News

Back in the Saddle


 

When Tait Shanafelt, MD, and his colleagues at the Mayo Clinic in Rochester, Minn., investigated whether medical residents who rated high on burnout also delivered lower quality care, they found an interesting correlation: Physicians who reported errors experienced more burnout, and burned-out physicians made more errors.1

“While the patient safety issue is paramount, there is also a pretty substantial personal cost to physicians when they perceive that they have made an error,” says Dr. Shanafelt, an assistant professor of medicine.

Whether or not a bad outcome stems from “errors,” hospitalists may experience a psychoemotional aftermath. They often suffer in silence, imagining that few other doctors make errors. This common experience has historically been covered by a veil of silence.2

How to Support a Colleague

  • Imagine what you would want someone to say to you if you had made a harmful error. Say that to your colleague.
  • Encourage the physician to describe what happened; Accept that assessment; do not minimize the importance of the mistake;
  • Disclose one’s own experience with mistakes to help reduce the colleagues sense of isolation;
  • Ask about and acknowledge the emotional impact of the mistake and regularly ask how the colleague is coping;
  • Acknowledge the pain of implementing the imperative to disclose and apologize to family and patient;
  • Acknowledge the inevitability of mistakes to trainees and hospitalist groups;
  • Suggest nurses, pharmacists, and other healthcare professionals seek trusting colleagues of their own;
  • Identify or form a group of peers in whom you can confidentially find support; and
  • Develop a best-practices guideline for your group and institution to deal with post-event care.—AS

Silent Struggle

Caregivers are largely hesitant to discuss their involvement in adverse events.

“Their reluctance to discuss this with their colleagues is a common barrier to work through this in constructive ways,” Dr. Shanafelt says.

Though clinical decisions have systems and individual components, when mistakes happen it’s the latter with which hospitalists struggle silently—and often dysfunctionally.

“Every serious adverse event has at least two victims: the patient and family; and the caregiver,” says Albert W. Wu, MD, a professor of health policy and management at Johns Hopkins University in Baltimore.3-5

Although there is merit in analyzing the mistake and learning from it, doing so without facing the personal consequences is insufficient.

“Even if there was a system factor that can be identified, physicians still feel personally responsible for their patients and they often carry a sense of guilt around with them,” Dr. Shanafelt says.

That feeling of responsibility is not necessarily a bad thing.

“It is important to recognize that everything is not a systems error,” says Lenny Feldman, MD, an assistant professor and hospitalist with the Division of General Internal Medicine at Johns Hopkins Hospital. “Individuals want to be able to take responsibility for the bad things that have happened, and there is a value to that.”

The medical profession has just begun to fully acknowledge the inevitability of errors and the need for clinicians to be trained to manage them. Emotional responses to bad outcomes or medical errors include fear, guilt, anger, embarrassment, humiliation, and depression, which can last days—or years.

“The cognoscenti of coping know that there are adaptive and maladaptive ways of coping,” says Dr. Wu. “Adaptive would be reframing and growing and learning from the incident, channeling the energy into trying to do better next time. Maladaptive strategies include denial, turning to alcohol, and becoming angry.”

Physicians who practice in hospitals are at particular risk for being involved in instances where patients are harmed, partly because of the acuity of patients and partly because they are repeatedly in this environment. In a way, for some physicians and nurses, it is like working in a war zone.

—Albert W. Wu, MD, professor of health policy and management, Johns Hopkins University, Baltimore

What Hospitalists Can Do

Healthcare is changing its culture so reporting adverse events is easier, without an emphasis on assigning blame.

Support is available by phone, disclosure protocols have been created, and practitioners work with risk management personnel to involve patients and families in discussions and apologies. These processes can give physicians a healthy way to be transparent about what happened and also to know that their institutions support them.

Mixed emotions are common after a bad choice or outcome, but the stakes are particularly high in hospital-based specialties.

“Physicians who practice in hospitals are at particular risk for being involved in instances where patients are harmed, partly because of the acuity of patients and partly because they are repeatedly in this environment,” Dr. Wu says. “In a way, for some physicians and nurses, it is like working in a war zone. It is necessary for you to return to that zone to work, even after something bad happens. That, in itself, can be traumatic.”

Experts accentuate the importance of providing hospitalists, especially young ones, the tools to help them recognize and manage post-event emotional baggage. These tools can serve as a roadmap on how to work through their experience.

Periodic debriefing with peers helps hospitalists discuss what’s going on in their practice. But if a hospitalist has not established this trust and support beforehand, it may be difficult to locate the right support after an event occurs.

“There is a healing that goes on when you are able to share with your colleagues who can tell you about their own experiences with this,” says Dr. Shanafelt.

Dr. Feldman agrees. After a couple of bad patient outcomes this year, he needed to talk as much as possible in a few forums, including with his hospitalist group leader and his peers. As the associate program director at his institution, he also checked in with his residents.

“I know how I’m feeling, which is horrible,” Dr. Feldman says. “You know if you’re doing it, your residents are probably doing the same thing.”

Teaching hospitalists can help change the culture by making them willing to share their own experiences with trainees.

“For supervising physicians to say, in effect, to medical students and residents, ‘In my own career, these are things I have experienced and how I’ve worked through them,’ can help young physicians recognize that identifying and working though the consequences of errors on both a professional and personal level is an important part of being a mindful physician,” says Dr. Shanafelt.

Open and humble sharing means trainees can act similarly.

“When we were first presenting our data to the residents in one of our early studies, I often felt like a priest with physicians coming me to confess their mistakes,” Dr. Shanafelt says. “After having this experience repeat itself over and over, I recognized that sharing this was a cathartic event for them.”

The most helpful thing hospitalists can do for each other is listen without judgment.

“We need to realize it is going to happen to each and every one of us, and be prepared to offer a shoulder to cry on to help your colleague work through it,” says Dr. Feldman.

Dr. Wu believes clinicians need to examine their capacity to offer such support.

“We are not as reassuring as we could be,” Dr. Wu says. “I think we tend to hold back, maybe because we are so fearful of the whole idea. Really admitting that this is a normal, common event frightens us too much.”

Error-Management Programs

Several notable hospital programs have or are developing programs to help doctors cope with medical errors.

  • The University of Arizona offers clinicians sessions with trauma treatment experts.
  • Johns Hopkins in Baltimore is developing a pilot program for caregiver support under the leadership of Janel D. Sexton, PhD, MA, a social and health psychologist and an assistant professor in the Department of Anesthesia and Critical Care Medicine.
  • Brigham and Women’s Hospital in Boston employs a program headed by the patient-anesthesiologist team of Linda Kenney and Rick Van Pelt, MD, following an incident in which Kenney nearly died when a preoperative sedative entered her bloodstream. The nonprofit organization Kenney founded in 2002, Medically Induced Trauma Support Services (MITSS), offers counseling and other supports to patients and families following unexpected complications resulting from medical treatment. Their Web site, www.mitss.org, lets providers report events so others can learn from them. MITSS advocates for the development of institutional support services for care providers using peer support.—AS

What Hospitalist Groups Can Do

Cleo Hardin, MD, section chief of pediatric hospital medicine at the University of Arizona in Tucson, says her department deals with post-event distress several ways. Her doctors talk with her, share in their departmental morbidity and mortality conference, and don’t ignore errors and bad outcomes.

“Anytime there is a bad outcome,” Dr. Hardin says, “it is very important for the leader of the group to meet with the individual to ask, ‘What do we need to do to reduce the likelihood that you’re going to develop post-traumatic stress disorder and that you’re going to question everything you do in the future? You are a good doctor. How do we keep you being a good doctor?’ ”

A show of support by the whole team is of utmost importance.

“There is a tremendous amount of camaraderie in the group, and we all understand [that clinical practice] is not an exact science,” Dr. Hardin says. “There’s a lot of art in medicine.”

An expression of that art showed up several years ago in her hospital’s pediatrics unit when a child died on Christmas Day.

“On the day an event happens, I think the person is reeling and in shock and can’t hear anything,” Dr. Hardin says. “I called the hospitalist to ask whether he needed coverage. He declined, saying he was afraid if he got off the horse, he would never get back on.”

The following month they discussed the event at their mortality and morbidity conference; the entire hospitalist section was there.

“We sat together, and it was very clear to the hospitalist involved in the event that he was not there alone,” Dr. Hardin says. “We told him how much we appreciated him and respected him, and we were there to be his support.”

What Leaders Can Do

As the director of the hospitalist program at Johns Hopkins Hospital, Daniel J. Brotman, MD, FACP, understands that the level of upset after a bad outcome can be dramatic.

“Whether or not it was your fault, and independent of any medical-legal ramifications, although those certainly exist,” he says, “there’s a personal sense of just being a human being; of wanting to go back; questioning whether you made a right decision, a wrong decision; and facing whether you would change anything if you could do it again.”

Dr. Brotman believes in leading by example. “What you want is an open-door policy where faculty members can say, ‘Something bad happened, I need to get it off my chest, and I need to do it now,’” he says.

The group leader also needs to know what happened in case there’s a need for damage control beyond the hospitalist group. The leader should ultimately be the one who confers forgiveness.

“If somebody feels they are keeping a secret, it’s going to make matters worse,” Dr. Brotman says.

Research confirms the needs for “confession, restitution, and absolution,” and hospitalists need their competence validated.6

Even though I [have been] honest and said, ‘I don’t think I would have made that decision,’ I also have said, ‘I know that in terms of your thought process, you were acting in the best interest of the patient … and you’re one of the most compassionate physicians I know,” Dr. Brotman says.

As leaders gather information on an adverse event, they may also be in a better position to advocate for the hospitalist in subsequent conversations. In so doing, they can save that individual further embarrassment and humiliation.

“I hope that I’m able to process what I was experiencing in a way that doesn’t paralyze me,” Dr. Feldman says. “But I hope it informs me to the gravity of the situation.” TH

Andrea Sattinger is a medical writer based in North Carolina.

References

  1. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-1078.
  2. Goldberg RM, Kuhn G, Andrew LB, et al. Coping with medical mistakes and errors in judgment. Ann Emerg Med. 2002;39(3):287-292.
  3. Wu AW. Handling hospital errors: is disclosure the best defense? Ann Intern Med. 1999;131(12):970-972.
  4. Wu AW. Medical error: the second victim. BMJ. 2000;320(7237):726-727.
  5. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265(16):2089-2094.
  6. Wears RL, Wu AW. Dealing with failure: the aftermath of errors and adverse events. Ann Emerg Med. 2002;39(3):344-346.

Next Article:

   Comments ()