Coaching Physicians Involved in Disclosure Cases

• 10/9/2009
• Author: Steven Berman
• Category: The Journal Blog
• 20965 Views
• 0 Comments
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This week, Randy Peto, lead author of "One System’s Journey in Creating a Disclosure and Apology Program,” which appeared in the October 2009 issue, guests on the blog. In the article, Dr. Peto and his colleagues describe the disclosure and apology program at the four-hospital Baystate Health system. In this blog, Dr. Peto discusses his experience, which occurred while the article was in press, in coaching a physician who was involved in a serious unanticipated outcome. The Journal welcomes your comments about this blog and your own experiences in the disclosure process.
 
We recently experienced a very serious unanticipated outcome for a patient undergoing an elective surgical procedure. The family was immediately informed of the situation, followed by a conversation the next day and a few short subsequent phone conversations. The exact cause of the unanticipated outcome was unclear. One of the physicians involved informed our risk management office of the case. A departmental colleague of the physician suggested that he also talk to me, as medical director for quality and patient safety, to gain additional feedback and advice about the best ways to proceed.
 
At the physician’s suggestion, we held our first meeting offsite at a location in which he was comfortable. He was clearly troubled by the seriousness of the outcome, particularly by the fact that at the time we didn’t yet know what caused the outcome. We spent about 3 hours together. I did more listening than talking.  The physician had run through the case multiple times in his head, trying to make sense of it all. He described the emotional impact of the case on himself and his family. We tried to anticipate what the patient’s family was feeling at this point in time, knowing that we’d never fully be able to put ourselves “in their shoes.”  We talked about the strain in waiting for additional data to be collected, including a root cause analysis and additional investigations. Amid the myriad events and unanswered questions following the adverse outcome, he seemed to gain some comfort from hearing me recite the four “wants/needs” of patients & families after an adverse event:
1)      To learn what happened
2)      To make the situation right as much as possible
3)      To receive an apology (if warranted)
4)      To change the system to reduce the risk of similar events happening to future patients
 
During the next few weeks, we had shorter conversations, some by e-mail and some in person. Additional data trickled in from the subsequent investigations.  The evolution and speed of the process (especially the early steps) were clearly not seamless to him, and he has provided some recommendations on how we might improve our disclosure infrastructure. For example, he stated that assistance should be provided in coordinating the communication and paperwork required in the immediate aftermath of a serious event—at a time when the medical team is emotionally traumatized.
 
The final investigation concluded that the outcome was not preventable, given the information known at the start of the surgical procedure. At this point, our conversations focused on planning for the major meeting with the family to present a comprehensive overview of the investigation’s findings and to provide an opportunity to ask questions. We talked both about the big things, as we again tried to anticipate how the family might be feeling a few weeks after the adverse event, as well as the small things, such as arranging for a comfortable room for an extended conversation. The major disclosure session with the family went well. The door was left open for future discussions, but no follow-up meetings were scheduled or have since occurred.
 
In developing our disclosure and apology program, we provided intensive training to some physicians to become “communication consultants.” We have not used those physicians extensively since the training, in part because of the historical comfort risk managers have gained in that consultant role. As for my own role as a communication consultant, I’ll probably learn my true worth in this process only after more difficult cases involving errors on the part of the hospital/clinicians and/or families who react to an adverse event in a challenging fashion. But it was reassuring to have my first disclosure “case” turn out reasonably well, despite the horrible outcome to the patient.
 
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