Surgeons and Error Disclosure

Research shows shortcomings in communication skills that experts say can be taught.

Commentators

• Thomas Gallagher, MD; University of Washington; Seattle, WA

• Wendy Levinson, MD; University of Toronto; Toronto, Ontario

• Jo Shapiro, MD, FACS; Brigham & Women’s Hospital; Boston, MA

Transcript

The Joint Commission says you have to do it. The specialty societies recommend it. Most physicians want to. But it’s still difficult to disclose medical errors to patients.

“There have been recommendations for a long time that errors be disclosed to patients, but the best available evidence that we have suggests that patients hear about harmful errors in their care only about a third of the time.”

Dr. Thomas Gallagher is a general internist and Associate Professor of Medicine, Medical History, and Ethics at the University of Washington in Seattle. In a study published in the November 2005 issue of the journal Surgery, Dr. Gallagher and colleagues reported a significant gap between what patients want during disclosure discussions, and how surgeons actually disclose. Using actors as standardized patients that present a consistent clinical scenario in a reproducible way, the research team videotaped surgeons disclosing hypothetical errors.

“We found that the surgeons did the best in the area of explaining the medical facts of the event. But they struggled in other areas. For instance, the surgeons had difficulty taking responsibility for the event, apologizing for the event, and very few of the surgeons said anything to the patients about how recurrences of the error would be prevented. And these are all areas and types of information that patients have told us in previous studies really matters to them.”

Why focus on surgeons?

“I think surgeons represent an ideal group to work on this challenging topic with, mostly because surgeons out of all of the specialties I think have the most experience communicating with patients about the topic of adverse events, and unanticipated outcomes and many surgeons are really masterful at doing that.”

Still, in Dr. Gallagher’s study of surgeons disclosing medical error, only about half validated the patient’s emotions and less than 10 percent discussed how similar errors would be prevented. Those are two elements of error disclosure that patients have been shown to value.

Dr. Gallagher says surgeons may have the same barriers to good disclosure as any other provider, such as fear of litigation, or misunderstanding what patients are looking for. Yet he says his newer research is pointing to surgery’s unique culture as an impediment.

That rings true for Dr. Jo Shapiro, pision Chief of Otolaryngology at Brigham & Women’s Hospital in Boston. Dr. Shapiro recently spoke to the annual meeting of the National Patient Safety Foundation about her real-life experience disclosing an error to one of her surgery patients.

“You’re told you’re captain of the ship. Now what does that mean? That means you take personal responsibility for every single thing that happens to that patient in your care whether or not it was your fault. You are responsible, and surgeons really internalize that. They really do. I mean, I don’t know where else you’re called captain of the ship and that’s how you’re trained. That was how I was trained.”

Dr. Shapiro describes how she felt when she had to tell a patient and his family about a complication that stemmed from human error. It was a known risk for that procedure that they had discussed beforehand.

“First thing you feel is really sad that someone is suffering, because you’re a healer so seeing people suffering makes you feel sad. And then there is the shame that you actually caused that suffering and then there’s the fear that you are going to somehow be ostracized, sued, humiliated publicly, etc. And then there is the anger that you feel very alone and why isn’t the system supporting you in this really difficult time for you as a professional. And then there’s the panic which results from a combination of all those other emotions.”

Dr. Shapiro’s message to the National Patient Safety Foundation meeting was that physicians can’t just be told to do better at disclosing medical errors. They need help doing it well, simply because it’s a very difficult thing to do. She says the instinct is to deny and avoid.

“And, of course, giving the patient detailed information about what happened and apologizing requires complete lack of denial and absolute transparency, and at the same time everything else is telling you: it didn’t happen; I can’t deal with this person; let me just avoid going to see them. Everything is working against doing the right thing… , you don’t just grow up and get this by osmosis being a clinician. It’s a real skill and like every single skill in medicine and in life, you are going to get better results if you train to do it.”

One of the foremost researchers in physician-patient communication in difficult situations and teaching physicians how to communicate effectively is Dr. Wendy Levinson. Dr. Levinson is the Chair of Medicine at the University of Toronto, and a co-author with Dr. Gallagher on his study of surgeons disclosing errors to patients. Dr. Levinson has done a number of randomized studies that demonstrated how physicians can be taught to be good communicators.

“Effective communication training requires practice and feedback and repetition and teaches very specific skills. So I think it is hard to teach global skills like being patient centered. It is much easier to teach specific skills like, ‘here are the four steps in disclosing an error and here’s how you should do them. Now let’s practice with a standardized patient and get feedback and try again.’ In that context, there is good evidence that has been shown in the fields of breaking bad news in Oncology, in teaching doctors about how to discuss advanced directives, that doctors improve their skills and so too they can improve their skills in this area.”

Even something as seemingly unteachable as empathy, which patients say is critical, Dr. Levinson says can be improved.

“Physicians frequently feel empathic for a patient. They see a patient feeling sad, but how does the patient know the doctor feels empathic unless the doctor says something? So you can teach physicians and this is often taught in communication workshops how to say, ‘I know this is really painful for you. I can see that this is really overwhelming news. I can understand feeling really distressed when you hear this.’ And then being silent and letting the patient respond and commenting again on the emotion. Frequently when doctors are themselves stressed, they stay away from the emotional content and talk about the facts. ‘Let’s go back to talking about what the facts are here.’ But what the patient probably needs is caring and empathy, and so that’s a very specific skill that can be taught. Even though you might feel anxious, comment on the feelings and be silent when needed.”

At Brigham & Women’s Hospital, Dr. Shapiro is participating in a peer support program that helps physicians who have been involved in an error. She says that physicians need to understand their own emotions and psychological reactions after an error, before they can be effective at disclosing to a patient.

“I think one of the things, for example, is helping surgeons be able to identify these emotions and normalize it. Let's say someone had come to me and said ‘you know what, I heard this happened and, you know, how are you? because I found that when it happened to me, I felt this way, that way, that way, and I just want you to know I’m here for you…’ It’s senior people who are willing to be trained to be peer support and not therapists at all but just, ‘Hey, you know, we want to normalize what somebody in this field calls a normal reaction to an abnormal situation.’ For me to feel responsible is very normal given my training…. and that is that involves very much acknowledging what you are feeling, and for a surgeon we should just acknowledge that this goes completely counter-cultural for us.”

One question is whether broad disclosure training of every clinician should take place or whether specialists in disclosure should be on-call to coach a physician immediately after an error takes place, and before disclosure to the patient begins. Dr. Levinson recommends both.

“I think given the lack of evidence, but my own best guess is that we should do education broadly so that when the situation arises, we can then have just in time coaching, but it doesn’t come out of the blue. So if you have never heard about this or gotten any education about it, then it is harder to have just in time coaching.”

Dr. Gallagher:

“I think the critical take-home message for physicians is the importance of getting help when they encounter a situation that might require disclosure of a serious error to patients. Fortunately, serious errors are relatively unusual, so it’s not likely that any inpidual physician will have much experience disclosing serious harmful errors to patients. Some physicians inadvertently disclose information about an error that, upon later analysis, turns out to be incorrect. If physicians talk with a colleague about an error, it’s possible that the colleague could be subpoenaed, so it’s important that the first step be consulting with the appropriate risk manager to make sure that those sorts of problems don’t happen.”