GOAL: Appreciate the idea of aftermath of medical error and idea of provider as second victim..
Context and Instructions: Read article to begin to appreciate medical errors can have on providers and get introduced to a way of thinking of how to support ourselves and colleagues who experience the aftermath of a medical error.
**Keep in mind that this session will focus on cases that are meant to draw out population level biases and ethical concerns in particular clinical interactions. We will be addressing more societal, systematic, and broader justice issues (e.g. human rights) in Week 4 of EHM. Likewise, we will come back to system level methods of advocacy (including advocacy for clinicians with underrepresented minority identities) in later weeks. Here, our intention is to start thinking creatively about how to build relationships with and advocate for patients.**
(2) Then, WATCH this TED Talk by philosopher Onora O’Neill on trust and trustworthiness…
As you’re watching, consider the following:
What kinds of vulnerabilities in the healthcare setting might cause one to be perceived as untrustworthy despite having a trustworthy character?
What are the distinctive responsibilities of clinicians to overcome bias in trusting their patients and achieve trustworthiness in their relationships with patients?
the concepts of autonomy and trust when the patient/family/physician may have different perspectives about the best course of action.
How do you think building trustworthiness relates to promoting patient autonomy?
(4) APPLY what you have learned so far by reflecting briefly on CASE 1…
ID / HPI: Beatrice is a 84 year old woman who was admitted to the hospital with a new diagnosis of tracheal cancer. She had been experiencing increasing shortness of breath at home for the past 2 months, but she had been avoiding the doctor. This shortness of breath got acutely worse 2 weeks ago and her friends at church convinced her to call 911. In the emergency department, she was found to have a large obstructing lesion on her trachea. She was taken for an emergent tracheotomy (incision in the anterior aspect of the neck directly into the trachea), and a biopsy of the tracheal mass, which came back positive for tracheal cancer. She was admitted to the hospital for surgical recovery. She continues to have a large amount of upper airway secretions that require suctioning deep inside the tracheostomy hole (otherwise they block her airway and prevent her breathing well). The suctioning has been done by respiratory therapy – Beatrice has not been able to do her own suctioning independently. When she has a large amount of secretions, she has respiratory distress and her oxygen level drops, requiring urgent suctioning and attention from multiple nurses, respiratory therapists, and members of her physician team. This has happened at least every other day since admission. The surgeons think the secretions may persist for weeks to months, and are related to the cancer.
Past Medical History: Moderate chronic obstructive pulmonary disease (COPD), stable. Diabetes mellitus type 2 , controlled with diet. Mild memory impairment (forgetful in the past few years with names)
Functional status: Stopped driving due to vision and her concern about memory. Managing her own bills and household, does her own cooking, cleaning, and other house chores. Has had a caregiver through state funding in the past to help with occasional grocery shopping.
Social History: Beatrice lives independently in a 1 level house out in the country, and has done so proudly since her husband died 9 years ago. She has no other family or friends who are able to support her 24 hours a day, or who are available to take her to prolonged treatments. Beatrice has 2 cats that she adores – her neighbor (who is also elderly) is caring for them right now – and they are a big reason she wants to go home.
Treatment options: Doctors feel that she is not a good candidate for cancer resection by laryngectomy; they recommended outpatient radiation therapy (daily for 6 weeks, 90 minutes per session) which may extend her life by several months. Without either of these, they estimate she will live 6-9 months, if she has good secretion management. Without good secretion management, she may have respiratory arrest due to the secretions blocking her airway or develop pneumonia. Members of the medical team think Beatrice needs to go to a nursing facility because they don’t think she can manage to do suctioning of her secretions on her own. There is some concern that she could die suddenly even on transport home because of trouble with secretion management. There is no option (that she can afford) that offers 24 hour home care.
Beatrice’s goals: Beatrice wants to go home ASAP and be in her own house. She declines a nursing facility or rehab facility under any circumstance. She is amenable to having suction equipment and oxygen delivered to her house. She doesn’t see how she could make radiation therapy happen. She states “I would rather die at home than sit in this hospital or go to a nursing home. That is no life.” She is able to clearly state her diagnosis, the recommendations of the medical team that she go to a skilled facility for respiratory management, and the risks, benefits, and consequences of going to a skilled facility vs. going home.
In class, we will use the Ethics Toolkit to work through the ethical analysis of the case. We will then have a large group discussion about Beatrice’s goals and those of the care team, and will wrestle with how they align and how they conflict. We will consider the concept of ‘first do no harm’ and how that applies in this case.
(5) Now WATCH this short clip from Dr. Gabor Maté…
And this TED Talk by Johann Hari…
After watching these talks, reflect on the case of Moira below…
(6) Finally, in light of what you’ve learned above, read and reflect on Case 2:
Moira is a 28yr old woman with two children (7 and 9yrs old). She has a history of endocarditis and has been admitted for volume overload. She has been admitted several times over the past 6 years and has already received multiple surgical interventions (including two valve replacements). Her endocarditis is exacerbated by ongoing IV drug use. While she is consistently open about her drug use and desire to stop, she continues to use. Each time, staff have been surprised by her ability to recover from surgery, but also frustrated by each new admission. She is currently being considered for a third valve replacement.
Moira alternates between passive acceptance of her care and anger at staff. She will sometimes knock food off her tray or verbally lash out at medical staff (e.g. “just leave me alone!” or “don’t pretend you care!”). Because of this, staff members have warned each other to take caution when entering her room. Moira has a behavior contract and often behaves more passively when her father (Rick) is in the room. So, the medical team often waits until the father is present to conference with the patient. But Moira is often alone in her room as her father is very busy with his job and taking care of Moira’s two children.
The medical team disagrees about whether or not to offer the valve to Moira. While one of her nurses doesn’t understand why it has not yet been offered, another feels burnt out from caring for Moira over several admissions and is frustrated by Moira’s lack of participation in her care. Similarly, while the attending is reluctant to do another valve replacement, the resident believes that she is a sufficiently good candidate medically.
Moira and her family have been consistently homeless or houseless. She had been staying in a shelter with her children prior to the current admission. While the children’s father is not present, Moira’s father Rick is very involved in her care and is in the process of adopting the two children.
Should Moira be offered another valve replacement?
In small groups, we will first use the Ethics Toolkit to work through the ethical analysis of the case, and then will run a mock family meeting to explore Moira’s goals and obstacles / challenges to her health and care.
Trust and the virtue of trustworthiness are integral to the moral life. At a very basic level, society requires trust to function (e.g. what if you couldn’t trust your bank to hold your money?, or e.g. what if you couldn’t trust that teachers were doing their best to provide accurate information?, or e.g. what if you couldn’t trust your doctors to keep their interactions with you confidential?). In order to survive and flourish with those around us, we must be able to trust each other.
It is important to note that trust also makes us vulnerable. To trust in another is to make oneself vulnerable to that person or system. This point is a key feature of patient care. Physicians depend on patient’s to trust them in their care for them to be successful. Likewise, patients depend on physicians not to abuse their trust. When physicians and patients are able to engage in trusting relationships and be trustworthy, we have a better chance of enhancing the wellbeing of the patient, the physician, and the relationship.
Relations of trust are also vulnerable to social norms and history. Norms that categorize a particular population as not trustworthy can affect patient care and pose significant challenges to clinician-patient relationships. For instance, it is common for clinicians to distrust the demands of patients with Sickle Cell Disease, particularly by doubting the validity of their requests for stronger pain medications in a crisis. This mistrust is tied up in social perception of opioids as well as the visible identity of being black (as many sickle cell patients are). So, when building trust and trustworthiness in relations with patients, we must acknowledge how social norms and history can affect those efforts.
Reading Aristotle is hard! But we think you can do it! It will create some discomfort for everyone. We do NOT expect you to master these concepts – it is more important in this session to be open, brave, vulnerable, and interested in growth than it is to be ‘right’. See what you can gather from the reading and use the PDF’s highlighting and prompts to guide you if you’re having trouble.
Read over this Facebook Post and reflect on how values and virtues can or cannot be demonstrated on social media. This was a post by a fellow student.
If you’re feeling eager for more… explore this article on How to Teach Doctors Empathy which talks about the growing emphasis on empathy training for health care professionals and describes a few such trainings across the country.
Start by reading this JAMA Piece of My Mind “Speak Up”which describes one physician’s experience with speaking up when witnessing micro-aggressions or biased comments or behavior in the clinical workplace.
Then read this post from STAT News that describes a medical student’s experience with racist comments during her clinical training and how it felt when no one spoke out against it.
ToolsforResponding to Bias
Goal: Communicate a message of disapproval without damaging interpersonal relations
Rehearse what you would do or say in situations before they occur
You know what feels most natural for you
Remember the Bystander effect
No one else will probably say anything
Consider saying something, even if it is a small effort
Decide whether to say anything
Silence is often interpreted as passive complicity
Consider saying something simple like “that’s not cool” or “I don’t appreciate that”
You don’t have to take a dramatic stand if you’re not comfortable or not able
Consider taking more time if:
You know you respond badly in the heat of the moment
You fear retaliation or mistreatment and need more support
The situation is not appropriate (ie during a patient care emergency)
Try to speak calmly, or consider waiting until another time
Try to avoid inducing defensiveness
Clarify or Restate what was said
Make sure you are understanding what was said
Make the speaker think about what they said
“So I am hearing you say….” Or even “excuse me, what was that you just said?”
If a joke was made, ask the speaker to explain it to you
When identifying the behavior, avoid labeling, name-calling or the use of loaded terms.
Describe the behavior; don’t label the person.
Appeal to principles
“I’m surprised to hear you say that. I think of you as more… (egalitarian, open-minded, etc).”
Change the subject (more effective than it sounds)
You may not change beliefs but you may change behavior
Reflect on what happened
Journaling or meditation
Debriefing with a peer or college mentor
It’s never too late to bring it up
Defer until later: “let’s talk about this when we have more time”
Bring it up later: “I’ve been thinking about what you said last week…”
Don’t get discouraged
You won’t know the lasting impact you’ll have later on, both for the speaker and those who were present
Know your resources
College mentors and college heads
Other trusted faculty
Student Affairs office
Traps to Avoid
Avoid making light of any comments, making jokes (which often backfire!), or getting defensive
What makes a good community? What values do communities hold? In thinking about building and enriching our own medical school community, and working together to establish some ‘norms’ of how we would like to engage, it is helpful to look for lessons from other academic communities.
The concept of a community agreement in higher education was advanced by the work of Earnest Boyer and other researchers and published in their report Campus Life: In Search of Community in 1990, funded by the Carnegie Foundation for the Advancement of Teaching. In their study, Boyer and colleagues identified six characteristics that define a positive academic community:
Boyer’s Principles of Community
A college is an educationally purposeful community, a place where faculty and students share academic goals and work together to strengthen teaching and learning on the campus
A college is an open community, a place where freedom of expression is uncompromisingly protected and where civility is powerfully affirmed.
A college is a just community, a place where the sacredness of the person is honored and where diversity is aggressively pursued.
A college is a disciplined community, a place where individuals accept their obligations to the group and where well-defined governance procedures guide behavior for the common good.
A college is a caring community, a place where the well-being of each member is sensitively supported and where service to others is encouraged.
A college is a celebrative community, one in which the heritage of the institution is remembered and where rituals affirming both tradition and change are widely shared.
Taken from Ernest L. Boyer’s Campus Life: In Search of Community, 1990
We share core professional values but sometimes our values conflict with those of another (perfectly reasonable) team member. The training and practice of an occupational therapist emphasizes safety, which was in direct conflict with patient autonomy in this specific patient case.
Conflicting opinions are a normal part of working in teams. Successful teams a) assume positive intent, b) listen to each other, c) make sure every person on the team expresses their view, and d) concludes conflicts by negotiating a plan for next step/s.
Place the patient at the center of the team. Understanding the patient’s perspective on health and healthcare places the patient at the center of the team’s conversation, and can help all team members get behind a plan that meets the patient’s needs.
Listening and speaking up are critical team skills. Listen as much (or more) than you speak. But speaking up is important for all team members to share their concerns or new information.
We can’t always be the hero. Sometimes we can’t “save” a patient. When we have different goals or health beliefs than a patient, we may not always feel good about our what we are able to do (allowed to do) for a patient or the patient’s outcome.
Don’t take it personally. When you feel challenged by a patient, ask other team members how it’s going for them. Don’t assume you’re the problem, or are the only one having difficulty. If you’re frustrated, it’s likely others on the team are too.
Talk to your team first. When you feel challenged by a patient, don’t go it alone. Use your team to help you problem solve. Difficult patients can split us as teams. Knowing other’s roles and responsibilities and using them to full potential can share the burden of high maintenance patients.
Think broadly when you think “team”. Physicians, nurses, pharmacists and social workers practice in close proximity, often rounding together, but other team members may not be in the loop. Remember to include everyone in challenging care decisions.
Support your team members. Especially when we have a challenging patient, we need to rely on and trust our team members to do their jobs. Work together to adopt a common approach.
Working with Challenging Patients
“Difficult” patients: Challenging behavior is often a sign that, from the patient’s perspective, her/his needs aren’t being met.
Engaging patients: Exploring patient’s preferences in a non-judgmental way is key to enhancing motivation and engagement, both of which are essential to effective care.
Respect for patient autonomy: Ultimately, patients make their own decisions. The challenge for providers is to take the journey with them, work creatively to bridge medical aims and patient priorities, and provide support.
This document reviews the importance of professionalism is the basis of medicine’s contract with society and that understanding the principles and responsibilities of medical professionalism is key to physicians social contract with society.
Why Does Professionalism Matter? : Trust, Transparency and Accountability
This video (3:34) shows senior physicians from around the country exploring why professionalism is integral to physicians maintaining trust with patients. It stresses that trust and accountability are key focuses to continue to keep at the center of physicians practice. At 1 minutes 30 seconds, the provider talks about how at times there will be conflict when there are competing needs but that it is important to embrace and face the conflict to better understand it.
Association Between Physician Burnout and Identification With Medicine as a Calling
This research paper seeks to evaluate the association between degree of professional burnout and physicians’ sense of calling. Study identifies that physicians who experience more burnout are less likely to identify with medicine as a calling. It implies that loss of the sense of medicine as a calling may have adverse consequences for physicians and patients
Conflict is frequent and inevitable in healthcare. Why?
We have different personal and professional values. Moral issues and values often play a role in medical care and decision-making, and the values of individual team members may at times conflict.
We may have a different understanding of the same patient or situation. For example, one physician may see a patient as having a potentially treatable illness, while another sees him as someone who is suffering and should be allowed to die peacefully.
There is often not a single “right” or evidence-based answer. The different experiences of team members may lead to different approaches to the same patient or issue.
We come from diverse cultural backgrounds. Team members – including patients – all bring their personalities and cultures to the table, and icebergs can bump.
Working in healthcare is stressful and can cause individual ‘resource depletion’. Fatigue, stress, and burnout all make conflict more likely.
We may have inadequate institutional resources, leading to tussles to get our patients what they need – the next operating room, an expensive medication, etc.
Health professionals AND medical students need to have a constructive approach to conflict
To provide the safest and highest quality care for patients
To create a safe learning and working environment for ourselves and our colleagues
To build and maintain relationships with each other. Health care team members often work together for years. Medical school classmates will be a source of support for each other, and may find themselves in the same residency programs and ultimately practicing together.
Conflict Handling Modes
TKI Conflict Handling Modes
A competing style is higher in assertion and lower in cooperation. Someone using a competing style might approach the conflict by making as strong a case as they can for their own position. They may be very amiable and polite about it – competing does NOT mean harsh – but they have a viewpoint that they strongly assert.
Perhaps someone using a competing style is very confident that hers is the correct position. She may be in a position of power and intend to pursue this course even if it is unpopular with others – a competitive style may avoid wasting time in meaningless discussion if the course is already set.
A collaborating style is both assertive and cooperative. Someone using a collaborative style might approach a conflict as an opportunity to work together to build the best possible understanding or solution. He would express his own perspective, but would also elicit and listen to the perspectives of others.
Perhaps someone using a collaborative style knows that each member of the group is likely to have different ideas and input, and that all might be contribute to the group’s understanding of a critical issue, or to solving a challenging problem. He may want to build strong relationships within the group, even though it might take a lot more time than a less cooperative style.
A compromising style is medium in both assertiveness and cooperativeness. Someone using a compromising style might approach the conflict as an opportunity to meet in the middle, to give and take to find something all group members can live with.
An avoiding style is low in both assertiveness and cooperativeness. Someone using an avoiding style does not share their own perspective or listen to others – they don’t want to engage with this conflict right now!
Perhaps someone using an avoiding style needs time to process their own thoughts or cool down, and they plan to return to the topic later on. Or perhaps the issue is unimportant to them, or they don’t think they have the power to make change.
An accommodating style is low on assertiveness, but high in cooperativeness. Someone who is using an accommodating style is putting the concerns or needs of others ahead of their own.
Perhaps someone using an accommodating style knows that the issue is far more important to the other(s) than it is to them, or that the relationship is more important than the issue.
An Approach to Handling Conflict
Can we insert vital talk web page here? http://vitaltalk.org/guides/conflicts/ ALT TEAM