Sorry seems to be the hardest word: Or is it?

Stuart LaneSydney Medical School

Nepean Hospital

Overview

• ODC• Qualitative research• PhD thesis – structure• PhD thesis – results and

interpretation• Conclusions

Background

• 1987 VA Hospital, Lexington, USA, • ‘To maintain a humanistic, care-giving

attitude with those who have been harmed• Rather than respond in a defensive and

adversarial manner’• Ten years later - drop in court cases and

claims• OD now forms part of health reform across

the world

Background

• November 1999, the Institute of Medicine (IOM) issues a report ‘To err is human’

• Almost 100,000 patients each year die in US hospitals due to preventable medical errors.

• Up to 67% of all patients admitted to hospital are exposed to a medication prescription error.

Open disclosure communication

• The principles of ODC– Be open and timely with communication– Acknowledge the error– Express regret – Recognise the reasonable expectations

of the patient, or their support person– Ensure support for health staff and

confidentiality

Is it working?

• Reports of decreased litigation• Lots of policies and documents• But not much evidence of teaching• Even less evidence of evaluation• Anecdotes

• People have little understanding of it• People are not aware of the policies• But they probably practice it to some degree

Findings

• 30% did not agree with disclosing medical errors to patients

• 20% did not agree that a physician should never tell the patient something untrue

• 40% did not agree that they should disclose financial relationships with drugs and devices

• 11% said they had told a patient something untrue in the previous year

Why?

Qualitative vs. Quantitative

• A finding or result is more likely to be believed if it is expressed as a number

• Many of these numbers are biased and reductionist

• The numbers are the convincing part• Quantitative research is powerful

amongst the medical profession

Qualitative researchers

• Seek a ‘deeper truth’• Or just a different truth• Really a different question• Study things in their natural setting• Attempt to make sense of, or

interpret, phenomena in terms of the meanings people bring to them

• Human behaviour is complex

Questions

• How many parents would consult their general practitioner when their child has a mild temperature?

• Why do parents worry so much about their children's temperature?

• What proportion of smokers have tried to give up?

• What stops people giving up smoking?

• Asthma and epilepsy as social conditions

PhD thesis

• Saying Sorry: Doctor’s experiences of open disclosure communication (ODC) following medication error?

Initial thoughts

• Doctors receive little or no communication education

• Medical school• Hospital practice

• It forms a significant part of their clinical practice. • Find their own way during their careers, to help

them develop strategies to assist them in dealing with difficult communication scenarios

• Simulation has shown promise as an adult learning tool

• Simulation with facilitated debriefing can assist in the learning and teaching of ODC

Mind mapping

Question 1

• Intern experiences of open disclosure communication with patients and their families?

Question 2

• Final year medical students experiences of a simulation session focussing on open disclosure communication with a patient’s family

Question 3

• Intern experiences of open disclosure communication with patients and their families after a simulation experience

Methodology

• How can we go about acquiring knowledge?

• Research design and justification of methods

• Phenomenology• Intentionality• The study of the ‘lived experience’• What is it like to be ..?’ ‘How do we make

sense of ..?

Theoretical perspective

• The philosophical stance informing the methodology

• Interpretevist• Meanings are constructed by humans as

they engage with the world they are interpreting.

• Humans make sense of the world based on their historical and social perspective.

Epistemological stance

• The theory of knowledge / the knowing of knowing

• Constructivism• Social phenomena develop in particular

social contexts. • Learners construct mental models to

understand the world around them

Data collection methods

• Interviews• Focus groups

Data collection methods

• Audio interviews• Illuminate the person’s experience

• Focus groups• Concentrated data collection to an

immediate event• Exploring reasoning and debate on the topic

Sampling

• Purposive for JMO interviews• Repeat sampling till thematic and theoretical

saturation

• Purposive for simulation scenarios• Expected to have an opinion

The simulation aspect

• 8 final year medical students• 2 groups of 4• Mannequin with deterioration• Team-leader speaks to family• Facilitated focus group after

watching

Analysis

• Interpretive Phenomenological analysis

• IPA (Johnathan Smith)– Try to make sense of the participant

trying to make sense of…

• Also grounded theory analysis for focus group data (Kathy Charmaz)

Reflexivity

• Needs to be happening • At all times • Throughout all processes’• Not just reflection but true analysis

• True reflexivity is almost impossible• Needed to discover my views on the

subjects and how they may influence• CMS Harvard/MIT

• Trial run of data collection• Prospective learning pathways grid

Results

• Provisional results• Still working through the final

conclusions• Four areas to highlight• SVU; We are sorry for your loss• The hardest word - mistake• Apologetic justification, ‘it’s the

patient’• The development of professionalism

SVU apology

• Easy to say sorry• ‘It is expected of us’• ‘It is what I would want to hear’• ‘I would say it even though I don’t really feel

it’

• Can’t stop saying it enough• Minimal empathy around sorry

• Genuine for the situation• But not for the saying sorry part

The hardest word

• Mistake / error is the stumbling block• This is what worries people litigation wise• Do people actually see it as an error?• Can they be sorry if they see no error?

• Dialogue of prefixes and sentence fillers• ‘A little bit too much’• ‘Slightly excessive’

• Frightening regularity• It is expected• It is the culture

Does this matter?

• Why is theory important• Bullying (Prof Helen McGrath)

– Self esteem vs. Self respect• Theory of apology• Is our ODC template good enough?• What does an apology mean in society• “Tuesdays, Thursdays and Fridays are tricky for me,

I’m sorry.” • “Best days for meetings are Mondays and

Wednesdays.”  • “Sorry to bother you.”• “Is now an okay time to talk for five minutes?”• This needs to be personal, not via the system

Famous apologies

Famous apologies

Famous apologies

Apology

Apologetic justification

• Its not me, it’s the patient• ‘It was her heart than was not strong enough for the

medication’• ‘She would have died anyway’• ‘It was OK because they got her back with Naloxone’• ‘He could not handle the side-effects of the morphine

• Can the system always be to blame?• Side-effects vs medication error• Where does the cognition of error lie?• Opinions changed after reflection

Learning from simulation

• Constructivist approach appears justified• It is beyond either behaviourism or

cognitivism• Creating a reflective environment that

goes beyond the simulation centre and the simulation session

• This can not be assessed by conventional means

• We need to move away from the obsession of validation

Notions of professionalism

• Professional identity vs. professionalism• Professional identity is constructed at the

level of the individual. The reality might not be ideal

• Professionalism is constructed by the community and medical profession as a whole of the idealized professional. The ideal may not be a reality

Notions of professionalism

• This needs to be a personal characteristic

• Blaming the system does not help• If it is not personal, how can one

reflect?• We don’t want a culture of blame• But is making people feel

accountable and responsible what is really needed?

So did simulation affect this

• People reflected far more• They thought about the development

of their practice• What they concluded was up to them• We need to help them draw the right

conclusions• And then reinforce them• The education needed is far bigger

than most anticipate

Take home messages

• Doctors are quite happy to say sorry• They still struggle to admit to errors / mistakes• Their communication can appear to rationalise it

as a patient problem rather than a practitioner problem

• Many of the errors that occur are not even seen as errors since they happen so frequently

• We need to instil the desire to develop professionalism at a personal level, by forging the development of the appropriate professional identities.

• A beurocratic template based on decreasing litigation is not what is needed

Take home messages

• This is about the sort of doctor that you are and you want to be

• This is about what you say and do when you have family conferences

• This is about what effect you want to have and have had

• This is about how you learn, keep learning, and want to keep learning

• This is about the professional identity you have moulded for yourself, and how you develop you professionalism

• CICM provides a template and others provide guidance – you fill in the rest

Questions?

Questions?