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.

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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.

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.

Dr. Lucian Leape Talks With Student Scholars in Telluride #TPSER7

What are the transforming concepts that need to be developed by a health care organization in order to instill a safe culture?

According to Lucian Leape MD, Adjunct Professor of Health Policy at Harvard University, who came to Telluride to share his wealth of knowledge and experience related to patient safety, there are five core concepts that need to be explored and implemented in order to first create a culture of respect. Those concepts are: 1) Reform medical education; 2) Integrate health care; 3) Find joy and meaning in work; 4) Engage consumers/patients; and 5) Adopt a transparent culture.

Dr. Leape’s challenge to our group — How do we motivate CEOs of health care organizations to make a culture of respect the priority? How do we develop awareness of the problem so that there is pressure for action? What can you do “from the bottom up?”

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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