Published in the November 2004 issue of Today’s Hospitalist
When Carol B. Liebman, JD, embarked on research exploring ways to help physicians better talk to patients about adverse events, she thought that she knew at least part of the solution: Give clinicians specialized training in how to talk to patients about errors, and you’ll head off problems like lawsuits.
Two years later, she is not so sure. While Ms. Liebman still believes that better communication will help reduce lawsuits and improve the overall patient safety climate, she no longer thinks that teaching physicians to be better communicators is the key to disclosing errors to patients and their families.
The problem, as Ms. Liebman learned from a demonstration project in which she and fellow researcher Chris Stern Hyman worked with physicians and clinicians at several Pennsylvania hospitals, is that talking to patients about serious adverse events may simply be too difficult for most physicians to do well.
“The big insight I gained was that we’re putting good people in positions where no one can succeed,” she says. “You’re setting them up for failure, and not because of any moral shortcomings on their part. It’s just that communicating with patients in these situations is just too difficult.”
That’s not to say that Ms. Liebman, a clinical professor at Columbia Law School in New York and a former litigator, thinks physicians should shy away from talking to patients when something goes wrong. She firmly believes that physicians and the health care system can do a better job of talking to patients and their families after an error or adverse event has occurred.
But instead of putting the burden on one or two physicians’ shoulders, Ms. Liebman says, hospitals need to offer support to do the job well.
Her solution? Identify a team of clinicians at hospitals and other facilities that can give physicians some much-needed help–and a little dose of objectivity–when disclosing errors to patients. She refers to the concept as a “disclosure consult,” and she pictures physicians using the service much like they consult physicians in other subspecialties for medical problems.
Ms. Liebman notes that the two-year project, which was funded by the Pew Charitable Trusts and summarized in the July/August issue of Health Affairs, yielded some other interesting insights into the disclosure of errors. Not surprisingly, many of the problems she found stem from a culture that does little to encourage physicians to step forward and accept responsibility.
Today’s Hospitalist talked to Ms. Liebman about her notion of a disclosure consult service, and how the medical system can do a better job of responding to errors and adverse events.
Why do you no longer think that communication training for physicians and clinicians is the key to disclosing errors?
We started off thinking that if we gave physicians and other clinicians communications training, they would be better communicators. We realized, however, that the sort of communication we’re talking about, after a serious error has occurred, is about as difficult as it gets.
Very few people, even the best trained and most experienced mediators, are equipped to have that conversation on their own behalf. It’s just too hard for physicians who are facing emotional turmoil themselves.
While I still believe that everyone can benefit from communication training, in the kinds of critical situations we’re talking about, it’s unlikely that even the best people can do it well. You’re not going to solve the communication problem by providing institution-wide communication training. It will be useful and give people tools, but it won’t solve the problem.
How would a communication consult service work?
You need a core group of people who are trusted internally, have received training and who can be called upon to help plan disclosure conversations. They also need to be there to help when those conversations go off track.
Ideally, we would identify the natural problem-solvers in an institution, the natural conflict-resolvers. They could include physicians, nurses, nurse managers, etc.
They could function like bioethics teams. Whenever a serious error is made or an adverse event occurs, the physicians involved could call and touch base with these people. Together, they could decide whether the physicians should go ahead and deal with the problem, talk about what they need to say, what the patient is likely to ask, make sure they have that information at hand, and generally think things through.
Would the disclosure consult service have a role in actually meeting with patients?
Someone from the disclosure consult service could also attend meetings with patients and their families. If things get complicated, that person could help guide the conversation.
This type of in-house consult could also give physicians coaching. Someone from the service could attend any meetings and give the physicians feedback. Instead of having training disassociated from an actual problem, the members of the consult service would be able to offer training and coaching in the moment, which is much more likely to have an impact.
During your work with the demonstration project, what kinds of problems did you see in the disclosure process?
In the two cases we mediated, we were astonished by the fact that widows of patients who died had questions about what had happened to their loved ones that had not been answered, and perhaps, had not been asked. In one case, there had been almost no communication. In the other case, while the communication had been conscientious, the woman had been brooding over things. She needed a chance to talk to medical staff and hear that there was nothing she could have done to prevent the problem.
The other thing that struck us was that the physicians involved in the care were not at the table, which almost interfered with the settlement of one case. I think it was sad for the physicians, because as traumatic and painful as it might have been to have sat at the table, the physicians never had a chance to apologize, and they never had a chance to be forgiven. That might not have happened, but had the physicians participated in the mediations, there would have been an opportunity for forgiveness and a repaired relationship.
What kinds of opportunities do physicians have to avoid these situations from arising in the first place?
What often gets in the way of making a decision that’s right both medically and humanely is a lack of time. Physicians often don’t take time to sit down and look at what’s really going on with patients.
Family members may take the stance that they want the person treated no matter what, or that they want the patient to die with dignity, but what does that really mean? If physicians can take the time to ask what that means and why itÃs important, they will avoid many of the horrible conflicts that can lead to court.
As a former litigator, how do you think the overall system needs to change?
The problems of the medical malpractice crisis and patient safety issues are linked. The behaviors that lawyers and risk managers and insurers have encouraged as a strategy to defend lawsuits–say as little as possible, don’t apologize–get in the way of discussions that can improve patient safety.
We need to gather all the necessary information and really sort out what happened. We also need to include patients and their families in these discussions and put them on the team instead of always viewing them as potential adversaries. If you don’t have those discussions, errors recur. We become trapped in a vicious cycle.
Physicians need to accept the notion that no matter how much they strive for perfection, there are going to be terrible errors. Rather than beating themselves up about it and being shamed and traumatized for it, we can talk about it and learn from it. That kind of follow-up can be a valuable function of these disclosure consults.
Physicians operate in a system in which the culture does not give them much space to process their feelings. Then we’re telling them to go talk to the family immediately, and to make that a successful and productive conversation. That is almost impossible.
