How can we teach?…

My Fellow Telluride Patient Safety Gurus,

What an incredible week! I have been so fortunate to be surrounded by such a brilliant group of people leading change all over the country. You have all inspired me and energized me to go back and promote the mission that we have all set out for ourselves- create a system that is patient first.

Inspired by Rick’s proverbs reminding us all that we are teachers and it is our responsibility to share the knowledge that we have gained to improve our systems, I’ve come up with an idea on how to approach teaching informed consent to our fellow residents.

But how do we teach?…How do we teach hundred of grown adults, physicians, those set in their ways with their own ideologies and beliefs that may or may not contradict yours. How do you teach change?…

Here’s my attempt:
Create an “Informed Consent Checklist.” What if we taught the complex art of informed consent as a systematic way of thinking how you approach the conversation, just like you would the steps of a central line. Gloria highlighted this point nicely- now she has a way to structure the conversation. It truly needs to be a step-wise approach that comes naturally and systematically after being taught the right way to do it.

The video gave a great structure on how to approach the conversation. We could use that as the learning tool to instill the importance and value of approaching the conversation in such a way. We can also add the structure of what needs to be covered- benefits, risk, alternatives, and doing nothing. This way it can be a comprehensive, step by step approach that is repeated time and time again until the “checklist” comes to mind unconsciously.

Let me know your thoughts, reservations, and tips for implementing. I think we can do this!

I want to thank you all again for an eye-opening experience that has re-energized me in the mission for disseminating patient safety efforts and changing our culture as we transform to a system that is truly “patient first.”

Shabs

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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.

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.

Nothing About Me, Without Me at #TPSER8

As I reflect on last week in Telluride, I keep returning to the exchange on informed consent and shared decision-making that was stimulated by watching Michael Skolnik’s story on film. The group concurred that their training around informed consent was all but non-existent during medical school and residency. As the conversation continued, it became clear that true patient-centered care would include this often missed opportunity to better understand a patient’s needs, values, preferences and goals as they relate to the risks and benefits of any (and every) procedure. What is successful hand surgery to a painter? Or knee surgery to a prima ballerina? Or heart surgery to a seventy-five year old grandfather who just wants to dance at his granddaughter’s wedding? How does that compare to a successful outcome for the surgeon? And perhaps just as important, does the surgeon know if her patient is painter? A dancer? A grandfather? And if not, how will that surgeon know the best way to proceed if a decision needs to be made on the patient’s behalf?

This is the “nothing about me, without me” that Harlan Krumholz MD mentioned during Michael’s story, and whose excellent piece on informed consent and shared decision-making published in JAMA can be found here. Krumholz was quoting Don Berwick MD, who co-authored a paper, Healthcare in a land called PeoplePower: nothing about me, without me in Health Expectations. This paper, published in 2001, was a result of a five-day retreat in Salzburg where health professionals, patient advocates, artists, reporters and social scientists gathered to discuss ways to best partner in healthcare–from shared decision-making on through policy and quality contracts. How powerful to have the patient as a partner when a critical decision needs to be made on their behalf–to know that as many potential risks as possible have been discussed, and that the decision to be made is the patient’s choice. Think of the comfort in having that knowledge if a less than optimal outcome occurs. It becomes a team loss–not two new adversaries taking sides.

With all the thought-provoking conversation and sharing of ideas this past week in Telluride, why not craft your own “Salzburg Seminar” paper? As the next generation of medicine, you have the power to create the new culture of medicine based on all the values discussed this past week, keeping the patient at the center.

Thinking about informed consent

I dont think that I’ve ever thought so much about informed consent as I did today.  I’ve always had the self-perception that I communicate well with patients, especially around planned procedures in the emergency department where I work. After today’s discussion, I recognize that I am doing a fine job, but I can also do so much better.

Informed consent is a shared decision making opportunity between patient and physician.  At its core, informed consent is a conversation with the goal of allowing the patient to ask questions and hopefully come away with a clear understanding of the procedure to be performed, as well and the risks and benefits of the procedure. Procedures, diagnostic tests, and medications can all be conversations that are pursued with patients under the vigilance of informed consent.

While the conversation is the essential element of informed consent, the informed consent paperwork can serve as both a checklist for the provider and a physical reminder to the patient that we are discussing potential harm and the physician will need the patient’s approval before pursuing any potentially risky treatment plans.

A discussion about informed consent to the level of detail that we had today needs to be part of all residency training in the first days of orientation and as refresher training later on in training.  All physicians can, and should, do much better in providing informed consent.

Patient-centered Care Education (Shared Decision Making)

Our second day in Telluride finished with the residents watching the award-winning film The Faces of Medical Error…From Tears to Transparency: The Story of Michael Skolnik”. The educational film addresses the importance of informed consent versus shared decision-making conversations – an important aspect of open and honest communication in healthcare that is still lacking in many health systems. The film asks the question – Can a conversation change an outcome? Can a conversation save a life?”

After the film, the residents engaged in a two-hour conversation with faculty and safety leaders on issues related to informed consent and shared decision making. When Paul Levy asked the residents how much training they get on this topic, every resident in the room acknowledged this three-hour session on informed consent/shared decision making was more education than they have received during their entire medical school and residency training to date. A sad commentary on the current state of medical education in areas of patient centered care.

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