from our second day at the Ah Haa school in the Sangre de Cristo mountains. The Michael Skolnik Story has served as the Telluride Patient Safety Summer Camp teaching tool that conveys lasting learning around shared decision-making and the informed consent process by connecting the heart with the head. Michael, like Lewis yesterday, is another senseless casualty of a healthcare culture slow to evolve. While the more overt failures to protect him may have come in the form of a poor informed consent process and lack of shared decision-making with his Mom, Patty, and Dad, David, there were also many poor choices made by those charged to care for him along the way.
Choice has come up a number of times, a number of different ways already this week. One of the residents yesterday mentioned a near miss she experienced with an infant, and how a number of nurses and residents knew long before the baby crashed that something was going wrong. Yet no one chose to challenge the poor treatment choices the attending physician was making. With a shaking voice she shared it was infinitely harder to look at what was only moments ago a healthy child, and know you could have chosen to do something to influence a better course for a patient. In both Michael and Lewis’ cases, others knew something was not going as it should in their care, but failed to speak up before it was too late. Everyone here in Telluride this week–everyone that touches healthcare–has the power to improve the life of a patient by the choices they will make upon returning home.
Choice was also at the center of Paul Levy’s (@PaulfLevy) negotiation session. Win-As-Much-As-You can, a game that allowed players to either cooperate and win a modest amount of money, or choose to break bad, and go for it all at the risk of losing the trust of the group, provided immediate consequences to choices made. The experience of negotiating a simulated real estate deal laid the framework for understanding first-hand how choosing to seek, and honor, the interests of the “other” in any deal, made for joint decisions that built relationships. These negotiation skills, Paul shared, would not only serve our attendees well when having to come to agreement on patient care with colleagues, but also in life when negotiating jobs or navigating relationships.
And as Day 2 at the Telluride Patient Safety Resident Summer Camp came to a close, Kim Oates MD (@KimRKO) from Australia encouraged attendees to reflect on what the barriers of showing more compassion in the daily delivery of healthcare might be. The residents shared the following list, and Kim gently guided the group to look at the flip side of their perceived barriers–to see where they might be able to squeeze in just a little more compassion.
- Self-preservation: Having to deliver bad news on a regular basis
- Maintaining the right level of professionalism
- Being exploited, or feeling taken advantage of, when being compassionate
- One’s own nature: Being more of a thinker than a feeler making expression of emotion more challenging. Kim commented that it’s good to know your own comfort zone, and to find authentic ways within one’s own limits.
- Lack of confidence, anxiety on how one is viewed by colleagues and patients–The closer to being an attending, the more greatly this resident valued training others to show compassion, as well as expressing it herself
- Cultural barriers that prevent touching — To show greater compassion in these cases, one resident suggested taking a meaningful pause, offering a tissue, listening, or sharing information. Kim suggested that while this approach may take more time upfront, it can save time overall because it improves relationships, and with it, patient care.
- Technology creates barriers — i.e. location of EMR requiring back to face the patient, walking in focused on iPad. Kim shared how he would rearrange his office before patients entered to remove physical barriers.
Kim closed the discussion by encouraging everyone to consider where they might add a little more compassion in their interactions with others, reminding the group that professionalism does not have to equal being emotionless.
Anna Quindlen is someone I have long admired. An aspiring journalism undergrad student, I read Living Out Loud almost twenty years ago, and was inspired by her need to share ‘the story’, as well as her ability to make a successful career out of doing so. Now, a well-known and respected Pulitzer Prize winning journalist and repeat best-selling author, Quindlen recently shared her wisdom and words with healthcare leaders–young and old–at the annual AAMC meeting in Philadelphia. It comes as no surprise that the accolades and tears shared in the Storify snapshot of tweets from her talk show organizers made an excellent choice by inviting her to speak. (Click image to go to Storify page if interested).
For those who missed her talk, Quindlen has given permission to the Arnold P. Gold Foundation to make the full text of her speech available until December 3rd, and it can be found here. Having read the transcript, I wanted to share some of the highlights in the event the tyranny of the daily takes priority and prevents the well-meaning click-through before 12/3.
Per her transcript, Quindlen shared the following:
- The story of a repeat surgery she recently underwent, along with the differences in the care she received from her anesthesiologists. Do you know who I am? is the takeaway for providers listening in, as the care team who understood her needs, values, preferences and goals knew who she was–someone who did not want a general anesthetic–and that made all the difference.
- The similarities between healthcare and journalism, and how in this day and age of technological advancement and depersonalization it is still the ability to hold the gaze of a fearful patient that makes the greatest impact.
- The story of the care her father, the patient, and she, the patient advocate, both received as they navigated and negotiated his stay on a burn unit. This story alone is worth the time for the click-through above, but in short, her father’s care team acknowledged and appreciated the knowledge she brought into the room, and as a result her father’s care plan was developed with the family’s needs, values, preferences and goals as the foundation. And while she says that the care he received was best-in-class, it was the social worker who stopped in to ask how they were doing, the nurse who played music for her father when she could not be present, the doctor who expressed three times his understanding of how hard it was to make the choice for palliative care, and the sympathy card she received from the staff, that stay with her now. But perhaps most important of all, she shares that her father’s care team:
…gave me a sense of power and control in a situation in which I was bound to feel powerless…they put a human face, a series of human faces, on my father’s care.
- And finally, she shared four “simple” takeaways for the audience: 1) Try to be present and in the moment 2) Acknowledge uncertainty 3) Practice empathy 4) Try to be kind
As news outlets continue to talk about patient harm, pushing for accountability and bantering about frequency, a more subtle form of harm occurs more frequently and is not meaningfully measured. That harm is steeped in the missed opportunity to know the patient. Providers fail patients on a human level because care providers are human, and humans caring for humans is far from a perfect science. Maybe it’s also about patients resetting expectations and not setting themselves up to be disappointed by, as Quindlen refers to, MDietys that are in fact just people like them. The four simple truths or takeaways she mentions are things all of us, patient–provider–caregiver–sister–son–father–boss–administrator, can ascribe to and make any encounter–healthcare or not–a better one.
Thank you, Anna Quindlen, for continuing to inspire others with your words!
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.
Having just returned from Telluride, I can share that the future of medicine looks extremely bright. Twenty-eight residents, all extremely passionate about patient safety, patient-centered care, shared decision-making and righting the wrongs they see in healthcare, have all promised to tell 10 colleagues about the empowering cultural messages shared in Telluride. They will then ask those 10 colleagues to share the lessons learned with 10 more, and so on…
As Telluride organizers Dave Mayer and Tim McDonald say, they will pay it forward.
Following are just a few of those messages in excerpts from resident reflections on the Transparent Health blog. All post can be found here.
From Dr. Kerrie Bossard — The opportunity that I see after completing this exercise is that although we can all make small incremental changes in our respective practices, how can we reshape the practice of medicine to make our small individual changes part of a bigger and more permanent cultural change? If all 28 of the scholars would communicate with 10 colleagues about the importance of shared decision-making and informed consent we could make a small change. But if we made our goals for next week bigger and decided to change the entire process for all residents for generations to come, we may succeed in making lasting change and forever changing the practice of medicine related to these issues…(continued here)
From Dr. Shabnam Hafiz — What an incredible week! I have been so fortunate to be surrounded by such a brilliant group of people leading change all over the country. You have all inspired me and energized me to go back and promote the mission that we have all set out for ourselves- create a system that is patient first… (continued here)
From Dr. Michelle Espinoza — …today’s experience was life changing…To be here in Telluride is truly a blessing, and to be surrounded by such knowledge, talent, wisdom and passion is AMAZING…Today I learned that I am not alone in thinking our hospitals are one of the most dangerous places for patients. That my internal conflict regarding my concerns for residency training is not isolated to my hospital, and that there are people who not only believe this is wrong, but have dedicated their lives to making a change…(continued here)
From Dr. Lauren Sontag — Shabs recent post, How Can We Teach, regarding her QI project standardizing an appropriate informed consent discussion. She says several times that we need to put “patients first.” It warms me from within to hear this; I was already going to put up a little post about that very idea. I had the great fortune to go to medical school at the Mayo Clinic in Minnesota, and the most important thing I learned there was this philosophy: the needs of the patient come first. When we believe this and act upon it, we have the courage to address problem behaviors among our peers (and even our attendings and consultants!). We find the moment to sit down instead of hovering near the exam room door and we don’t accept the status quo. Consider it as a mantra for yourself and something you teach others!
From Dr. Stephanie Wappel — …It is so easy to become jaded in medicine, especially as a resident, and this is exactly what I needed at this point in my life to reinforce why I went into medicine in the first place: for the patient. I’m making a personal commitment to myself and to everyone here at TSRC that I am taking this home and will implement more patient safety measures and quality improvement at my home program…I am going to start with resident education because I feel like this is the greatest need at present. We can each make a difference as long as we keep our eye on the common goal which is the health and safety of the patient…(continued here)