Focus on Quality
Commentary
Physician Participation in Incident Learning By Suzanne B. Evans, MD, MPH
e358
JOURNAL
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ONCOLOGY PRACTICE
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develop an overinflated sense of self. These physicians have difficulty accepting their error and are unable to admit to its existence. Error is extremely difficult to manage for these physicians. These individuals are more caught up in their own experience with the error than the patient’s experience. Now, the concept of medical narcissism is quite extreme and certainly pathologic; I would assert that it is rare. More likely is that physicians have difficulty with the tension created when an error occurs. Physicians typically look at themselves as competent, intelligent, and qualified individuals. The commission of a medical error refutes that self-image, and to live inside that tension and resolve it is uncomfortable. One piece of the picture missing from the Smith et al investigation is the relationship between reporting behaviors and feeling culpable for the error. Are physicians not reporting errors because they feel the individual closest to the point of error is most responsible for this reporting? What is the relationship between discovery of error, reporting the error, and the responsibility for the error occurrence and reporting? It is not surprising that physicians, removed from the treatment machine, are not reporting errors in the administration of treatment. There are many more errors involving physician work that are not accounted for in traditional error reporting systems. Physicians are responsible for developing the prescription, determining the target volume, and approving the plan. This process is one we are trained to do; however, as we all recognize, medicine is often more art than science. Do we give hypofractionated radiotherapy or conventional radiotherapy? Do we ask for 95% coverage to 95% of the volume or 100% to 100%? Do we treat all nodes, some nodes, or no nodes? Our treatmentrelated decisions have a relativism of appropriateness, and as such the concreteness of error is lessened. In the world of radiation prescription, something is right because we say it is, which is a concrete basis on which to judge errors in prescribed intent for the rest of the treatment team. However, if an error occurs that is still within the standard of care but outside the prescribed intent, this idea of relativism may be impactful in terms of physician participation in reporting. In order to report, one has to believe that one’s process can be improved by reporting. Many of the interventions taken thus far in the safety and quality movement have been centered on processes other than the physician workflow. It may be that physicians are not reporting because they do not believe reporting will result in any positive change in their processes. With the launch of ROILS, it will be intriguing to see whether this trend observed in the four participating academic centers is replicated on a national level. ASTRO has obtained American Board of Radiology approval that participation in ROILS will be consid-
V O L . 10, I S S U E 5
Copyright © 2014 by American Society of Clinical Oncology
Downloaded from jop.ascopubs.org on May 21, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Smith et al1 present in this issue of Journal of Oncology Practice, “Physician Attitudes and Practices Related to Voluntary Error and Near-Miss Reporting.” This is an important topic, which has not been previously explored in the field of radiation oncology. The authors are to be congratulated for this novel and thoughtful investigation of the barriers to physician reporting. In this article, the authors reveal that physicians are highly unlikely to participate in voluntary error and near-miss reporting. Of note, this is not the case for other voluntary error reporting systems. Wake Up Safe, the specialty specific patient safety organization (PSO) for pediatric anesthesiology, reports that all of the their reporting is done exclusively by anesthesiologists (Donald Tyler, MD, MBA, personal communication, May 20, 2014). So it would seem that physicians as a group can be successfully enticed to participate in such systems. The Smith et al article reveals that there is an overriding theme of embarrassment, which is a profound barrier to error reporting. It is unclear what physicians are embarrassed about. Is it embarrassment in front of the health care team? Is it embarrassment in front of their physician colleagues? Is it embarrassment in front of patients? Each of these scenarios would require a different response. Open forums to discuss errors in the clinic could mitigate embarrassment in front of the health care team and physician colleagues. Such forums would promote rapid realization by physicians that one’s most accomplished colleagues are also involved in error. Participation by one’s institution in the Radiation Oncology Incident Learning System (ROILS), administered by Clarity PSO and sponsored by the American Society for Radiation Oncology (ASTRO) and American Association of Physicists in Medicine, would allow institutions to benchmark themselves among the other highquality institutions involved in this effort. This would allow clinicians to understand that errors happen everywhere. If this embarrassment centers around the patient interaction, disclosure training can be provided. Physicians are typically the ones who discuss an error with the patient, and acknowledging error within the team may make this disclosure more imminent or important. Many physicians do not have disclosure training and therefore are uncomfortable with disclosure. To tell a patient that an error occurred that may affect their likelihood of cure, complication, or confidence is incredibly difficult. Virtual patient encounters with disclosure coaches observing to give immediate feedback has been a successful model for such training, and could lower impedance to error reporting. However, this embarrassment concept could be more complicated. John Banja writes in his text2 about the theory of medical narcissism. This concept suggests that some physicians, after years of being treated with respect and deference, begin to
iors regarding error between radiation oncologists and other specialists to understand how we can facilitate error reporting by radiation oncology physicians. Author’s Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. Corresponding author: Suzanne B. Evans, MD, MPH, Yale University School of Medicine, 15 York Street, New Haven, CT, Phone 203-200-1630, Fax 203-785-4622; e-mail: [email protected]. Suzanne B. Evans, MD, MPH, is a radiation oncologist and assistant professor in Therapeutic Radiology at Yale University School of Medicine, where she also serves as an error disclosure coach. She is vice chair of American Society of Therapeutic Radiology (ASTRO) Multidisciplinary Quality Assurance Subcommittee, a member of the ASTRO Clinical Affairs and Quality Council, and co-chair of the Patient Safety Track for the ASTRO Annual Meetings. She has been involved in the planning and implementation of the Radiation Oncology Incident Learning System since 2012.
DOI: 10.1200/JOP.2014.001526; published online ahead of print at jop.ascopubs.org on August 5, 2014.
References 1. Smith KS, Potters KM, Harris L, et al: Physician attitudes and practices related to error and near-miss reporting. J Oncol Pract 10:350-e357, 2014 2. Banja JD: Medical Errors and Medical Narcissism. Sudbury, MA, Jones and Bartlett, 2005
Copyright © 2014 by American Society of Clinical Oncology
3. Reznek MA, Barton BA: Improved incident reporting following the implementation of a standardized emergency department peer review process. Int J Qual Health Care [epub ahead of print on April 25, 2014]
S E P T E M B E R 2014
•
jop.ascopubs.org
e359
Downloaded from jop.ascopubs.org on May 21, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
ered toward maintenance of certification. Hopefully, this will help enhance physician participation. If physician participation is still lacking, we may need to rethink the incident reporting portal. It may be that there needs to be a physician portal reporting component with ROILS looking at items specific to physician workflow. Such a portal might inquire about numbers of patients one has on treatment, time of day segmentation was performed, level of interruptions during the workflow step, level of comfort treating that specific patient, whether it was a cross coverage, whether there was an opportunity for preplanning segmentation review, whether the patient was presented at chart rounds before starting therapy, or whether the patient was a rush start for any reason. Review of these reports in a regular fashion could increase their utility. Toward this end, our colleagues in emergency medicine have found that a nonpunitive peer review process in which incident reports were reviewed in a constructive manner was helpful in increasing physician incident reporting.3 I am impressed by the careful analysis provided by Smith et al.1 Undoubtedly, continued research is needed in this arena. Ideally, we can pinpoint the differences in attitudes and behav-
Commentary
Physician Participation in Incident Learning By Suzanne B. Evans, MD, MPH
e358
JOURNAL
OF
ONCOLOGY PRACTICE
•
develop an overinflated sense of self. These physicians have difficulty accepting their error and are unable to admit to its existence. Error is extremely difficult to manage for these physicians. These individuals are more caught up in their own experience with the error than the patient’s experience. Now, the concept of medical narcissism is quite extreme and certainly pathologic; I would assert that it is rare. More likely is that physicians have difficulty with the tension created when an error occurs. Physicians typically look at themselves as competent, intelligent, and qualified individuals. The commission of a medical error refutes that self-image, and to live inside that tension and resolve it is uncomfortable. One piece of the picture missing from the Smith et al investigation is the relationship between reporting behaviors and feeling culpable for the error. Are physicians not reporting errors because they feel the individual closest to the point of error is most responsible for this reporting? What is the relationship between discovery of error, reporting the error, and the responsibility for the error occurrence and reporting? It is not surprising that physicians, removed from the treatment machine, are not reporting errors in the administration of treatment. There are many more errors involving physician work that are not accounted for in traditional error reporting systems. Physicians are responsible for developing the prescription, determining the target volume, and approving the plan. This process is one we are trained to do; however, as we all recognize, medicine is often more art than science. Do we give hypofractionated radiotherapy or conventional radiotherapy? Do we ask for 95% coverage to 95% of the volume or 100% to 100%? Do we treat all nodes, some nodes, or no nodes? Our treatmentrelated decisions have a relativism of appropriateness, and as such the concreteness of error is lessened. In the world of radiation prescription, something is right because we say it is, which is a concrete basis on which to judge errors in prescribed intent for the rest of the treatment team. However, if an error occurs that is still within the standard of care but outside the prescribed intent, this idea of relativism may be impactful in terms of physician participation in reporting. In order to report, one has to believe that one’s process can be improved by reporting. Many of the interventions taken thus far in the safety and quality movement have been centered on processes other than the physician workflow. It may be that physicians are not reporting because they do not believe reporting will result in any positive change in their processes. With the launch of ROILS, it will be intriguing to see whether this trend observed in the four participating academic centers is replicated on a national level. ASTRO has obtained American Board of Radiology approval that participation in ROILS will be consid-
V O L . 10, I S S U E 5
Copyright © 2014 by American Society of Clinical Oncology
Downloaded from jop.ascopubs.org on May 21, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
Smith et al1 present in this issue of Journal of Oncology Practice, “Physician Attitudes and Practices Related to Voluntary Error and Near-Miss Reporting.” This is an important topic, which has not been previously explored in the field of radiation oncology. The authors are to be congratulated for this novel and thoughtful investigation of the barriers to physician reporting. In this article, the authors reveal that physicians are highly unlikely to participate in voluntary error and near-miss reporting. Of note, this is not the case for other voluntary error reporting systems. Wake Up Safe, the specialty specific patient safety organization (PSO) for pediatric anesthesiology, reports that all of the their reporting is done exclusively by anesthesiologists (Donald Tyler, MD, MBA, personal communication, May 20, 2014). So it would seem that physicians as a group can be successfully enticed to participate in such systems. The Smith et al article reveals that there is an overriding theme of embarrassment, which is a profound barrier to error reporting. It is unclear what physicians are embarrassed about. Is it embarrassment in front of the health care team? Is it embarrassment in front of their physician colleagues? Is it embarrassment in front of patients? Each of these scenarios would require a different response. Open forums to discuss errors in the clinic could mitigate embarrassment in front of the health care team and physician colleagues. Such forums would promote rapid realization by physicians that one’s most accomplished colleagues are also involved in error. Participation by one’s institution in the Radiation Oncology Incident Learning System (ROILS), administered by Clarity PSO and sponsored by the American Society for Radiation Oncology (ASTRO) and American Association of Physicists in Medicine, would allow institutions to benchmark themselves among the other highquality institutions involved in this effort. This would allow clinicians to understand that errors happen everywhere. If this embarrassment centers around the patient interaction, disclosure training can be provided. Physicians are typically the ones who discuss an error with the patient, and acknowledging error within the team may make this disclosure more imminent or important. Many physicians do not have disclosure training and therefore are uncomfortable with disclosure. To tell a patient that an error occurred that may affect their likelihood of cure, complication, or confidence is incredibly difficult. Virtual patient encounters with disclosure coaches observing to give immediate feedback has been a successful model for such training, and could lower impedance to error reporting. However, this embarrassment concept could be more complicated. John Banja writes in his text2 about the theory of medical narcissism. This concept suggests that some physicians, after years of being treated with respect and deference, begin to
iors regarding error between radiation oncologists and other specialists to understand how we can facilitate error reporting by radiation oncology physicians. Author’s Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. Corresponding author: Suzanne B. Evans, MD, MPH, Yale University School of Medicine, 15 York Street, New Haven, CT, Phone 203-200-1630, Fax 203-785-4622; e-mail: [email protected]. Suzanne B. Evans, MD, MPH, is a radiation oncologist and assistant professor in Therapeutic Radiology at Yale University School of Medicine, where she also serves as an error disclosure coach. She is vice chair of American Society of Therapeutic Radiology (ASTRO) Multidisciplinary Quality Assurance Subcommittee, a member of the ASTRO Clinical Affairs and Quality Council, and co-chair of the Patient Safety Track for the ASTRO Annual Meetings. She has been involved in the planning and implementation of the Radiation Oncology Incident Learning System since 2012.
DOI: 10.1200/JOP.2014.001526; published online ahead of print at jop.ascopubs.org on August 5, 2014.
References 1. Smith KS, Potters KM, Harris L, et al: Physician attitudes and practices related to error and near-miss reporting. J Oncol Pract 10:350-e357, 2014 2. Banja JD: Medical Errors and Medical Narcissism. Sudbury, MA, Jones and Bartlett, 2005
Copyright © 2014 by American Society of Clinical Oncology
3. Reznek MA, Barton BA: Improved incident reporting following the implementation of a standardized emergency department peer review process. Int J Qual Health Care [epub ahead of print on April 25, 2014]
S E P T E M B E R 2014
•
jop.ascopubs.org
e359
Downloaded from jop.ascopubs.org on May 21, 2015. For personal use only. No other uses without permission. Copyright © 2014 American Society of Clinical Oncology. All rights reserved.
ered toward maintenance of certification. Hopefully, this will help enhance physician participation. If physician participation is still lacking, we may need to rethink the incident reporting portal. It may be that there needs to be a physician portal reporting component with ROILS looking at items specific to physician workflow. Such a portal might inquire about numbers of patients one has on treatment, time of day segmentation was performed, level of interruptions during the workflow step, level of comfort treating that specific patient, whether it was a cross coverage, whether there was an opportunity for preplanning segmentation review, whether the patient was presented at chart rounds before starting therapy, or whether the patient was a rush start for any reason. Review of these reports in a regular fashion could increase their utility. Toward this end, our colleagues in emergency medicine have found that a nonpunitive peer review process in which incident reports were reviewed in a constructive manner was helpful in increasing physician incident reporting.3 I am impressed by the careful analysis provided by Smith et al.1 Undoubtedly, continued research is needed in this arena. Ideally, we can pinpoint the differences in attitudes and behav-
