Why is Pushing the Wrong Button So Easy?

By Sarveshwari Singh

On the first day of the Telluride East Summer Camp, Kathy Pischke-Winn and Dr. Joe Halbach organized a game using dominoes.   It really showed how miscommunication in health care can happen so easily and how simple steps can prevent it.

We assembled in groups of three — one person role-played a doctor, another a nurse, and the other an administrator.  The physician sat with his/her back to the nurse and instructed the nurse how to arrange the dominos according to a prescribed pattern.  The nurse couldn’t ask any questions.  Not surprisingly, the nurse didn’t arrange them correctly.

This scenario brought home how communication disconnects among clinicians happens so often in health care, and it underscores why a leading cause of errors is failure in communication.  Also, informal rules can deter students and residents from asking questions, which can lead to a really bad outcome. That’s what happened to Lewis Blackman, as we saw in Tears to Transparency.

Next, the group got a different domino pattern and could have a briefing before the start of the game.  Also, I noticed that in our group, the person playing the physician gave more precise instructions and repeated them for more clarity.  So there was learning and improvement between the first and second rounds. This time, the person role-playing the nurse arranged the dominoes correctly.

I took away from this experience lessons on how I need to be precise in communicating, whether in the classroom, at work or at home.


John Wooden’s Spirit Alive and Well in Telluride–#TPSER8

“If they haven’t learned it, you haven’t taught it.” This was a Woodenism oft quoted at the Resident Summer Camp in Telluride by special guest faculty, Paul Levy. Wooden and Levy are both coaches and teachers in their respective fields–one hospital administration and the other NCAA Men’s Basketball. With that statement, they both take responsibility to the fullest extent for successfully transferring knowledge to those they themselves are charged with educating.  As I reflect on that week, this message rang especially true during the group’s conversation on informed consent and shared decision-making.

One of the residents had mentioned how surprised he was at an intelligent patient’s off-the-mark retelling of the information he had just conveyed. “It was like apples and orange,” he said, as John Wooden’s words rang loud and clear in my head. It was also becoming clear that as care providers, the role also encompasses educator on a daily basis. And a challenging educator role at that–having to teach all levels of experience and understanding during a busy day in a very short amount of time. Add to that challenge the fact that health psychology literature states patients retain only 30% of the information shared in a clinical setting and couple that with the stress of illness. Wow! How many ways can you say the same thing so that each patient can “teach back” the information you shared in a way that conveys an understanding?

As individuals, we sometimes forget that our knowledge can be unique and only as helpful at times as our ability to communicate it to others. In medicine, an entirely different language is spoken, and those not involved in immersion will be starting at a disadvantage, no matter the level of intelligence. As Harlan Krumholz MD said during The Michael Skolnik Story, “patients will nod along with you–it’s just social niceties. They want to send back approval,” but continues to point out that patients are also scared, anxious, worried and in the course of that conversation it’s hard for them to concentrate–that “their ability to listen carefully to what is being transmitted is limited…because they are in a position of weakness and it’s hard to take in the information.”

These two very important themes from Telluride –communication and education– highlighted the need to improve on the transfer of knowledge to a patient, as well as where the gaps in medical education curriculum still exist. How much time is dedicated to development of these “soft” skills that are cornerstones of patient-centered care throughout a medical education? Reaching to leadership in industries outside healthcare to fill these holes until they become required learning is being done more so now than ever. Knowledge shared through Coach Wooden’s legacy, and Duke Coach Mike Krzyzewski, as well as the leadership at Telluride which includes founders David Mayer MD and Tim McDonald MD/JD, thought leaders in transparency such as Lucian Leape MD and Rick Boothman JD and patient advocates like Helen Haskell and Patty Skolnik–offer new perspectives on unsolved healthcare challenges.

Please share leadership examples from those who have touched your life and set positive examples as mentors, teachers, leaders, and coaches. Add links and involve them in our conversations here in Telluride.

Conflict Resolution at #TPSER8


Shelly Dierking is leading a workshop in conflict resolution today at the Telluride Patient Safety Educational Roundtable and Summer Camp. Residents are using role play of cases to highlight where conflict management breaks down and how best to build it back up.

What is coming to light is that there is variance that needs to be managed on a daily basis, and without teamwork and systems in place to manage and support those at the front lines, it’s only a matter of time before a tipping point is reached and the patient suffers. Not to mention the care providers who have the best of intentions, are human and who suffer along with their patients when an error occurs.

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