Hard Conversations: How to Teach Medical Residents the Elements of Error Disclosure

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There are many potential barriers to disclosure of adverse events and medical errors. First, admission of a mistake (or even an untoward outcome in the absence of a mistake) carries risk to the caregiver. They may fear litigation, loss of job or licensure, and loss of reputation. Second, there is considerable diversity of patients’ expectations as well as institutional culture regarding what patients wish to know and what they have a right to know. Also, it is sometimes difficult to explain complex medical phenomena in a way that is meaningful to the patient. Perhaps more importantly, there is a paucity of training regarding the essential elements of a disclosure conversation combined with very little practice during residency training.

This last piece is the core of a workshop my colleagues and I are giving at the Society for Education in Anesthesia Spring Meeting in Salt Lake City this weekend. Co-sponsored by the American Society of Anesthesiologists, this meeting is targeted towards educational leaders of residency programs in the US. Our workshop, entitled Talking to Families After Critical Events: Educating Our Residents, is intended to help educators develop curricula to teach the art of disclosure. We consider the essential elements of these conversations to include:

· An account of the events, including any errors or care decisions that may be linked to the adverse outcome

· An apology if a mistake has been made, and empathy for the outcome

· What will happen next?

  • A care plan to treat the patient, and an understanding of the prognosis or impact
  • An investigation timeline, so that patients and families know when they can expect to hear the facts (which are usually not known in the immediate aftermath, and require a root cause analysis or other event debrief)
  • Any institutional changes that will improve safety and prevent the error from happening again

Because errors that result in significant adverse outcomes are fortunately rare in anesthesiology, residents may not receive much “real world” practice during their training years. We suggest using role-play opportunities based on simulation, video, or standardized patient interactions for practice of this important aspect of professional development. Virtual simulation or medical gaming may also be an avenue for practice.

Though barriers do exist, there are many benefits to full disclosure. Beyond the obvious ethical obligation to do so, disclosure studies show that these challenging conversations actually lead to enhanced trust between patient and doctor, as well as reduced litigation. The processes bulleted above lead to learning, not only for those involved, but usually for the institution at large. Finally, it has been well demonstrated that physicians bear significant psychological burdens when they are involved in an adverse outcome, whether an error was involved or not. Disclosure may help mitigate the impact of the “second victim” phenomenon on those caregivers, which ultimately improves safety for all subsequent patients.

What do you think are the essential elements of a physician or hospital response to error?

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