Premature closure and the importance of a differential diagnosis #TPSER8

By Barbara C. Nzegwu, M3
The University of Toledo College of Medicine

The first day of the telluride roundtable was filled with great introduction into the great discussions that we would be having the rest of the week. We started with the story of 15 year old Lewis Blackman and how he lost his life due to a costly mistake and inattentiveness made by  his medical team. This was a powerful story to me not only because his mother, Helen Haskell, was among us sitting just two rows ahead of me, but also because as the story was being told, I was able to pick up on what the diagnosis of a perforation with the symptoms of an acute abdomen as the movie told his story.  And I only have a third year medical student education.  I felt the injustice and the less than standard of care that Lewis and his family had received. One of the objectives of the movie was to understand the term premature closure and to recognize when we are doing it in medical practice. To me the term premature closure means that one doesn’t take time to go through a differential diagnosis. It means that doctors, residents, students become so set in their thoughts, mindsets, ways that we think that once we’ve come up with what we think the diagnosis is, then we can never be wrong. I remember learning the concept of differential diagnosis in my 1st and 2nd years of medical school. I was not particularly fond of it because I always thought it took too much time. I remember thinking, “Why do I need another diagnosis when this presentation is so classic, it can only be just this one answer?” It was during my third year of medical school that the concept became so invaluable to me in regards to the chief complaints of my patients.  Once a differential diagnosis is set, then the process of ruling out can occur. And this occurs by lab tests and imaging in conjunction with revisiting the key items from the history and physical. The fact that Lewis didn’t have any such process conducted throughout the course of his medical care is injustice and is not the standard of care. I sincerely pray to God that as I continue with my medical education and even when I begin my practice, that I never adopt a practice of premature closure and that I will always practice going through a differential.

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Where is the Med Student Andon Cord?


LEAN in a nutshell–Dave LaHote’s masterful diagram

The theme of our second day at Telluride was about reporting, risk management and quality improvement. We learned about the great examples that UIC and the University of Michigan Health System have set in adopting a policy of transparency and timely open and honest communication with patients when it comes to medical errors. The systems not only have resulted in improving direct communication between providers and patients, but have also led to significant cost savings (click here to learn more). The most important aspect of the system is that it allows a health system to engage in continuous quality improvement and learn from its mistakes.

However, as the discussion continued, we realized that while events at these health systems will trigger a process of error analysis and patient communication, many systems are severely lacking in a mechanism for medical students and residents to report errors and contribute to the process of continuous quality improvement for themselves and the system. Referencing LEAN manufacturing, what medical students and residents lack is an andon cord, a mechanism that “stops the line” and alerts management of a quality improvement problem. Without a process for safe reporting, medical students and residents become underutilized participants of the quality system.

The above diagram was drawn by LEAN expert, Dave LaHote. The diagram, while simple, wholly captures the essence of LEAN. What LEAN aims to do is align best practice standards with reality. If reality is different, then there is a process in place that allows individuals to “stop the line” and alert the need for a timely response of analysis and creation of a countermeasure to realign reality with the standard.

For those of you who do have a system for medical student error reporting, how does it work? Do you receive any feedback on errors that you report? Do these errors include only severe adverse events or near misses too? Are the reports anonymous? Is it a computer form or a trusted faculty member that you can report to? Tell me, describe your andon cord.

Lewis Blackman Film Discussion Day 1 – Telluride

Student scholars and medical education leaders joined in a group discussion after watching the film that shed light on areas of opportunity in healthcare across the country. Comments touched on the over-arching failure of leadership that led to the communication breakdown in Lewis’ case and the national need to empower students, interns and nurses to ask the necessary questions to keep patients safe today.  When no one is willing to say “I don’t know” the patient is at risk. Lewis and his mom, Helen Haskell, whose life’s work has become keeping all of us safe in the hospital, paid the ultimate price for the inability to exchange three simple words.

What can be done to create a culture starting in medical school that welcomes these questions, allows providers to maintain belief in their abilities while still doubting an initial diagnosis and communicate with one another openly, transparently and with respectful professionalism?

Skolnik Medical Transparency Expansion Bill Expands Information Available To Patients

On June 10th of this year, Colorado Governor Bill Ritter signed Senate Bill 124, better known as the Michael Skolnik Medical Transparency Expansion Bill, enlarging the circle of healthcare professionals in the state of Colorado that must make available all information related to their training, qualifications, criminal, disciplinary and malpractice history to healthcare consumers.

In 2007, Senator Morgan Carroll of Colorado, along with Patty and David Skolnik, championed the original Michael Skolnik Medical Transparency Act (HB 07-1331). This bill requires physicians in Colorado to report education, certain business relationships, malpractice involvement, and any disciplinary action or crimes. The bill is named after Patty and David’s son Michael, whose needless death at twenty-five years-old was the result of a surgery where related information was not disclosed to the family. Since Michael’s death in 2004, his mother, Patty Skolnik, has fought for greater transparency in healthcare. The expansion bill, passed earlier this summer, is further acknowledgement that there is a need to nurture a patient-centered approach to the delivery of health care services that starts with transparency.

Congratulations to Patty and David on this recent milestone in their continued efforts to make healthcare safer for all of us. Their ability and willingness to transform their tragic loss into prevention of similar events is changing the culture of medicine for the better.

McDonald, Mayer and UIC Awarded AHRQ Grant to Further Patient Safety Efforts

On June 11, the Department of Health and Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ) awarded a number of grants to support State and health systems in their efforts to implement and evaluate patient safety approaches and medical liability reform. Transparent Health Co-Founders, Tim McDonald MD and Dave Mayer MD, along with the University of Illinois at Chicago, are the Principal, and Co-Investigator respectively, on one of the largest remunerated demonstration and planning grants recently awarded by AHRQ, a part of President Barack Obama’s patient safety and medical liability initiative announced last year. See press release for additional details.

“As Co-Executive Directors of the University of Illinois at Chicago Institute for Patient Safety Excellence [UIC IPSE], Dave Mayer and I feel highly honored that our grant proposal: The Seven Pillars: Bridging the Patient Safety – Medical Liability Chasm received notice of $3M in funding from AHRQ,” comments McDonald. “The grant provides UIC IPSE the resources to transport the “principled approach” to patient harm to at least nine other Chicago area medical centers.”

“The “Seven Pillars” approach, with its emphasis on transparency, 1.) Puts patients first 2.) Concentrates on effective communication 3.) Focuses on the prevention of medical errors and; 4.) Provides for a rapid, compassionate response when inappropriate care causes patient harm,” explains McDonald. “With a rigorous research model, we intend to demonstrate the effectiveness of this approach at improving patient safety while simultaneously reducing medical liability. Once demonstrated we hope the model will become a “best practice” throughout all of healthcare and replace the traditional “deny, defend, shame and blame” response to patient harm as it currently exists.”

This is continued affirmation that patient safety, as well as a patient-centered response to medical error, is becoming an even greater priority in the cultural shift medicine is beginning to embrace. We look forward to sharing more about the progress of the Seven Pillars project.

Visitors and Guests

In May, our newly appointed leader of CMS, Dr. Don Berwick, gave the graduation address at Yale University Medical School where his daughter was entering the ranks of newly anointed physicians. The graduation address has all but gone viral, making its way to those of us in Chicago so interested to hear the heart-felt health care experiences Dr. Berwick shares whenever he speaks. While the entire address was quite moving, what struck me most was the humility with which he views his profession, and his place within the circle of doctor-patient involvement. Here is an excerpt that I found particularly moving and speaks to the importance of delivering health care in a way that puts the patient first:

…What is at stake here may seem a small thing in the face of the enormous health care world you have joined. It is as a nickel to the $2.6 trillion industry. But that small thing is what matters. I will tell you: it is all that matters. All that matters is the person. The person. The individual. The patient. The poet. The lover. The adventurer. The frightened soul. The wondering mind. The learned mind. The Husband. The Wife. The Son. The Daughter. In the moment.

In the moment, it is all about choice. You have a magical opportunity. You have the opportunity to decide. Yes, you can read the rule book; and someday you can even write the rule book. Decide. Yes, you can hide behind the protocols and the policies. Decide. Yes, you can say “we,” when you mean, “I.” Yes, you can lock the door. “Sorry, Mrs. Gruzenski, your 30 minutes are up.” You can say that. But, you can also unlock the door. You can ask, “Shall I call you “Dr. Gruzenski”? “Would you like to be alone?” “Is this a convenient time?” “Is there something else I can do for you?” You can say, “You‟re the boss.” You can say, “Tell me about the best trip you ever took. Tell me about the time you saw your daughter born.”

…Decide. You can read the rules. Or, you can say, “Pardon me.” “Pardon this unwelcome interruption in your lives. Thank you for inviting me to help. Thank you for letting me visit. I am your guest, and I know it. Now, please, Mrs. Gruzenski, Dr. Gruzenski, what may I do for you?”…

To see the entire address go to http://www.ihi.org or google ‘don berwick yale medical school address’…and please, share your comments.

Shared Decision-Making and Open, Honest Communication Change Outcomes

Rick Boothman sharing insights on open and honest communication related to adverse events.

What an amazing and invigorating second day of discovery and consensus building at our Telluride Roundtable on “Open and Honest Communication Skills in Healthcare”. The high altitude and beautiful mountain valley scenery have ways of opening up creative thought processes that lead to amazing new ideas. Some reflections from day two:

  1. Our second day focused on what patients and family expect related to open and honest communications in the domains of (a) informed consent and (b) when harm occurs from our care. Rosemary Gibson and Helen Haskell led the morning session which quickly evolved from the concept of informed consent to one of shared decision-making. David Longnecker talked about the “partnership” between patients and their caregivers when decisions on care need to be made and stressed that open and honest communication must go both ways in those critical discussions.  Cliff Hughes from Australia and Rick Boothman from Michigan both highlighted that open and honest conversations between patients and caregiver is not only the first component in transparent care, it is one of the best risk management strategies an organization can put in place because open and honest conversation reduces the “surprise factor” that can occur later if care does not go as expected. The morning ended with the consensus conclusion that “open and honest conversations can change outcomes” when it comes to true informed consent and shared decision-making related to patient care.
  2. The afternoon session was devoted to building curricular models around open and honest communication when harm occurs. Rick Boothman and Tim McDonald led small group break-outs that put together a curricular model on the current medical-legal environment and how a “principled approach” to unanticipated harm reduces medical liability, improves patient safety and helps restore trust. The students were totally engaged and worked alongside patients and healthcare leaders to put together an outstanding curricular model that will help educate inter-professional caregivers and attorneys on the importance of open and honest communication in healthcare.

David Pierce sharing his small group work from one of the break-out sessions.

Day two was a remarkable day – everyone broke from our traditional mental models that held us back on Monday and focused all creative and disruptive energies on the topic at hand. The student’s active participation in both our small group breakouts and large group consensus building sessions added great insights. Their ability to see issues related to open and honest communication in healthcare without pre-existing biases brought emphasis to right from wrong.

A solid foundation for a curricular model on open and honest communication skills is now in place. I am confident participants will build on this foundation in the next three days and produce a solid product by the end of the week.



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