thomas h. gallagher, md university of washington
TRANSCRIPT
Thomas H. Gallagher, MDUniversity of Washington
Curricular deficiencies◦ Curriculum focused mostly on history-taking
Ignores MD communication with other healthcare providers
◦ Communication training insufficiently intense◦ Failure to recognize communication as skill
“Bedside manner”--can’t be taught (or measured) Communication discounted as “soft,” “touchy-feely”
Little opportunity to practice, get feedback Learners struggle to apply general skills to specific
situations Culture of medicine values technical
proficiency over interpersonal skills
Patient satisfaction Ethics, professionalism Complaints, malpractice claims Health outcomes Safety culture, transparency; disclosure
and reporting of adverse events and errors
Allows learner to practice complex communication skills, receive feedback in safe environment
Allows learners to confront communication dilemmas that are important but uncommon
Types of simulations◦ (role plays, interactive computer cases,
rehearsal)◦ Standardized patients
Standardized patients are individuals trained to:◦ Present consistent scenario◦ Be reliable observers of behavior◦ Offer feedback
Extensively validated as assessment tool◦ Now used in high-stakes certifying exams
Increasingly used as research methodology
Recognize communication as a skill◦ Can be learned, practiced, improved, discussed
with colleagues◦ Worthy of learner’s attention
Need cases that take learners out of their comfort zone without overwhelming them
Ability to practice, receive feedback on key skills
Creating high-fidelity cases Identifying key observable skills
◦ Communication incredibly complex task Easy for learners to express socially
desirable behaviors
Designed to assess whether simulation improves healthcare workers’ knowledge, attitudes, and skills in two areas:
1. Team communication about error2. Error disclosure to patient
Growing experimentation with disclosure approaches
New standards State laws re disclosure, apology Increased emphasis on transparency in
healthcare generally
Many harmful errors not disclosed to patients When disclosure does take place, it often falls
short of meeting patient/family expectations
What do team members owe one another?◦ Absolute loyalty?◦ Falling on sword?
What are roles of different team members in the disclosure process?
Practicing physicians & nurses◦ 40 nurse-physician teams (½ surgeons and OR nurses;
½ medical physicians and nurses)◦ 40 control group teams
Actors◦ 1 standardized team member per team
Plays role of hospital administrator Helps team progress through simulation, think out loud
◦ 1 standardized patient per case, 2 cases per simulation
12 Risk Manager “Coaches”
1. Team discussion and planning for disclosure◦ Team discusses what happened, responsibility for
the error, and plan what they will disclose to the patient
2. Team Error Disclosure
◦ The team discloses the error to a standardized patient
Acknowledge error occurred Offer facts regarding error Solicit and respect team members’ views of what
happened Negotiate differences respectfully Avoid blaming; respond appropriately to blaming
behavior Respond empathetically to team members’
emotions
Plan roles for disclosure discussion Advocate for full disclosure Identify core content of full disclosure
◦ Explicit statement that error occurred◦ What happened, implications for patient health◦ Why it happened◦ How will recurrences be prevented
Explicit apology Anticipate patient questions and
emotions and plan team responses Negotiate differences respectfully
Team member introductions Empathetic disclosure of core content
◦ Ask patient what they know about error◦ Explicitly state that error occurred◦ Implications for patient health◦ Solicit patient questions, respond truthfully
Make explicit apology Explain how recurrences will be prevented Avoid blaming team members; resist patient’s
attempts to fix blame Empathetic communication with patient Plan for future meetings
Web assessment◦ Case-based: 2 cases, 2 different team approaches◦ Knowledge, skills, attitudes assessed tied to coaching
priorities and simulations◦ Participants complete web-based assessment pre and
post training ◦ Controls take web assessment (pre and post) but
without the training Other data sources
◦ Videos of simulations◦ Debriefing interviews with participants
Patient admitted to ICU with recurrent seizures Given loading dose of Dilantin (300 TID), then
switched to 300 QD Physician writing transfer orders to floor
mistakenly writes for larger loading dose Error not noticed by nursing, pharmacy Patient falls, hits head; Dilantin level 29. Head
CT normal Patient thinks another seizure caused her fall
Simulation design◦ Maximizing learning potential of simulation
Skilled coach essential◦ Maximizing case fidelity
Nature of events Choice of case Actor training
Interprofessional interaction Role of standardized team member in simulation
Especially important in engaging “Silent team member” Simulation implementation
Managing logistics of recruitment, scheduling a major undertaking Coordinate schedules of two clinically active subjects, 3
actors, risk manager coach, at least two team members for each session
Immersive simulation around communication possible outside simulation center◦ Even senior clinicians found experience
educational Providing expert coaching, feedback is key Logical challenges can be substantial Multiple opportunities for communication
simulations on other interprofessional topics
Thomas Gallagher (PI) – Medicine Lynne Robins-Medical Education Sarah Shannon – Nursing Peggy Odegard – Pharmacy Sara Kim – Medical Education Doug Brock – Medical Education Carolyn Prouty – Project Manager Odawni Palmer – Support Staff Andrew Wright-Surgery