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.


2011 Telluride Patient Safety Roundtable Thank You

Telluride 2011 Alumni

Telluride Patient Safety Roundtable Attendees June 2011

A tremendous thank you to the faculty who shared their time, wisdom and experience during this year’s 7th Annual Telluride Patient Safety Roundtable. An equal thank you to the student scholars who shared their own experiences, enthusiasm to learn more about patient safety and willingness to step up as leaders related to this very important aspect of delivering care to patients.

I feel privileged to have been included in this meeting, and look forward to hearing more about the projects students and faculty will contribute to both patient care and medical education as a result of this year’s roundtable.

Please comment on your experiences in Telluride, as well as on how your projects are progressing!

Climbing Mountains Related to Improving Patient Care

Patient Safety Roundtable Hike Destination

Bear Creek Falls, Telluride, CO Final Destination Telluride Patient Safety Roundtable Hike June 2011

 As we were making the five-hour drive from Telluride back to Denver, Tim McDonald likened the movement toward transparent, patient-centered care to climbing the same mountains that surrounded us that week. A team building 2.5 mile hike up to Bear Creek Falls at an ending elevation of ~10K feet on our third day at the Telluride Patient Safety Educational Roundtable provided plenty of opportunity to get to know our fellow attendees on both a more personal and professional level. It also served as a wonderful analogy, as Tim suggested, to the challenges inherent in delivering patient-centered care by teams of individuals who bring a variety of strengths, weaknesses and skill to each encounter.
As we climbed the mountain, sharing stories of our families and our work lives, we all grappled with the demands of the environment. Some were better physically prepared for a hike at altitude, others were overcoming fears–of heights, of their ability to make it up and back, of being able to keep pace with the group. But a wonderful thing happened along the way. Any weaknesses some in our group may have experienced along the route were eagerly supported by the strengths of others. As a result, all made it up to see the majesty of the natural falls rushing strong off the mountain side. Respect for each individual in the group was the first priority, regardless of hiking experience or ability, and everyone ultimately benefited from that respect.
Providing care to patients can indeed be similar to hiking at altitude. The environment is going to make demands upon care providers that are outside of their control. As a care team, the choice exists to respectfully support one another in the face of those demands or not. Dr. McDonald’s analogy of improving care and climbing mountains is spot on, on so many levels, and I know, having hiked a number of mountains, that traveling with a supportive group not only makes it more enjoyable, but is also the safest way to travel.

Bullying in Hospitals: What’s the Solution?

The focus of this year’s Telluride Patient Safety Educational Roundtable is to develop solutions for disruptive behavior in medicine. Some of the required reading for the week examined how other health systems are confronting issues such as bullying in the workplace. Our patient safety and quality experts from Australia, Kim Oates and Cliff Hughes, have shared information on the New South Wales health policy statement on how to combat bullying in the workplace. A second reading, an article by A Lazare & R Levy in Chest (Chest 2011;139;746-751), discusses how humiliation in medicine leads to less than optimal care, and offers strategies on how to apologize for inflicting such an offense so that healing follows.

A post on the physician led blog, KevinMD entitled “Hospital bullying requires everyone to share in the blame and solution” written by Kevin Pho himself, addresses the need discussed this past week in Telluride to change a culture that “perpetuates” bullying. He also agrees that this requires a team effort–not just physicians, but nurses, hospital administrators and medical educators as well.

Social media allows all of us to network with those we may once have never met, learn from teachers whose paths we may have never crossed and affect the lives of others in ways we may never even know. By sharing the solutions, conversations and ideas discussed throughout the week, a patient somewhere may be the ultimate benefactor of this meeting. Isn’t that why we are all here? Continue to share what you have learned in Telluride and what you discover after leaving. Stay connected via the blog, the Telluride Patient Safety Roundtable Alumni page on facebook or through our Twitter hashtag (#TPSER7).

Will You Stay With Me?

Cliff Hughes, CEO at New South Wales, Australia Clinical Excellence Commission shared a story Wednesday afternoon that exemplified what patient-centered care is all about. When Cliff’s patient, a 52-year-old truck driver named Neville was not going to live through the night, Neville asked Cliff if he would stay with him. Without hesitation, Cliff agreed and not only stayed to share prayer and poetry, but was also able to reunite Neville with his estranged daughter and 6-week old granddaughter before dying.

Cliff then posed two questions to the student scholars and patient safety leaders in the room.

“Is it unusual for you to cry?”

“Do you forget about the individual in the technology of care?”

“This is the way I want you to treat me, and how I will treat you. It’s no different in Australia than in the United States,” he said.

The final assignment for the day was for students to write down what they will change within themselves in order to deliver this depth of patient-centered care.

As Dave Mayer MD closed the meeting he reminded us of another patient-centered address given by Don Berwick MD to Yale Medical School’s 2010 graduating class. A link to a portion of his speech is found on another Transparent Health post:

What does patient-centered care mean to you? Can you share an example of patient-centered care you delivered or witnessed at your institution?

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