2014 APDS SPRING MEETING
Simulated Disclosure of a Medical Error by Residents: Development of a Course in Specific Communication Skills Steven E. Raper, MD, Andrew S. Resnick, MD, and Jon B. Morris, MD Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania OBJECTIVES: Surgery residents are expected to demon-
strate the ability to communicate with patients, families, and the public in a wide array of settings on a wide variety of issues. One important setting in which residents may be required to communicate with patients is in the disclosure of medical error. This article details one approach to developing a course in the disclosure of medical errors by residents. DESIGN: Before the development of this course, residents had no education in the skills necessary to disclose medical errors to patients. Residents viewed a Web-based video didactic session and associated slide deck and then were filmed disclosing a wrong-site surgery to a standardized patient (SP). The filmed encounter was reviewed by faculty, who then along with the SP scored each encounter (5-point Likert scale) over 10 domains of physician-patient communication. The residents received individualized written critique, the numerical analysis of their individual scenario, and an opportunity to provide feedback over a number of domains. A mean score of 4.00 or greater was considered satisfactory. Faculty and SP assessments were compared with Student t test. SETTING: Residents were filmed in a one-on-one scenario
in which they had to disclose a wrong-site surgery to a SP in a Simulation Center.
and SP in 5 domains. The residents found this didactic, simulated experience of value (Likert score Z4 in 5 of 7 domains assessed in a feedback tool). Qualitative feedback from the residents confirmed the realistic feel of the encounter and other impressions. CONCLUSIONS: We were able to quantitatively demon-
strate both competency and opportunities for improvement across a wide range of domains of interpersonal and communication skills. Residents are expected to communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds. As academic surgeons, we must be mindful of our roles as teachers, mentors, and coaches by teaching good communication skills to our residents. Courses such as the one described here can help in improving physician-patient communication. The differing perspectives of faculty and SPs regarding resident performC 2014 ance warrants further study. ( J Surg 71:e116-e126. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: ACGME core competencies, apology, disclosure of adverse outcomes, physician-patient communication COMPETENCIES:
Professionalism, Interpersonal Communication Skills, Systems-Based Practice
and
PARTICIPANTS: A total of 12 residents, shortly to enter
the clinical postgraduate year 4, were invited to participate, as they will assume service leadership roles. All were finishing their laboratory experiences, and all accepted the invitation. RESULTS: Residents demonstrated satisfactory competence
in 4 of the 10 domains assessed by the course faculty. There were significant differences in the perceptions of the faculty
Correspondence: Inquiries to Steven E. Raper, MD, JD, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 4 Silverstein Pavilion, 3400 Spruce Street, Philadelphia, PA 19104; e-mail: [email protected]
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INTRODUCTION External pressures for the disclosure of adverse outcomes have been increasing for some time.1 Educating residents in disclosure of adverse outcomes is particularly difficult; these conversations are sensitive, require a particular communication skill set, and may be conducted in the setting of considerable emotional distress.2,3 The Accreditation Council for Graduate Medical Education has, among other core competencies, mandated the development of interpersonal and communication skills; residents must acquire
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.06.020
interpersonal and communication skills for exchanging information effectively with patients and families.4 At academic medical centers, residents frequently care for patients who have sustained adverse outcomes.5,6 Despite the importance of this topic, only a minority of trainees receive training in error disclosure.7 Few doctors in training receive feedback about disclosure skills or know how to access institutional resources for support after making an error.8 The lack of formal training has led some commentators to conclude that trainees may not be prepared to disclose medical errors, create a worrisome trend in how apologies are made, and enhance individual and institutional liability.9 Therefore, it is critical for physicians— including residents—who are disclosing adverse outcomes to know how to conduct themselves. As a means of educating residents in communicating adverse outcomes, 12 residents, shortly to enter the clinical postgraduate year 4, were invited to participate in a course on how to disclose medical error. All were finishing their laboratory experiences, and all accepted the invitation.
METHODS The University of Pennsylvania surgery residency communication course incorporated principles of etiquette-based communication, a series of behaviors designed to enhance physician-patient communication.10 The course was also loosely based on a course in the disclosure of adverse outcomes developed by James W. Pichert and Gerald B. Hickson of the Vanderbilt University Center for Patient and Professional Advocacy, a course in which the faculty reviewer had participated.11 Individuals invited to undergo training were introduced to the basics of adverse event disclosure first through a Web-based didactic session and associated slide deck. Once the didactic materials were reviewed, the residents participated in a disclosure scenario. The scenario included the obvious injury, obvious error problem of a wrong-site surgical procedure (Appendix 1).12 The scenario was realized using standardized patients (SPs) and residents were filmed disclosing the wrong-site error to the SP. The filmed encounter was reviewed and scored by faculty who had previously participated in the Vanderbilt Center for Patient and Professional Advocacy course. The review included numerical scoring according to an assessment tool used by both faculty and SP; aspects of the assessment tool used by both the faculty and the SP were adapted in part from a previous report (Appendix 2).13 The score sheet used a Likert scale with 5 anchors: inappropriate, minimally appropriate, somewhat appropriate, substantially appropriate, and completely appropriate.14-16 The optimal number of Likert-type scale response alternatives has been well researched, and for this study, 5 appeared adequate for discrimination purposes.17-21 The analysis included 10 domains assessing a variety of communication elements
including the providers’ ability to use effective communication strategies with a focus on the providers’ ability to engage in open-ended questioning, respond to emotions, convey sympathy, relay medical information, and convey commitment to well-being. In addition, each resident was asked to provide anonymous feedback intended to improve the course for future course participants and to review their individual filmed scenario. Each resident received feedback in the form of an individualized written critique. This course was attended by senior-level residents (entering the postgraduate 4 clinical year), about to embark on the senior clinical phase of their residency, when their supervisory position might require the use of such disclosure skills. As residents with some autonomy and decisionmaking responsibility, it is likely they will be involved in caring for patients with medical injuries that are ultimately the responsibility of the attending surgeon. Arguably, all residents should learn truth telling from day 1 of residency, but there is little published literature on how to teach this skill. Using an evaluation tool, the residents were able to provide anonymous feedback to the course organizers (Appendix 3). This was intended to be an intentionally difficult scenario. The events are necessarily contrived, but one of the paramount issues residents should consider as they finish the clinical residency is to take universal precautions against making a wrong-site procedure seriously. Although letting a wrong-site procedure to happen is generally considered a “systems error” for the health care organization and those involved, the one holding the knife will most directly shoulder the consequences. The scenario was developed, and SPs were briefed in advance for the role. Scheduling concerns led to the inability to use the same actor in all scenarios for resident participants. When the scenario was written, there were approximately 20 responses the actor could use depending on the resident’s initial comments. The impression of the SPs and faculty was that the residents were interacting as if it were essentially a real encounter, a fact echoed by some of the written feedback of the residents. The scenario was designed for wrong-site surgery and is considered an “obvious/obvious,” which means obvious error causing an obvious injury.12 The intent was that the attending surgeon was not present for the wrong-site incision, and it was assumed that a properly experienced resident was responsible for the actual incision. In this scenario, the attending surgeon first had a meeting with the patient to disclose the obvious fact that the wrong side was incised. However, the resident was not present, so he or she did not know what was said by the attending surgeon. Statistical Analysis For each of the 10 domains of communication, the mean, median, and mode were calculated. Faculty and SP scores
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were compared with Student unpaired t test with significance set at p o 0.05.22
faculty, although the differences were not deemed satisfactory or statistically significant (Table 3). Evaluation of Course Faculty by Residents
RESULTS Evaluation of Residents by Course Faculty and SPs Quantitative Analysis Of the 10 domains scored by faculty, 4 had a satisfactory Likert score of Z 4.0: responsiveness to questions asked, acknowledgment of responsibility for role in the incident, communication at an appropriate patient learning level, and a clear message (Table 1). Although an average score of 43.0 might in some circumstances be considered adequate, for purposes of this scenario, only a score Z4.0 was considered satisfactory. The remaining 6 domains were considered to reflect opportunities for improvement with mean scores of o4.0: residents addressed extraclinical issues, demeanor in responding to questions asked, communication through nonverbal behavior, allowance of adequate time to process information, acknowledged feelings of the patient, and outlined a clear plan for follow-up. In 8 of the 10 communication domains evaluated, the faculty scored the students higher than the SPs on a 5-point Likert scale (Table 1). The distribution of scores of both faculty and SP varied widely from domain to domain and provided a more granular and visually understandable analysis of the data (Fig.). The SP scored only one domain satisfactory with a Likert score of Z4.0, that of acknowledgment of responsibility for role in the incident (Table 2). When faculty scores were compared with SP scores, faculty scored the residents statistically significantly higher in 5 domains: responsiveness to questions asked, acknowledgment of responsibility for the role in the incident, residents addressed extraclinical issues, communication at an appropriate patient learning level, and a clear message (Table 2). In 5 domains, there were no significant differences: demeanor in responding to questions asked, communication through nonverbal behavior, allowance of adequate time to process information, acknowledged feelings of the patient, and outline of a clear plan for follow-up (Table 3). In 2 of these domains—nonverbal communication and clear plan for follow-up—the SP scored the residents higher than
Quantitatively, students gave the course faculty a 4.0 or greater on the Likert scale in 5 of 7 domains: accurate reflection of real-life encounter, nature of the simulation environment, emotional involvement and empathy felt by the student, the quality of the SP, and quality of the written feedback (Table 4). Overall, 2 domains were scored with a mean value of o4.0: residents expressed a desire for more context and did not feel their performance was altered by the examination setting (Table 4). Qualitatively, free-text written comments were loosely grouped into 4 themes: more feedback from course faculty, further counseling regarding what patients could do, resolve discrepancies in the scenario owing to the artificial nature, and how the encounter prepared the students for future interactions (Table 5).
DISCUSSION Development of the Course Disclosure of medical errors is encouraged by a variety of policy makers.23 The Joint Commission has, as an element of performance for RI 01.02.01, stated that responsible physicians inform patients about unanticipated outcomes related to sentinel events.24 The Institute of Medicine has also offered policy proposals supporting disclosure as a patient safety concern.25 The National Quality Forum has advocated, as a safe practice, that patients and families should receive timely, transparent, and clear communication concerning serious unanticipated outcomes.26 Disclosure may also have a positive effect on the physician-patient relationship in terms of changing physicians, trust, and satisfaction.27 Insurers are also coming to the realization that adequate communication may reduce unnecessary malpractice claims.28 Disclosure may also be a legal requirement. Many states have enacted laws requiring disclosure of adverse events to patients or their families or both. For example, in Pennsylvania, the Medical Care Availability and Reduction of Error Act requires health care providers to report “serious events” (events that result in death or unanticipated injury to the patient requiring additional
TABLE 1. Satisfactory Perceptions of Resident Performance by Faculty in a Disclosure Scenario Domains of Communication Responsiveness to questions asked Acknowledged responsibility for role in the incident Communication at appropriate patient learning level Message clear
Mean
⫾SD
Median
Mode
4.00 4.33 4.50 4.33
0.63 0.52 0.55 0.52
4.00 4.00 4.50 4.00
4 4 4 4
SD, standard deviation. e118
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FIGURE. A total of 10 histograms representing difference in the evaluation of residents by course faculty and standardized patients. For each of the 10 individual graphs, the axes and scale are the same; the x-axis represents the Likert scale (1 ¼ inappropriate, 2 ¼ minimally appropriate, 3 ¼ somewhat appropriate, 4 ¼ substantially appropriate, and 5 ¼ completely appropriate), and the y-axis represents the sum of individual resident scores for each of the 5 Likert categories.
health care services) in writing to the patient or a family member.29 Given such a broad range of administrative imperatives requiring disclosure, it is surprising how little has been published on how to impart such communication skills to residents. One such resource is the ACS Surgery chapter on Interpersonal and Communication Skills.30 When considering how to educate residents in disclosure or other important communications skills, it becomes necessary to
determine how residents might, of their own accord, disclose such outcomes. Fewer than half of residents, when surveyed, would definitely disclose an adverse event and then only when obvious.9 Etiquette-based communication is an approach to clearly set expectation for all resident (indeed all physician) encounters with their patients.21 Elements of etiquette-based encounters include the resident’s introduction by name and role, sitting rather than standing, physical patient contact, and open-ended
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TABLE 2. Perceptions of Resident Performance by Faculty and SP in a Disclosure Scenario Domains of Communication Responsiveness to questions asked Faculty SP Acknowledged responsibility for role in the incident Faculty SP Addressed extraclinical issues Faculty SP Communication at appropriate patient learning level Faculty SP Message clear Faculty SP
Mean
⫾SD
Median
Mode
4.00* 3.50
0.63 0.55
4.00 3.50
4 3
4.33* 4.00
0.52 0.00
4.00 4.00
4 4
3.33* 2.50
1.03 0.84
3.00 2.00
3 2
4.50* 3.33
0.55 0.52
4.50 3.00
4 3
4.33* 3.17
0.52 0.41
4.00 3.00
4 3
SD, standard deviation. *p o 0.05.
TABLE 3. Perceptions of Resident Performance by Faculty and SP in a Disclosure Scenario Domains of Communication
Mean
⫾SD
Median
Mode
3.83 3.83
0.75 0.41
4.00 4.00
4 4
3.33 3.67
1.03 0.52
3.00 4.00
3 4
3.83 3.33
0.75 0.52
4.00 3.00
4 3
3.50 3.50
0.84 0.55
3.00 3.50
3 4
3.33 3.50
0.82 0.55
3.50 3.50
4 4
Demeanor in responding to questions asked Faculty SP Communication through nonverbal behavior Faculty SP Allowed adequate time to process information Faculty SP Acknowledged feelings of patient Faculty SP Outlined a clear plan for follow-up Faculty SP SD, standard deviation.
TABLE 4. Resident-Student Evaluation of Faculty Domain of Encounter
Mean ⫾ SD
Median
Mode
Desire for more context Accurate reflection of real-life encounter Nature of simulation environment Emotional involvement and empathy Performance altered by the examination setting The standardized patient Quality of the written feedback
3.67 4.17 4.00 4.17 3.67 4.00 4.00
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
3.5 4.0 4.0 4.0 3.5 4.5 4.0
3 4 3 4 3 5 3
0.82 0.75 0.89 0.75 0.82 1.26 0.89
SD, standard deviation.
questioning.31 These elements were worked into the critique for all residents especially if they were not observed. In particular, 2 of 12 chose to stand despite a readily available chair next to the SP’s bed. Another consideration in the development of the course was related to how apologies are made during the disclosure. e120
Overall, 25% of the residents made statements constituting admission of liability and opened the health care organization to possible vicarious liability. Reduction of medical liability claims and costs by implementation of a robust disclosure program has growing support.32 Such disclosure requirements are silent on guidance for physicians about
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TABLE 5. Themes Derived From Qualitative Feedback on Course From Students 1. Feedback from preceptor Role of risk management Role of patient affairs Fiduciary concerns 2. Concerns regarding what patient could do Tape record Produce documents Call attorney/family 3. Resolve discrepancies in domains 4. Preparedness for future interactions Insight into real-life interactions Better prepared to deal with adverse outcomes in future
when or how to disclose errors, yet communications regarding disclosure should be considered carefully as they can affect patient behavior.27,33 Apologies, or statements like “it was a mistake,” are not a good idea. Although there is certainly ethical support in some circles for “I am sorry” as a possible way to decrease the number and size of settlements in malpractice cases, or to help with the healing of patients who have experienced an adverse event, the law is not so forgiving.34 Therefore, it is critical for physicians who are disclosing bad outcomes to know how to conduct themselves.35 An apology is a statement of remorse, regret, and responsibility and essentially proves a case for medical negligence.34 The residents were told that general expressions of empathy or support are about as far as they should go. Residents must be taught to understand their limited but important role in the disclosure process. Such information was felt important in the development of the communication course. Several institutions have reported a reduction of claims and costs with the implementation of a robust disclosure program—the so-called communication and resolution program (CRP).36,37 Factors that contributed to early adopter success, include a strong champion embedded in the health care system, investments communicating the program to clinicians who may for a variety of reasons resist such transformative change, and patience in implementation.37 For CRPs to function properly, a number of criteria have been identified. Liability insurers must agree to a full disclosure protocol for provider insurance contracts; clinical leaders and administrators must disseminate a clear expectation that full disclosure will occur for all adverse disclosures; CRPs must be translated into easily understood protocols; and most importantly, practitioners must have disclosure coaches and opportunities to practice what to say to patients about unexpected events.35 There are significant infrastructure investments that must also be developed for successful disclosure: a system for rapid reporting of adverse events and establishment of experienced “SWAT teams” to conduct investigations, causation analyses, and coordination of the disclosure plan.35 Clearly, the clinicians at the leading
edge of patient care—including residents—are necessarily only one of the many components to the provision of proper disclosure. Qualitative Analysis and Corrective Actions Given the complexities inherent in a one-on-one interaction between 2 individuals, mere quantitative analysis cannot alone provide the detail that individualized observation and critique can provide. There were a number of specific challenges that the SP set for the residents. These could best be analyzed in a less-formal, qualitative approach. Elements of the scenario that were particularly scrutinized included the following: whether the resident stood or sat and whether there was physical contact (such as a brief physical examination), whether a tape recording was allowed, whether an apology was made and if so did it constitute an admission, whether the resident advised against an attorney, whether the resident disclosed who actually made the wrong incision, whether the resident addressed the uncertainty of not having had precise knowledge of what actually did occur, and whether the resident attempted to obligate the institution financially. Qualitatively, all residents did a commendable job in the scenario. The residents appeared somewhat more stiff and formal than attending surgeons who had attended a similar course in prior years. In general, responses to questions asked by the SP were appropriate for the interaction, fact based, and reflected a calm, collected demeanor. All were counseled that sensitive conversations are best carried out uninterrupted by avoidable distractions and to always remember to render cell phones or other devices silent. However, no “real world” calls or text messages interrupted the scenario. All residents were calm and body language conveyed appropriate support during the interaction. Among the residents, 10 sat and 2 chose to stand. A total of 3 performed a short physical examination, which could in real encounters further develop a bond and put the patient at ease. All were felt to have provided adequate time for the “patient” to process the information being disclosing. Overall, 11 residents elected to allow the patient to record the conversation (one after “checking” and finding a “policy” allowed such a recording); only 1 resident did not do it in a respectful but firm way. It is worth having the residents think about what to do if a patient wishes to write notes, produces a tape recorder, or asks if his lawyer can listen in on speaker phone. Strategies include deflecting a recording with a sincere concern that such a recording is likely to hamper the ability to speak freely. If one is truly uncomfortable with such a request, the residents are told that it is perfectly acceptable to interrupt the conversation to another time and obtain advice from legal counsel. However, they are told to be sure to address any urgent clinical
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needs the patient may have, such as the need for an altered pain medication regimen or wound concerns. In response to the question regarding “should I get a lawyer?” 3 advised against the patient seeking counsel. A total of 3 residents gave explicit apologies with admissions using the phrases “I am so sorry, I made an error,” “I apologize, there were human errors,” and “there was an error in my judgment.” Comments by 6 could have been construed as trying to obligate the medical center in paying costs. Residents were subsequently reminded that they do not have a fiduciary relationship within their training institution, should advocate for the patient, but should not make offers to compensate any additional medical or other costs or state that any costs incurred could be waived. Discussion was pitched at an appropriate learning level for the patient, without overly technical jargon, and yet not condescending. A total of 11 residents acknowledged that the resident themselves made the wrong incision; 1 refused, even under aggressive questioning, to disclose who made the incision; and 3 stated that the attending was not present in the operating room at the time of the wrong incision. Only one speculated as to what happened regarding other members of the team. The residents were counseled to seek out the attending surgeon’s version of the event before discussion with the patient. A basic issue is the need for the resident to seek out the attending surgeon or otherwise find out what the attending surgeon said to formulate an ethical plan for disclosure, and yet, only 2 residents attempted to find out from the SP what the attending surgeon disclosed, the remaining 10 did not. After the scenario, residents were counseled to find out what the attending surgeon said regarding the incision made while the attending surgeon was out of the operating room. Here, although the patient is to be evaluated for pain, it is likely the issue of what happened will arise. Therefore, the residents were given suggestions about how to know what was disclosed to know what to discuss: a call to the attending surgeon to clarify and present unified information would be one approach or to ask the patient about their perceptions of the attending surgeon’s conversation. All acknowledged the feelings of the “patient” in a manner appropriate for the interaction. Attempts to address extraclinical issues were somewhat brief and may reflect resident unfamiliarity with the administrative resources available to assist in patient’s needs. Advice was provided on the question as to what is included in the consent. Specifically, that informed consent documents generally are required to provide information on the risks of a specific procedure. Other risks, such as wrong-site surgery, retained objects, falls off gurneys, and other risks extrinsic to a given procedure, are not generally given. Furthermore, these “never events” are not expected to occur, and generally do not factor in to a patient’s decision to undergo an operation. Residents were counseled as to one of the most difficult decisions in an initial conversation about an error: what e122
facts to disclose and what should legitimately be discussed only after further investigation. In this scenario, the resident made the incision, and this fact will eventually become known by the patient. To eliminate the impression that the resident is trying to create a “cover-up,” it is probably best to let the patient know of this fact as soon as possible. All acknowledged the need for further communication, but the commitment for future contact with the patient was generally indefinite. It was noted that it was appropriate for the senior resident to commit to future contact with the patient in follow-up for further discussion, offer to organize such a meeting, and to answer questions that arise. Open lines of communication are essential for maintaining a relationship with the patient, and it is not optimal to leave such contact up to the patient’s discretion. None appreciated the fact that patients often want some acknowledgment that the adverse event that happened to them will not be repeated. Patients frequently want to be reassured that what happened to them will not happen to others. Residents also were counseled that patients may have had their trust in the resident (or attending surgeon) shaken by events. It was noted to be appropriate to offer to have the follow-up care provided by another resident. Such offers, however, must not look like the resident is trying to abandon the patient.
LIMITATIONS There were some areas of opportunity for improvement in future courses. There was no baseline assessment, as the goal was to develop a course of basic skills that were presumed to be lacking. Course directors were explicit that the evaluation tool should not be considered a “report card” to be used in overall evaluation of the residents for such important decisions as whether to move to the next clinical level. Given the limited resources, there were not enough course faculty reviewers to rigorously analyze interobserver reliability of the evaluation tool. However, 1 faculty reviewer did review all 12 videos, but several SPs were used. Despite these limitations, a fairly broad distribution of scores suggested that the scorers did not have a preconceived idea of what an individual’s score should be. The scenarios were not rigorously scripted nor were the Likert scores anchored to specific tasks (introduction, sitting, and physical contact). SPs did not always touch upon each element to which a resident’s response could have been assessed. For instance, not all residents were asked about elements of the informed consent document. Furthermore, focusing the course on disclosure of medical error limits widespread utility of such a course. Recently, an objective, structured communication assessment of residents has been proposed in which additional scenarios include the delivery of bad news, management of a disruptive patient, and management of a patient with drug-seeking behavior.38
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Consideration should also be given to the use of the informed consent process as a communication opportunity. The small sample size does not allow any demographic studies, to determine whether educational background, gender, age, or other factors might bear on empathic or other communication skills possessed by individual residents. As noted in the section Results, the residents who participated in the course felt their communications skills were enhanced. Ultimately, one measure of success would be the reduction of malpractice claims, but such an outcome would not likely be the result of one initiative.
CONCLUSION Filming and reviewing residents disclosing medical errors to SPs allowed a quantitative assessment of competency as well as identifying opportunities for improvement in individual resident’s communication skills. As here, such communication skills can be taught by exposing residents to specific situations, but more research needs to be done in identifying circumstances in which resident communication skills should be optimally enhanced. Also, the differing perspectives of faculty and SPs regarding resident performance warrants further study. As academic leaders, we must be mindful of our roles as teachers, mentors, and coaches. The data presented here suggest that such courses can help teach residents how to improve physician-patient communication —even under difficult circumstances. Good communications skills are critical for a variety of reasons, including ethical imperatives, compliance with existing law, medical liability exposure, and most importantly, quality patient care.
APPENDIX 1. THE SIMULATION SCENARIO To SimCenter Staff: Scenario to be given to the subject before meeting the Standardized Patient. Resident-student should read over for 2 to 3 minutes before the simulation begins. Scene: A recovery room. There is a tape recorder and a consent form on the nightstand. To the Resident: The patient is an otherwise healthy 40-year-old man who underwent a right inguinal hernia operation earlier today. The problem is that during that operation, you as the operating resident first made an incision in the left inguinal area. The intern was called before the operation to do the day of surgery update and mark the patient. The mark made was an “X” on the left groin, the “X” intended to signify the incorrect side. You were called at the last minute by the attending surgeon who asked you to get started while she attended a mandatory patient safety meeting. You prepared the left groin thinking the “X” denoted the correct side; the circulator was off getting antibiotics for the anesthesia
resident. During the time out, your phone rang and you asked the circulator to answer it, expecting an update on a floor patient who was crashing. The results of the computed tomography were not normal. The time out was completed with the nurse holding the phone to your ear as you addressed the problem. After making the incision and encircling the cord with a Penrose drain, the attending surgeon arrives and states that this patient was to have a right inguinal hernia repair. After closing the left groin and performing the right inguinal hernia repair, the patient is taken to the recovery room. After the patient awakens, the attending surgeon has a conversation with the patient disclosing the obvious fact that there are 2 groin incisions, but you had been called away to a Rapid Response to transfer a ward patient whose health was deteriorating to the surgical intensive care unit and did not hear the interchange of attending surgeon and patient. You have been called by the postanesthesia care unit, informing you that the patient needs to be evaluated for pain that is not being controlled by oral medications. The nurse also states that there seems to be excessive swelling and bruising in the left groin incision. After examination, you determine the pain needs to be treated with IV opioid but the left groin is fine. As you turn to leave, the patient asks “Doctor, may I ask you a couple of questions?” This is a list of questions to be asked by the Standardized Patient depending on the responses of the subject. The Resident Student should not see this ahead of time: To the Standardized Patient: The goal here is to try to get the subject to admit that they made the incision and that the attending surgeon was not present. The patient begins by saying “Dr. _____, I never met you before. Were you present during my operation?” “My wife suggested I tape record this talk. May I turn it on?” “I thought it was strange that the younger doctor marked my left groin when I told him it was the right side. He said the ‘X’ means ‘don’t operate’ and would notify the team that the left side was incorrect so people would know to operate on the right side. Is that the correct approach?” The patient then asks after the response from doctor, “Can you please tell me how my surgeon made a mistake and operated on my left groin?” If the subject admits to making the wrong incision, then the patient asks, “I am very confused; why did my doctor say it was her that made the wrong cut?” Or, if not, the patient then says depending on the response: “Doctor, I read Atul Gawande’s book, Better, and he said a good way to avoid such problems is to use check lists and time outs. Did my doctor have a checklist to follow?” “What steps does the checklist say to do?” “Such a protocol sounds fool-proof; how could a mistake like this happen?”
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The patient then asks, “Well, I trusted my doctor to take care of me. She did cut me on both sides, didn’t she? How could she let this happen?” “Well Dr. _____, I’m sorry to press the issue, but I can show you my copy of the consent form, it doesn’t say anywhere that operating on the wrong side was a potential complication. Did you know this could happen?” “Was my doctor present for the time out and my whole procedure?” “Did my doctor do the whole procedure, or did she let you do some?” If, at this point, the subject has not yet admitted they made the mistaken incision, the patient asks “Doctor, do I have your word that you didn’t cut my left groin?” “Doctor, would you be willing to write down exactly what you think happened? “Well, what do we do now? I feel like my pain is ten times worse with both groins cut open.” “I don’t want to have to pay for this mistake; can you guarantee I won’t be charged for any of this?” “Do you think I should get a lawyer?”
APPENDIX 2. DISCLOSURE TRAINING SESSION FACULTY AND SP EVALUATION TOOL Disclosure Training Session Faculty Evaluation Participant ID # Please rate the clinician in the following categories using the provided scale Demeanor in responding to questions asked: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Responsiveness to questions asked (should provide facts but not speculate): INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Acknowledged responsibility for his/her role in the incident (should not take responsibility for something for which it is not evident that he/she is responsible): INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Communication through non-verbal behavior: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Allowed adequate time for patient to process information: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Acknowledge feelings of patient and family: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Addresses extra-clinical issues (clinician should not address those issues outside his/her area of expertise such as financial compensation, time off from work, etc): INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Communication took place at appropriate learning level for patient/family member: e124
INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Message clear: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Outlined clear plan for follow-up: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5
APPENDIX 3. DISCLOSURE TRAINING SESSION STUDENT EVALUATION TOOL Disclosure Training Session Student Evaluation Please rate the disclosure course in the following categories using the provided scale: Desire for more context: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Accurate reflection of real-life encounter: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Artificial nature of simulation environment: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Emotional involvement and empathy: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Performance altered by the examination setting: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 The standardized patient: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Quality of the written feedback: DISAGREED WITH THE AGREED WITH THE FEEDBACK FEEDBACK ❑1 ❑2 ❑3 ❑4 ❑5 How could the session be improved? (Feel free to continue on back) What did you find most helpful? (Feel free to continue on back)
REFERENCES 1. Gallagher TH, Studdert D, Levinson W. Current
concepts: disclosing harmful medical errors to patients. N Engl J Med. 2007;356(26):2713-2719. 2. West CP, Huschka MM, Novotny PJ, et al. Associ-
ation of perceived medical errors with resident distress and empathy: a prospective longitudinal study. J Am Med Assoc. 2006;296(9):1071-1078. 3. Hevia A, Hobgood C. Medical error during residency: to
tell or not to tell. Ann Emerg Med. 2003;42(4):565-570. 4. Accreditation Council for Graduate Medical Education.
ACGME Common Program Requirements. Available
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at: 〈http://www.acgme.org/acgmeweb/Portals/0/PFAs sets/ProgramRequirements/CPRs2013.pdf〉; Accessed 9.03.14.
18. Matell MS, Jacoby J. Is there an optimal number of
5. Mizrahi T. Managing medical mistakes: ideology,
19. Peter JP. Reliability a review of psychometric basics
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and recent marketing practices. J Mark Res. 1979;16 (1):6-17.
6. Wu AW, Folkman S, McPhee SJ, Lo B. Do house
20. Cox EP. The optimal number of response alternatives
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for a scale: a review. J Mark Res. 1980;17(4):407-422.
7. White AA, Gallagher TH, Krauss MJ, et al. The
attitudes and experiences of trainees regarding disclosing medical errors to patients. Acad Med. 2008;83 (3):250-256. 8. Bell SK, Delbanco T. The impact of an educational
intervention to improve the patient, family, and clinician experience after harmful events. Acad Med. 2010;85(6):1010-1017. 9. White AA, Bell SK, Krauss MJ, et al. How trainees would
disclose medical errors: educational implications for training programmes. Med Educ. 2011;45(4):372-380. 10. Kahn MW. Etiquette-based medicine. N Engl J Med.
2008;358(19):1988-1989. 11. Vanderbilt Center for Patient and Professional Advocacy.
Disclosure: The How and When of Communicating About Unexpected Outcomes and Errors. Available at: 〈http://www.mc.vanderbilt.edu/centers/cppa/educa tion/disclosure.html〉. Accessed 14.03.14. 12. Pichert JW, Hickson GB, Pinto A, Vincent C.
Communicating about unexpected outcomes, adverse events, and errors. Carayon C, ed. Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. 2nd ed. Boca Raton, FL: CRC Press, 2012 [chapter 25]. 13. Chan DK, Gallagher TH, Reznick R, Levinson W. How
surgeons disclose medical errors to patients: a study using standardized patients. Surgery. 2005;138(5):851-858. 14. Likert R. A technique for the measurement of atti-
tudes. Arch Psychol. 1932;140(1):1-55. 15. Blais J-G, Grondin J, Loye N, Raîche G. Rasch’s
alternatives for Likert Scale Items? Study 1: reliability and validity. Educ Psychol Meas. 1971;31(3):657-674.
21. Flamer S. Assessment of the multitrait–multimethod
matrix validity of Likert scales via confirmatory factor analysis. Multivariate Behav Res. 1983;18(3):275-306. 22. Fabri PJ, Knierim TH. Simple calculation of the unpaired
t test. Surg Gynecol Obstet. 1988;167(5):381-382. 23. Sanbar SS. Medical error disclosure and apology,
Sanbar SS, ed. American College of Legal Medicine: Medical Malpractice Survival Handbook. Philadelphia, PA: Mosby/Elsevier, 2007 [chapter 6]. 24. The Joint Commission. Hospital Accreditation Require-
ments: Rights and Responsibilities of the Individual (RI). Available at: 〈https://e-dition.jcrinc.com/Main Content.aspx〉; Accessed 9.03.14. 25. Sage WM, Gallagher TH, Armstrong S, et al. How
policy makers can smooth the way for communicationand-resolution programs. Health Aff (Millwood). 2014;33(1):11-19. 26. Safe Practices for Better Healthcare—2010 Update: A
Consensus Report. Washington, DC. National Quality Forum 2010. Available at: 〈http://www.qualityfo rum.org/Publications/2010/04/Safe_Practices_for_Bet ter_Healthcare_%E2%80%93_2010_Update.aspx〉; Accessed 7.03.14. 27. Mazor KM, Reed GW, Yood RA, Fischer MA, Baril J,
Gurwitz JH. Disclosure of medical errors: what factors influence how patients respond? J Gen Intern Med. 2006;21(7):704-710. 28. Hickson GB, Jenkins AD. Identifying and addressing
communication failures as a means of reducing unnecessary malpractice claims. N C Med J. 2007;68 (3):362-364.
model’s contribution to the study and item response scales formulation in opinion/perception questionnaires. J Appl Meas. 2010;11(4):337-351.
29. The Medical Care Availability and Reduction of Error
16. Blais J-G, Grondin J. The influence of labels associated
Available at: 〈http://www.acssurgery.com/acssurgery/insti tutional/tableOfContent.action#〉 Accessed 26.05.14.
with anchor points of Likert-type response scales in survey questionnaires. J Appl Meas. 2011;12(4):370-386. 17. Lunney GH. Using analysis of variance with a
dichotomous dependent variable. An empirical study. J Educ Meas. 1970;7(4):263-269.
(MCARE) Act. 40 P.S. §1303.308(b). 30. ACS Surgery. Interpersonal and Communication Skills.
31. Block L, Hutzler L, Habicht R, et al. Do internal
medicine interns practice etiquette-based communication? A critical look at the inpatient encounter. J Hosp Med. 2013;8(11):631-634.
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32. Kachalia A, Kaufman SR, Boothman R, et al. Liability
36. Gallegos A. Disclosure programs reduce lawsuits but
claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153(4):213-221.
bring challenges. ACS Surgery News. Available at: 〈http://www.acssurgerynews.com/index.php?id=1488 3&cHash=071010&tx_ttnews[tt_news]=240297〉; Accessed 8.03.14.
33. Etchegaray JM, Ottosen MJ, Burress L, et al. Structur-
ing patient and family involvement in medical error event disclosure and analysis. Health Aff (Millwood). 2014;33(1):46-52. 34. Raper SE. No role for apology: remedial work and the
problem of medical injury. Yale J Health Policy Law Ethics. 2011;11(2):267-330. 35. Hendrich A, McCoy CK, Gale J, Sparkman L, Santos P.
Ascension Health’s demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise. Health Aff (Millwood). 2014;33(1):39-45.
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37. Mello MM, Boothman RC, McDonald T, et al.
Communication-and-resolution programs: the challenges and lessons learned from six early adopters. Health Aff (Millwood). 2014;33(1):20-29. 38. Caron A, Perzynski A, Thomas C, Saade JY,
McFarlane M, Becker J. Development of the objective, structured communication assessment of residents (OSCAR) tool for measuring communication skills with patients. J Grad Med Educ. 2013;5(4): 570-575.
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Simulated Disclosure of a Medical Error by Residents: Development of a Course in Specific Communication Skills Steven E. Raper, MD, Andrew S. Resnick, MD, and Jon B. Morris, MD Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania OBJECTIVES: Surgery residents are expected to demon-
strate the ability to communicate with patients, families, and the public in a wide array of settings on a wide variety of issues. One important setting in which residents may be required to communicate with patients is in the disclosure of medical error. This article details one approach to developing a course in the disclosure of medical errors by residents. DESIGN: Before the development of this course, residents had no education in the skills necessary to disclose medical errors to patients. Residents viewed a Web-based video didactic session and associated slide deck and then were filmed disclosing a wrong-site surgery to a standardized patient (SP). The filmed encounter was reviewed by faculty, who then along with the SP scored each encounter (5-point Likert scale) over 10 domains of physician-patient communication. The residents received individualized written critique, the numerical analysis of their individual scenario, and an opportunity to provide feedback over a number of domains. A mean score of 4.00 or greater was considered satisfactory. Faculty and SP assessments were compared with Student t test. SETTING: Residents were filmed in a one-on-one scenario
in which they had to disclose a wrong-site surgery to a SP in a Simulation Center.
and SP in 5 domains. The residents found this didactic, simulated experience of value (Likert score Z4 in 5 of 7 domains assessed in a feedback tool). Qualitative feedback from the residents confirmed the realistic feel of the encounter and other impressions. CONCLUSIONS: We were able to quantitatively demon-
strate both competency and opportunities for improvement across a wide range of domains of interpersonal and communication skills. Residents are expected to communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds. As academic surgeons, we must be mindful of our roles as teachers, mentors, and coaches by teaching good communication skills to our residents. Courses such as the one described here can help in improving physician-patient communication. The differing perspectives of faculty and SPs regarding resident performC 2014 ance warrants further study. ( J Surg 71:e116-e126. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: ACGME core competencies, apology, disclosure of adverse outcomes, physician-patient communication COMPETENCIES:
Professionalism, Interpersonal Communication Skills, Systems-Based Practice
and
PARTICIPANTS: A total of 12 residents, shortly to enter
the clinical postgraduate year 4, were invited to participate, as they will assume service leadership roles. All were finishing their laboratory experiences, and all accepted the invitation. RESULTS: Residents demonstrated satisfactory competence
in 4 of the 10 domains assessed by the course faculty. There were significant differences in the perceptions of the faculty
Correspondence: Inquiries to Steven E. Raper, MD, JD, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 4 Silverstein Pavilion, 3400 Spruce Street, Philadelphia, PA 19104; e-mail: [email protected]
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INTRODUCTION External pressures for the disclosure of adverse outcomes have been increasing for some time.1 Educating residents in disclosure of adverse outcomes is particularly difficult; these conversations are sensitive, require a particular communication skill set, and may be conducted in the setting of considerable emotional distress.2,3 The Accreditation Council for Graduate Medical Education has, among other core competencies, mandated the development of interpersonal and communication skills; residents must acquire
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.06.020
interpersonal and communication skills for exchanging information effectively with patients and families.4 At academic medical centers, residents frequently care for patients who have sustained adverse outcomes.5,6 Despite the importance of this topic, only a minority of trainees receive training in error disclosure.7 Few doctors in training receive feedback about disclosure skills or know how to access institutional resources for support after making an error.8 The lack of formal training has led some commentators to conclude that trainees may not be prepared to disclose medical errors, create a worrisome trend in how apologies are made, and enhance individual and institutional liability.9 Therefore, it is critical for physicians— including residents—who are disclosing adverse outcomes to know how to conduct themselves. As a means of educating residents in communicating adverse outcomes, 12 residents, shortly to enter the clinical postgraduate year 4, were invited to participate in a course on how to disclose medical error. All were finishing their laboratory experiences, and all accepted the invitation.
METHODS The University of Pennsylvania surgery residency communication course incorporated principles of etiquette-based communication, a series of behaviors designed to enhance physician-patient communication.10 The course was also loosely based on a course in the disclosure of adverse outcomes developed by James W. Pichert and Gerald B. Hickson of the Vanderbilt University Center for Patient and Professional Advocacy, a course in which the faculty reviewer had participated.11 Individuals invited to undergo training were introduced to the basics of adverse event disclosure first through a Web-based didactic session and associated slide deck. Once the didactic materials were reviewed, the residents participated in a disclosure scenario. The scenario included the obvious injury, obvious error problem of a wrong-site surgical procedure (Appendix 1).12 The scenario was realized using standardized patients (SPs) and residents were filmed disclosing the wrong-site error to the SP. The filmed encounter was reviewed and scored by faculty who had previously participated in the Vanderbilt Center for Patient and Professional Advocacy course. The review included numerical scoring according to an assessment tool used by both faculty and SP; aspects of the assessment tool used by both the faculty and the SP were adapted in part from a previous report (Appendix 2).13 The score sheet used a Likert scale with 5 anchors: inappropriate, minimally appropriate, somewhat appropriate, substantially appropriate, and completely appropriate.14-16 The optimal number of Likert-type scale response alternatives has been well researched, and for this study, 5 appeared adequate for discrimination purposes.17-21 The analysis included 10 domains assessing a variety of communication elements
including the providers’ ability to use effective communication strategies with a focus on the providers’ ability to engage in open-ended questioning, respond to emotions, convey sympathy, relay medical information, and convey commitment to well-being. In addition, each resident was asked to provide anonymous feedback intended to improve the course for future course participants and to review their individual filmed scenario. Each resident received feedback in the form of an individualized written critique. This course was attended by senior-level residents (entering the postgraduate 4 clinical year), about to embark on the senior clinical phase of their residency, when their supervisory position might require the use of such disclosure skills. As residents with some autonomy and decisionmaking responsibility, it is likely they will be involved in caring for patients with medical injuries that are ultimately the responsibility of the attending surgeon. Arguably, all residents should learn truth telling from day 1 of residency, but there is little published literature on how to teach this skill. Using an evaluation tool, the residents were able to provide anonymous feedback to the course organizers (Appendix 3). This was intended to be an intentionally difficult scenario. The events are necessarily contrived, but one of the paramount issues residents should consider as they finish the clinical residency is to take universal precautions against making a wrong-site procedure seriously. Although letting a wrong-site procedure to happen is generally considered a “systems error” for the health care organization and those involved, the one holding the knife will most directly shoulder the consequences. The scenario was developed, and SPs were briefed in advance for the role. Scheduling concerns led to the inability to use the same actor in all scenarios for resident participants. When the scenario was written, there were approximately 20 responses the actor could use depending on the resident’s initial comments. The impression of the SPs and faculty was that the residents were interacting as if it were essentially a real encounter, a fact echoed by some of the written feedback of the residents. The scenario was designed for wrong-site surgery and is considered an “obvious/obvious,” which means obvious error causing an obvious injury.12 The intent was that the attending surgeon was not present for the wrong-site incision, and it was assumed that a properly experienced resident was responsible for the actual incision. In this scenario, the attending surgeon first had a meeting with the patient to disclose the obvious fact that the wrong side was incised. However, the resident was not present, so he or she did not know what was said by the attending surgeon. Statistical Analysis For each of the 10 domains of communication, the mean, median, and mode were calculated. Faculty and SP scores
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were compared with Student unpaired t test with significance set at p o 0.05.22
faculty, although the differences were not deemed satisfactory or statistically significant (Table 3). Evaluation of Course Faculty by Residents
RESULTS Evaluation of Residents by Course Faculty and SPs Quantitative Analysis Of the 10 domains scored by faculty, 4 had a satisfactory Likert score of Z 4.0: responsiveness to questions asked, acknowledgment of responsibility for role in the incident, communication at an appropriate patient learning level, and a clear message (Table 1). Although an average score of 43.0 might in some circumstances be considered adequate, for purposes of this scenario, only a score Z4.0 was considered satisfactory. The remaining 6 domains were considered to reflect opportunities for improvement with mean scores of o4.0: residents addressed extraclinical issues, demeanor in responding to questions asked, communication through nonverbal behavior, allowance of adequate time to process information, acknowledged feelings of the patient, and outlined a clear plan for follow-up. In 8 of the 10 communication domains evaluated, the faculty scored the students higher than the SPs on a 5-point Likert scale (Table 1). The distribution of scores of both faculty and SP varied widely from domain to domain and provided a more granular and visually understandable analysis of the data (Fig.). The SP scored only one domain satisfactory with a Likert score of Z4.0, that of acknowledgment of responsibility for role in the incident (Table 2). When faculty scores were compared with SP scores, faculty scored the residents statistically significantly higher in 5 domains: responsiveness to questions asked, acknowledgment of responsibility for the role in the incident, residents addressed extraclinical issues, communication at an appropriate patient learning level, and a clear message (Table 2). In 5 domains, there were no significant differences: demeanor in responding to questions asked, communication through nonverbal behavior, allowance of adequate time to process information, acknowledged feelings of the patient, and outline of a clear plan for follow-up (Table 3). In 2 of these domains—nonverbal communication and clear plan for follow-up—the SP scored the residents higher than
Quantitatively, students gave the course faculty a 4.0 or greater on the Likert scale in 5 of 7 domains: accurate reflection of real-life encounter, nature of the simulation environment, emotional involvement and empathy felt by the student, the quality of the SP, and quality of the written feedback (Table 4). Overall, 2 domains were scored with a mean value of o4.0: residents expressed a desire for more context and did not feel their performance was altered by the examination setting (Table 4). Qualitatively, free-text written comments were loosely grouped into 4 themes: more feedback from course faculty, further counseling regarding what patients could do, resolve discrepancies in the scenario owing to the artificial nature, and how the encounter prepared the students for future interactions (Table 5).
DISCUSSION Development of the Course Disclosure of medical errors is encouraged by a variety of policy makers.23 The Joint Commission has, as an element of performance for RI 01.02.01, stated that responsible physicians inform patients about unanticipated outcomes related to sentinel events.24 The Institute of Medicine has also offered policy proposals supporting disclosure as a patient safety concern.25 The National Quality Forum has advocated, as a safe practice, that patients and families should receive timely, transparent, and clear communication concerning serious unanticipated outcomes.26 Disclosure may also have a positive effect on the physician-patient relationship in terms of changing physicians, trust, and satisfaction.27 Insurers are also coming to the realization that adequate communication may reduce unnecessary malpractice claims.28 Disclosure may also be a legal requirement. Many states have enacted laws requiring disclosure of adverse events to patients or their families or both. For example, in Pennsylvania, the Medical Care Availability and Reduction of Error Act requires health care providers to report “serious events” (events that result in death or unanticipated injury to the patient requiring additional
TABLE 1. Satisfactory Perceptions of Resident Performance by Faculty in a Disclosure Scenario Domains of Communication Responsiveness to questions asked Acknowledged responsibility for role in the incident Communication at appropriate patient learning level Message clear
Mean
⫾SD
Median
Mode
4.00 4.33 4.50 4.33
0.63 0.52 0.55 0.52
4.00 4.00 4.50 4.00
4 4 4 4
SD, standard deviation. e118
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FIGURE. A total of 10 histograms representing difference in the evaluation of residents by course faculty and standardized patients. For each of the 10 individual graphs, the axes and scale are the same; the x-axis represents the Likert scale (1 ¼ inappropriate, 2 ¼ minimally appropriate, 3 ¼ somewhat appropriate, 4 ¼ substantially appropriate, and 5 ¼ completely appropriate), and the y-axis represents the sum of individual resident scores for each of the 5 Likert categories.
health care services) in writing to the patient or a family member.29 Given such a broad range of administrative imperatives requiring disclosure, it is surprising how little has been published on how to impart such communication skills to residents. One such resource is the ACS Surgery chapter on Interpersonal and Communication Skills.30 When considering how to educate residents in disclosure or other important communications skills, it becomes necessary to
determine how residents might, of their own accord, disclose such outcomes. Fewer than half of residents, when surveyed, would definitely disclose an adverse event and then only when obvious.9 Etiquette-based communication is an approach to clearly set expectation for all resident (indeed all physician) encounters with their patients.21 Elements of etiquette-based encounters include the resident’s introduction by name and role, sitting rather than standing, physical patient contact, and open-ended
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TABLE 2. Perceptions of Resident Performance by Faculty and SP in a Disclosure Scenario Domains of Communication Responsiveness to questions asked Faculty SP Acknowledged responsibility for role in the incident Faculty SP Addressed extraclinical issues Faculty SP Communication at appropriate patient learning level Faculty SP Message clear Faculty SP
Mean
⫾SD
Median
Mode
4.00* 3.50
0.63 0.55
4.00 3.50
4 3
4.33* 4.00
0.52 0.00
4.00 4.00
4 4
3.33* 2.50
1.03 0.84
3.00 2.00
3 2
4.50* 3.33
0.55 0.52
4.50 3.00
4 3
4.33* 3.17
0.52 0.41
4.00 3.00
4 3
SD, standard deviation. *p o 0.05.
TABLE 3. Perceptions of Resident Performance by Faculty and SP in a Disclosure Scenario Domains of Communication
Mean
⫾SD
Median
Mode
3.83 3.83
0.75 0.41
4.00 4.00
4 4
3.33 3.67
1.03 0.52
3.00 4.00
3 4
3.83 3.33
0.75 0.52
4.00 3.00
4 3
3.50 3.50
0.84 0.55
3.00 3.50
3 4
3.33 3.50
0.82 0.55
3.50 3.50
4 4
Demeanor in responding to questions asked Faculty SP Communication through nonverbal behavior Faculty SP Allowed adequate time to process information Faculty SP Acknowledged feelings of patient Faculty SP Outlined a clear plan for follow-up Faculty SP SD, standard deviation.
TABLE 4. Resident-Student Evaluation of Faculty Domain of Encounter
Mean ⫾ SD
Median
Mode
Desire for more context Accurate reflection of real-life encounter Nature of simulation environment Emotional involvement and empathy Performance altered by the examination setting The standardized patient Quality of the written feedback
3.67 4.17 4.00 4.17 3.67 4.00 4.00
⫾ ⫾ ⫾ ⫾ ⫾ ⫾ ⫾
3.5 4.0 4.0 4.0 3.5 4.5 4.0
3 4 3 4 3 5 3
0.82 0.75 0.89 0.75 0.82 1.26 0.89
SD, standard deviation.
questioning.31 These elements were worked into the critique for all residents especially if they were not observed. In particular, 2 of 12 chose to stand despite a readily available chair next to the SP’s bed. Another consideration in the development of the course was related to how apologies are made during the disclosure. e120
Overall, 25% of the residents made statements constituting admission of liability and opened the health care organization to possible vicarious liability. Reduction of medical liability claims and costs by implementation of a robust disclosure program has growing support.32 Such disclosure requirements are silent on guidance for physicians about
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TABLE 5. Themes Derived From Qualitative Feedback on Course From Students 1. Feedback from preceptor Role of risk management Role of patient affairs Fiduciary concerns 2. Concerns regarding what patient could do Tape record Produce documents Call attorney/family 3. Resolve discrepancies in domains 4. Preparedness for future interactions Insight into real-life interactions Better prepared to deal with adverse outcomes in future
when or how to disclose errors, yet communications regarding disclosure should be considered carefully as they can affect patient behavior.27,33 Apologies, or statements like “it was a mistake,” are not a good idea. Although there is certainly ethical support in some circles for “I am sorry” as a possible way to decrease the number and size of settlements in malpractice cases, or to help with the healing of patients who have experienced an adverse event, the law is not so forgiving.34 Therefore, it is critical for physicians who are disclosing bad outcomes to know how to conduct themselves.35 An apology is a statement of remorse, regret, and responsibility and essentially proves a case for medical negligence.34 The residents were told that general expressions of empathy or support are about as far as they should go. Residents must be taught to understand their limited but important role in the disclosure process. Such information was felt important in the development of the communication course. Several institutions have reported a reduction of claims and costs with the implementation of a robust disclosure program—the so-called communication and resolution program (CRP).36,37 Factors that contributed to early adopter success, include a strong champion embedded in the health care system, investments communicating the program to clinicians who may for a variety of reasons resist such transformative change, and patience in implementation.37 For CRPs to function properly, a number of criteria have been identified. Liability insurers must agree to a full disclosure protocol for provider insurance contracts; clinical leaders and administrators must disseminate a clear expectation that full disclosure will occur for all adverse disclosures; CRPs must be translated into easily understood protocols; and most importantly, practitioners must have disclosure coaches and opportunities to practice what to say to patients about unexpected events.35 There are significant infrastructure investments that must also be developed for successful disclosure: a system for rapid reporting of adverse events and establishment of experienced “SWAT teams” to conduct investigations, causation analyses, and coordination of the disclosure plan.35 Clearly, the clinicians at the leading
edge of patient care—including residents—are necessarily only one of the many components to the provision of proper disclosure. Qualitative Analysis and Corrective Actions Given the complexities inherent in a one-on-one interaction between 2 individuals, mere quantitative analysis cannot alone provide the detail that individualized observation and critique can provide. There were a number of specific challenges that the SP set for the residents. These could best be analyzed in a less-formal, qualitative approach. Elements of the scenario that were particularly scrutinized included the following: whether the resident stood or sat and whether there was physical contact (such as a brief physical examination), whether a tape recording was allowed, whether an apology was made and if so did it constitute an admission, whether the resident advised against an attorney, whether the resident disclosed who actually made the wrong incision, whether the resident addressed the uncertainty of not having had precise knowledge of what actually did occur, and whether the resident attempted to obligate the institution financially. Qualitatively, all residents did a commendable job in the scenario. The residents appeared somewhat more stiff and formal than attending surgeons who had attended a similar course in prior years. In general, responses to questions asked by the SP were appropriate for the interaction, fact based, and reflected a calm, collected demeanor. All were counseled that sensitive conversations are best carried out uninterrupted by avoidable distractions and to always remember to render cell phones or other devices silent. However, no “real world” calls or text messages interrupted the scenario. All residents were calm and body language conveyed appropriate support during the interaction. Among the residents, 10 sat and 2 chose to stand. A total of 3 performed a short physical examination, which could in real encounters further develop a bond and put the patient at ease. All were felt to have provided adequate time for the “patient” to process the information being disclosing. Overall, 11 residents elected to allow the patient to record the conversation (one after “checking” and finding a “policy” allowed such a recording); only 1 resident did not do it in a respectful but firm way. It is worth having the residents think about what to do if a patient wishes to write notes, produces a tape recorder, or asks if his lawyer can listen in on speaker phone. Strategies include deflecting a recording with a sincere concern that such a recording is likely to hamper the ability to speak freely. If one is truly uncomfortable with such a request, the residents are told that it is perfectly acceptable to interrupt the conversation to another time and obtain advice from legal counsel. However, they are told to be sure to address any urgent clinical
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needs the patient may have, such as the need for an altered pain medication regimen or wound concerns. In response to the question regarding “should I get a lawyer?” 3 advised against the patient seeking counsel. A total of 3 residents gave explicit apologies with admissions using the phrases “I am so sorry, I made an error,” “I apologize, there were human errors,” and “there was an error in my judgment.” Comments by 6 could have been construed as trying to obligate the medical center in paying costs. Residents were subsequently reminded that they do not have a fiduciary relationship within their training institution, should advocate for the patient, but should not make offers to compensate any additional medical or other costs or state that any costs incurred could be waived. Discussion was pitched at an appropriate learning level for the patient, without overly technical jargon, and yet not condescending. A total of 11 residents acknowledged that the resident themselves made the wrong incision; 1 refused, even under aggressive questioning, to disclose who made the incision; and 3 stated that the attending was not present in the operating room at the time of the wrong incision. Only one speculated as to what happened regarding other members of the team. The residents were counseled to seek out the attending surgeon’s version of the event before discussion with the patient. A basic issue is the need for the resident to seek out the attending surgeon or otherwise find out what the attending surgeon said to formulate an ethical plan for disclosure, and yet, only 2 residents attempted to find out from the SP what the attending surgeon disclosed, the remaining 10 did not. After the scenario, residents were counseled to find out what the attending surgeon said regarding the incision made while the attending surgeon was out of the operating room. Here, although the patient is to be evaluated for pain, it is likely the issue of what happened will arise. Therefore, the residents were given suggestions about how to know what was disclosed to know what to discuss: a call to the attending surgeon to clarify and present unified information would be one approach or to ask the patient about their perceptions of the attending surgeon’s conversation. All acknowledged the feelings of the “patient” in a manner appropriate for the interaction. Attempts to address extraclinical issues were somewhat brief and may reflect resident unfamiliarity with the administrative resources available to assist in patient’s needs. Advice was provided on the question as to what is included in the consent. Specifically, that informed consent documents generally are required to provide information on the risks of a specific procedure. Other risks, such as wrong-site surgery, retained objects, falls off gurneys, and other risks extrinsic to a given procedure, are not generally given. Furthermore, these “never events” are not expected to occur, and generally do not factor in to a patient’s decision to undergo an operation. Residents were counseled as to one of the most difficult decisions in an initial conversation about an error: what e122
facts to disclose and what should legitimately be discussed only after further investigation. In this scenario, the resident made the incision, and this fact will eventually become known by the patient. To eliminate the impression that the resident is trying to create a “cover-up,” it is probably best to let the patient know of this fact as soon as possible. All acknowledged the need for further communication, but the commitment for future contact with the patient was generally indefinite. It was noted that it was appropriate for the senior resident to commit to future contact with the patient in follow-up for further discussion, offer to organize such a meeting, and to answer questions that arise. Open lines of communication are essential for maintaining a relationship with the patient, and it is not optimal to leave such contact up to the patient’s discretion. None appreciated the fact that patients often want some acknowledgment that the adverse event that happened to them will not be repeated. Patients frequently want to be reassured that what happened to them will not happen to others. Residents also were counseled that patients may have had their trust in the resident (or attending surgeon) shaken by events. It was noted to be appropriate to offer to have the follow-up care provided by another resident. Such offers, however, must not look like the resident is trying to abandon the patient.
LIMITATIONS There were some areas of opportunity for improvement in future courses. There was no baseline assessment, as the goal was to develop a course of basic skills that were presumed to be lacking. Course directors were explicit that the evaluation tool should not be considered a “report card” to be used in overall evaluation of the residents for such important decisions as whether to move to the next clinical level. Given the limited resources, there were not enough course faculty reviewers to rigorously analyze interobserver reliability of the evaluation tool. However, 1 faculty reviewer did review all 12 videos, but several SPs were used. Despite these limitations, a fairly broad distribution of scores suggested that the scorers did not have a preconceived idea of what an individual’s score should be. The scenarios were not rigorously scripted nor were the Likert scores anchored to specific tasks (introduction, sitting, and physical contact). SPs did not always touch upon each element to which a resident’s response could have been assessed. For instance, not all residents were asked about elements of the informed consent document. Furthermore, focusing the course on disclosure of medical error limits widespread utility of such a course. Recently, an objective, structured communication assessment of residents has been proposed in which additional scenarios include the delivery of bad news, management of a disruptive patient, and management of a patient with drug-seeking behavior.38
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Consideration should also be given to the use of the informed consent process as a communication opportunity. The small sample size does not allow any demographic studies, to determine whether educational background, gender, age, or other factors might bear on empathic or other communication skills possessed by individual residents. As noted in the section Results, the residents who participated in the course felt their communications skills were enhanced. Ultimately, one measure of success would be the reduction of malpractice claims, but such an outcome would not likely be the result of one initiative.
CONCLUSION Filming and reviewing residents disclosing medical errors to SPs allowed a quantitative assessment of competency as well as identifying opportunities for improvement in individual resident’s communication skills. As here, such communication skills can be taught by exposing residents to specific situations, but more research needs to be done in identifying circumstances in which resident communication skills should be optimally enhanced. Also, the differing perspectives of faculty and SPs regarding resident performance warrants further study. As academic leaders, we must be mindful of our roles as teachers, mentors, and coaches. The data presented here suggest that such courses can help teach residents how to improve physician-patient communication —even under difficult circumstances. Good communications skills are critical for a variety of reasons, including ethical imperatives, compliance with existing law, medical liability exposure, and most importantly, quality patient care.
APPENDIX 1. THE SIMULATION SCENARIO To SimCenter Staff: Scenario to be given to the subject before meeting the Standardized Patient. Resident-student should read over for 2 to 3 minutes before the simulation begins. Scene: A recovery room. There is a tape recorder and a consent form on the nightstand. To the Resident: The patient is an otherwise healthy 40-year-old man who underwent a right inguinal hernia operation earlier today. The problem is that during that operation, you as the operating resident first made an incision in the left inguinal area. The intern was called before the operation to do the day of surgery update and mark the patient. The mark made was an “X” on the left groin, the “X” intended to signify the incorrect side. You were called at the last minute by the attending surgeon who asked you to get started while she attended a mandatory patient safety meeting. You prepared the left groin thinking the “X” denoted the correct side; the circulator was off getting antibiotics for the anesthesia
resident. During the time out, your phone rang and you asked the circulator to answer it, expecting an update on a floor patient who was crashing. The results of the computed tomography were not normal. The time out was completed with the nurse holding the phone to your ear as you addressed the problem. After making the incision and encircling the cord with a Penrose drain, the attending surgeon arrives and states that this patient was to have a right inguinal hernia repair. After closing the left groin and performing the right inguinal hernia repair, the patient is taken to the recovery room. After the patient awakens, the attending surgeon has a conversation with the patient disclosing the obvious fact that there are 2 groin incisions, but you had been called away to a Rapid Response to transfer a ward patient whose health was deteriorating to the surgical intensive care unit and did not hear the interchange of attending surgeon and patient. You have been called by the postanesthesia care unit, informing you that the patient needs to be evaluated for pain that is not being controlled by oral medications. The nurse also states that there seems to be excessive swelling and bruising in the left groin incision. After examination, you determine the pain needs to be treated with IV opioid but the left groin is fine. As you turn to leave, the patient asks “Doctor, may I ask you a couple of questions?” This is a list of questions to be asked by the Standardized Patient depending on the responses of the subject. The Resident Student should not see this ahead of time: To the Standardized Patient: The goal here is to try to get the subject to admit that they made the incision and that the attending surgeon was not present. The patient begins by saying “Dr. _____, I never met you before. Were you present during my operation?” “My wife suggested I tape record this talk. May I turn it on?” “I thought it was strange that the younger doctor marked my left groin when I told him it was the right side. He said the ‘X’ means ‘don’t operate’ and would notify the team that the left side was incorrect so people would know to operate on the right side. Is that the correct approach?” The patient then asks after the response from doctor, “Can you please tell me how my surgeon made a mistake and operated on my left groin?” If the subject admits to making the wrong incision, then the patient asks, “I am very confused; why did my doctor say it was her that made the wrong cut?” Or, if not, the patient then says depending on the response: “Doctor, I read Atul Gawande’s book, Better, and he said a good way to avoid such problems is to use check lists and time outs. Did my doctor have a checklist to follow?” “What steps does the checklist say to do?” “Such a protocol sounds fool-proof; how could a mistake like this happen?”
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The patient then asks, “Well, I trusted my doctor to take care of me. She did cut me on both sides, didn’t she? How could she let this happen?” “Well Dr. _____, I’m sorry to press the issue, but I can show you my copy of the consent form, it doesn’t say anywhere that operating on the wrong side was a potential complication. Did you know this could happen?” “Was my doctor present for the time out and my whole procedure?” “Did my doctor do the whole procedure, or did she let you do some?” If, at this point, the subject has not yet admitted they made the mistaken incision, the patient asks “Doctor, do I have your word that you didn’t cut my left groin?” “Doctor, would you be willing to write down exactly what you think happened? “Well, what do we do now? I feel like my pain is ten times worse with both groins cut open.” “I don’t want to have to pay for this mistake; can you guarantee I won’t be charged for any of this?” “Do you think I should get a lawyer?”
APPENDIX 2. DISCLOSURE TRAINING SESSION FACULTY AND SP EVALUATION TOOL Disclosure Training Session Faculty Evaluation Participant ID # Please rate the clinician in the following categories using the provided scale Demeanor in responding to questions asked: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Responsiveness to questions asked (should provide facts but not speculate): INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Acknowledged responsibility for his/her role in the incident (should not take responsibility for something for which it is not evident that he/she is responsible): INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Communication through non-verbal behavior: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Allowed adequate time for patient to process information: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Acknowledge feelings of patient and family: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Addresses extra-clinical issues (clinician should not address those issues outside his/her area of expertise such as financial compensation, time off from work, etc): INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Communication took place at appropriate learning level for patient/family member: e124
INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Message clear: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Outlined clear plan for follow-up: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5
APPENDIX 3. DISCLOSURE TRAINING SESSION STUDENT EVALUATION TOOL Disclosure Training Session Student Evaluation Please rate the disclosure course in the following categories using the provided scale: Desire for more context: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Accurate reflection of real-life encounter: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Artificial nature of simulation environment: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Emotional involvement and empathy: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Performance altered by the examination setting: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 The standardized patient: INAPPROPRIATE COMPLETELY APPROPRIATE ❑1 ❑2 ❑3 ❑4 ❑5 Quality of the written feedback: DISAGREED WITH THE AGREED WITH THE FEEDBACK FEEDBACK ❑1 ❑2 ❑3 ❑4 ❑5 How could the session be improved? (Feel free to continue on back) What did you find most helpful? (Feel free to continue on back)
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