Published in the February 2014 issue of Today’s Hospitalist
IT’S ONE THING TO COME TO GRIPS WITH MISTAKES you make on the job “there’s plenty of literature and guidance for that. But what if you believe a colleague has done something wrong? One bioethics expert contends that it’s time to change a culture in which physicians fear that a confrontation might elicit an angry response, jeopardize relationships with colleagues, raise liability questions and label you a “rat.”
“Physicians find the need to talk with a colleague about a quality problem so intimidating that they often avoid these conversations altogether,” says Thomas H. Gallagher, MD, professor of medicine and professor in the department of bioethics and humanities at the University of Washington School of Medicine in Seattle.
His solution for avoiding that awkwardness? Put patient safety and patient rights first, not your own professional worries.
A new culture of collective accountability would make it easier to talk to colleagues about errors you think they have made, says Dr. Gallagher, who authored an article published in the Oct. 31, 2013, New England Journal of Medicine. The piece was based on the results of a working group of experts in patient safety, medical malpractice, communication, bioethics, professionalism, and health policy.
The article used a hypothetical example in which a neurologist sees a stroke victim whose primary care physician missed atrial fibrillation shown on two electrocardiograms. Because hospitalists rotate on and off services, the “referring physician” in such a scenario could in fact be another hospitalist, he notes.
Fortunately, hospitalists may be the clinicians most likely to understand the importance of facing a colleague’s error in a productive manner because of their background in quality improvement and patient safety, he adds.
“We want it to be the norm in medicine to have respectful conversations with colleagues that aren’t framed as, ‘I’m the snitch and you’re the perp,’ ” says Dr. Gallagher, who is also director of the hospital medicine program. “It needs to be the expectation that we reach out to them and we’d want them to reach out to us.”
According to Dr. Gallagher, three principles should guide the way physicians approach a colleague’s potential error. The first is to put patients and families ahead of being a “good colleague.” Doing so will make it harder to ignore the nagging feeling that something someone else has done does not seem quite right.
The next is to explore the situation. You may not be exactly sure what happened, especially if you weren’t there when the care was delivered. Moreover, the information in the chart may not be complete. Gather information in a way that doesn’t imply the colleague did something wrong. To do so, talk directly with the colleague, “guided by a spirit of curiosity and discovery, not accusation,” Dr. Gallagher says.
The colleague may know important information that’s not in the medical record, shedding new light on the situation. Based on that discussion, you might agree that there wasn’t an error and the process ends. Or you might agree that there is an error and that one or both physicians need to tell the patient. Or you might disagree.
The third principle “that institutions should take the lead “can help in any of those scenarios. “Ultimately, it’s the institution’s responsibility that patients are informed about errors, regardless of who’s involved,” Dr. Gallagher points out.
Hospitals can fill that role by giving physicians resources such as disclosure coaches who can facilitate peer-to-peer discussions and help dial down defensiveness. Many institutions already have such coaches available 24/7 for disclosure counseling, he says.
In a situation like the one cited in the NEJM article, Dr. Gallagher says the hospitalist ideally would reach out to the primary care physician and see if they could reach consensus on what should be disclosed to the patient. If the primary care physician does not agree that the patient was in a fib, for instance, the hospitalist might turn to an institutional resource, such as a formal consult from a cardiologist or help from a quality committee. The goal would be to help the two doctors reach consensus and, if they decide an error occurred, to determine how to tell the patient.
Liability and other concerns
One major concern is that disclosing a colleague’s error will trigger litigation. While there’s evidence that disclosing your own error makes litigation less likely, Dr. Gallagher admits that this situation is different.
“Not much is known about how to talk to a patient about another clinician’s care in ways that don’t precipitate lawsuits, but a common reason patients file a claim is because no one would tell them what happened,” he says. He believes it’s reasonable to infer that better communication about errors in general decrease the chance of being sued.
There’s also concern that one physician’s idea of an error is not another’s. Dr. Gallagher says the spectrum ranges from, “It’s not what I would do” to an error so obvious it calls a colleague’s competence into question.
And many worry that a formal report to an institution might elicit a disproportionate response: a full-fledged investigation into what was only a minor error, or no institutional action in response to a serious one. Often, the answer to both concerns, he says, is to spend time fact-finding informally through discussions with the involved colleague before drawing conclusions.
The learning curve
Hospitalists may transition smoothly to a new culture of accountability. They’re used to having what can be awkward conversations with patients.
But they still need to practice their skills to make those conversations work and leave the door open to greater transparency. “I’m not suggesting that talking to one another would be easy,” Dr. Gallagher says. “But skills training would give the framework and structure to have discussions so, ‘I know what to do here and how to move forward.’ ”
Trying to find a better way to discuss colleagues’ potential errors with patients is a natural next step, he notes, now that physicians are more comfortable disclosing their own errors. In addition, institutions are increasingly implementing communication and resolution programs to emphasize disclosure and transparency. Hospitals now may offer disclosure training through their malpractice insurer.
For now, Dr. Gallagher thinks official guidelines are premature. He’d like to develop training models to help physicians learn to have more effective conversations and measure the impact of such training on quality and safety.
Despite the challenges, physicians can take heart from how they’ve progressed over the past 15 years with another tough topic: palliative care.
“Over time, we learned the skills involved and recognized how important it is to patients, and that led to a revolution in how we handle awkward conversations about end of life,” he says. “The same thing needs to happen here.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.