Telluride Day 2 Reflection by Yimei Huang Pharm.D Candidate 2015

The day started with Dr. Cliff’s “railmen story”–Listen to the Rhythm. I was deeply impressed by Dr. Cliff’s kindness to, and caring for others, whom he does not know and may never know. Not only did he give extra notice to the things easily overlooked as a passerby, but he also carried out his caring despite the inconvenience to himself. I was thinking to myself what in the world could stop this devoted man from becoming extraordinary? He is so caring to the world outside of his expertise, then what level of caring does he pay to his field? I was also reflecting on myself on how far I am behind him as for the caring heart—-how often I overlook what’s going on outside because I am already quite full with my own business?

A fun thing for today was Teeter Totter Game. This was my first time playing the game personally, and I really enjoyed the moments when our team worked so closely for a common end. At those moments, I felt so supported, accompanied and comfortable to come up with and share ideas with my teammates to work out a better plan. We were successful, but it was not the outcome itself that is dearest to me. It was the process before, during and after that 10 minutes. I would say every team has achieved this process and experienced the similar feeling as ours.

The most emotional and thought-provoking activity of the day was discussing the film “The Story of Michael Skolnik”. As I said in the meeting, I am curious to know what measures have been taken in the past ten years to improve. What has been done to cut off the unnecessary incentives that make surgeons desire to do procedures and even induce patients to agree? What has been done to guarantee a second-point checker for the clinical decision even when patients themselves do not have the second resource accessible? What has been done to ensure that risks are thoroughly informed rather than partially? How well is the fact of surgeon’s expertise and experience honestly communicated to patients? How often does it still exist that assuring patient of one senior surgeon to win their signature but actually carrying out the procedure by his/her student? Maybe taping or video taping the informed consent conversation would help? Maybe a consultant meeting with everyone involved in the case would help? Maybe a written form of patient’s teach-back document files to the supervision level would help? Where are we getting right now?

The day ended with a recap on Dr. Cliff’s Listen to the Rhythm. What an inspiring day!

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Infection Rates: It’s not just transparency, it’s informed consent

One of the highlights of the Telluride Patient Safety Summer Camp was the in-depth discussion of the meaning of informed consent. It is not as straightforward as “here, sign this”. In fact the paper consent itself is in a sense the last and least component of informed consent. I was a bit surprised and secretly glad to hear some places have rid themselves of the informed consent form, which reinforces the notion that informed consent is some kind of administrative scut to be dished out to residents. Informed consent isn’t extra, it isn’t something for special procedures, it really should be an integrated part of every doctor-patient relationship. The heart of it is shared decision making and coming to the best course of action based on the patient’s preferences, values, needs, and goals. (“Preferences, values, needs, and goals” was in fact one of my takeaways – a mental checklist worth committing to memory.) Granted, we do have a long way to go in learning the best way to approach individual patients. The ideal of informed consent and shared decision making poses a number of difficult issues. For example, people don’t perceive risks and benefits in the most rational way, especially when presented as numerical probabilities.

Doctor: “The risk of death is 1 in 100,000.”

Patient: “I’m sorry, all I heard was death!”

(Lest we think we are special, it’s people who struggle with perception, not just patients.)

Further difficulties arise when patients are in some ways incapable of truly understanding certain risks because they do not live in the healthcare world. They haven’t seen what it’s like to be in the ICU for a prolonged stay with a “complicated post-op course”. And of course, there is the perception that risks are things that happen to other people, but not to me.

To add to the complexity, doctors may inject their own biases – either optimism or otherwise – into conversations about risks and benefits. “The risks include bleeding, infection, and death, but that’s like any procedure. We kind of have to say that with pretty much any procedure we do these days…”

Again – I think we have a good idea what the ideal of informed consent looks like, but the issues presented in getting there are a different story.

That said, the issue of publishing infection rates comes up in the context of transparency. In fact, infection rates have everything to do with informed consent, too. If I’m having a procedure that puts me at risk for infection, wouldn’t it be nice to know exactly how much risk I’m undertaking, particularly from hospital to hospital? Sure, I could find some bulk statistics for the infection risk of the procedure in a textbook (or government website) somewhere, and that information is likely to be outdated. If I’m having the procedure done at hospital X, then the most accurate estimate of my true risk of infection will most likely be the actual rate of infections at hospital X. If a hospital has enough volume of a certain procedure, they ought to track their own complication rates. It’s more than just transparency, it’s about being as honest and as forthright as you can, and providing patients with the best, most accurate and up-to-date information about what kind of outcomes they can expect when they come to your hospital.

Getting to 50

By Nicole T. Jiam, Johns Hopkins University School of Medicine

About a month ago, I was sitting in on a clinical correlation led by an aneurysm neurosurgeon and his patient at the Johns Hopkins Hospital. These clinical correlations are incredible opportunities for medical school students to learn directly from the patients themselves by hearing their story and then asking them questions.

During this particular clinical correlation, the neurosurgeon discussed the importance of informed consent and the decision making process that stretches over several weeks. The decision to undergo a surgery and which neurosurgeon requires deliberation and time.

At one of the meetings prior to the operation, the Johns Hopkins neurosurgeon candidly told his patient: “One of the most important ways of evaluating physician competency is case volume. You want to pick a surgeon that has a huge wealth of experience doing this procedure.”

To which the patient responded by asking, “So… how many aneurysms have you done?”

During our clinical correlation, the patient recounted the neurosurgeon getting onto his computer. After a few minutes or so, the physician replies, “You will be my 537th.”

In the clinical correlation Q&A, a classmates asks the neurosurgeon, “What number determines competency?” It, of course, varies due to a number of factors, but 50 was thrown as a minimum number.

My classmate then re-raises his hand.

“Well… how do you get to that 50?”

It was a very legitimate question. One I had asked myself.

In these past couple of days, I have witnessed what happens when physicians fail to uphold their responsibility to their patients. Michael Skolnik was a young teenager that died unnecessarily because a neurosurgeon did not provide true informed consent. He did not disclose to the Skolniks that he had only done two cases prior to Michael’s. Furthermore, the neurosurgeon did not take the time to discuss the risks of the surgery and alternatives to the craniotomy. To Skolnik’s neurosurgeon, informed content meant a mere signature and 15 seconds of his time. A life was lost because of this missed conversation.

It was a heart wrenching story, and I felt ashamed for my profession. Telluride Patient Safety Roundtable forced us scholars to face these necessary truths. That lives are lost when we view informed consent as an annoyance rather than a responsibility we owe our patients.

But alas, we revisit the question – how do residents achieve that level of competency without endangering a patient’s life? Someone’s going to have to be number 1…

The Johns Hopkins neurosurgeon answered the question with this:

It is important to be honest with your patient. When a patient comes to me and tells me, “I don’t want a resident touching me”, I will ask him what does he mean by touching. If the patient means draping and prepping, etc., then I will let him know Johns Hopkins is a teaching hospital and that it would be better for him to seek care at a private hospital. But if he means the aneurysm/core of the case, I tell them that I will only let a resident that can do the procedure as good, if not better than me, “touch the patient.”

Residents have been frustrated with me in the past, saying I don’t let them do anything. But that’s because they cannot do the procedure at the standard I demand […] I do believe some residents can become as good as me. They may not be able to do it as quickly but they can certainly achieve the same level of proficiency […]. Aneurysms are not for everyone. I’d be happy to refer to them to a career counselor.

When I first heard his response, it was with mixed emotions. I understand how dangerous aneurysms are. But wasn’t that a bit harsh to imply a career change?

After hearing Michael Skolnik’s story, I recall this answer with fresh perspective and humility. This Johns Hopkins neurosurgeon demanded a standard of care we all owe our patients. How would I feel if a neurosurgeon killed my little brother by refusing to acknowledge his shortcomings? Yes, we all have to learn – but not when lives are at stake.

And if we’re not good enough, maybe we shouldn’t be holding the scalpel in the first place.

By Aaron Cantor, MS1 Pennsylvania State College of Medicine

In just the first day, I feel refreshed to listen to, and take part in, the unique conversations that develop spontaneously after activities and during breaks.  I hope we can discuss results of increased patient safety as a group with regard to medical student training at free-of-charge clinics.  These venues often provide care to vulnerable populations, who medical students may “help” by performing common procedures or assisting an overworked volunteer physician.  Many procedures have an inherent learning curve in which mistakes are common during the learning stages, and these mistakes may cause undue harm to the patient.  There is certainly a fine line between a medical student providing helpful care and learning versus harmful mistakes and discouraging patients from visiting again.  Medical students may also overestimate their skills and find themselves in uncomfortable situations without readily available assistance.  For example, I am aware of situation at a clinic where MSIs and MSIIs were allowed to insert a speculum for a Pap smear.  The students were never formally trained in this procedure but some staff in senior positions thought it would be a good learning opportunity.  Similarly, I have been offered to practice venipuncture for the first time at a health clinic even though I had no prior experience.  Yes, it seemed to be good chance to learn and a relatively innocuous procedure, but I still felt uncomfortable with trying this procedure for the first time on vulnerable patients who may already lack trust in the medical community.  Advances in patient safety should help avoid these situations but the counterargument focuses on what better methods can be employed to provide experiential training on real people.  I think practicing on each other would be a good start, but certain procedures obviously negate this possibility.

See One, Do One…#TPSER8

There’s an old adage in medical education “see one, do one, teach one.” I don’t particularly subscribe to it in a literal sense because I think training requires a more intensive learning process than that.  But sometimes it does apply quite nicely.  A perfect example of this was on Wednesday when I helped run a session about shared decision making and informed consent at our new house staff orientation.  The session consisted of a viewing of the video of Michael Skolnik’s story followed by a moderated discussion with the house staff.  The idea came out of a casual conversation with my hospital’s Associate Vice President for Academic Affairs.  I thought it would be a helpful to new residents to think about these important issues before they really start on the wards and she let me run with it.   Just two weeks out of TPSER8, I just felt the itch to continue sharing what I’ve learned.  I had never led anything like this, but after seeing how David Mayer and Tim McDonald guided our discussion in Telluride I was inspired to try it myself.  I had some great help from a fellow Telluride alum, Hilary Kunizaki as well as several other CIR staff who came for the session.  Here are a few comments from the new house staff:

  • I asked, “What do you do when patients don’t understand a treatment or procedure?” and had some great responses: “draw a picture”, “have someone else ask” and “figure out if there is a language barrier”
  • In regards to the stereotype that general practitioners know less than specialists, the interns suggested that specialists should work with PMDs in a team-like manner, concentrate on common goals and the interests of patients, and verify information by referring back to the literature.
  • There was some hesitance among  house staff who might be doing a procedure for the first time about admitting their inexperience to patients so I pushed them to consider an appropriate response.  Interns said they would tell patients that “they were under supervision and working with attending X who has x number of years of experience.”
  • Important strategies to verify consent included the “teach-back” method, assessing capacity to make a decision, and involvement of family members.
  • One intern said that “no one patient is an island” and echoed the consensus that involving family members is important even if the patient is over the age of being legally able to sign an informed consent document.
  • Some difficulties that residents mentioned when performing informed consent include language barriers, time, and dealing with patients who are uncooperative.

Overall, the new house staff seemed to really enjoy having the opportunity to be engaged in a discussion rather than just hear a lecture about the importance of informed consent.  I think this further proved the importance of narratives in medicine.  I’m looking forward to holding more conversations like this in the future.

It’s All About Conversation #TPSER8

The theme for Day Two in Telluride brought home the value of conversation and communication. Shared decision-making and the process of informed consent once again provided fuel for a robust conversation following Day Two’s viewing of the educational documentary film, From Tears to Transparency–The Story of Michael Skolnik. One student’s comment, “We can’t expect the patient’s family to know they need to be informed,” was a good reminder that keeping patients and families at the center of the solutions being generated in Telluride is again why we are all here.

A second student commented that after the group’s conversation, she now feels “unqualified to get an informed consent,” sharing that she always refers to the risks and benefits of a procedure, but has never discussed alternatives to the procedure. Like the family, unaware of what they need to be informed about, how will medical students know what the informed consent process encompasses unless they are taught? Over the course of these three weeks in Telluride, the need for greater education around informed consent and shared decision-making has been made very clear. Thanks to all for your contributions to this conversation! Continue it here on the blog–

Also, with us this week in Telluride is SolidLine Media, a team of creative filmmakers from Chicago responsible for the production of last year’s Telluride Roundtable video and the award-winning films, The Stories of Lewis Blackman and Michael Skolnik. The films never fail to generate conversation around the tough situations that arise as a result of a medical error. Greg Vass, Executive Producer at SolidLine, has a team of 7 this year to capture additional footage for future projects.  As always, the team wholeheartedly embraces our mission of improving healthcare, and SolidLine intern, Ryne Knudson, wrote an insightful post, Reflections from the Interns, on their blog around his impressions of filming our group.

And finally, the small and large group discussions along with team-building exercises throughout the week are the heart of the learning model in Telluride. This photo captures a small group deep in discussion on leadership topics taught by Ann Gunderson on Day Two.

On “Informed” Consent and Walking the Line by Natalie Kress #TPSER8

As day two neared a close, a spontaneous conversation amongst roommates touched on two topics relevant to our discussions today.

1.  “Informed” Consent

The goal of informed consent is simple: to provide the necessary information that allows the patient to reach a decision regarding his or her health.  Today we discussed the pitfalls that have led me to view the word informed in a different light.  From obtaining consent in less-than-ideal situations to forms filled with complicated jargon, it seems to me that the current consent process requires the patient to be vigilant.  In many ways it seems that the burden of responsibility to understand the decision-at-hand has been placed on the patient.  Is a system where the burden of responsibility is placed on the patient safe?

2.  Value in Walking the Line?

In various activities yesterday and today, the theme of self-evaluation has been prevalent.  We have been asked to self-evaluate our leadership and listening skills, to name a few.  One interesting tangent from these introspective activities was discussed informally this evening:  what is the value, as a medical professional, in walking the line?  Despite being told to set our personal biases aside when interacting with patients (which is much easier said than done), would it be beneficial to walk the line/ride the fence on certain issues?  Would this approach allow you as a caregiver to be flexible in understanding your patients?  On how many issues do you truly have the ability to understand both sides of the argument?  And how valued is this trait in medicine?

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