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