Shared Decision-Making

Safety is more than preventing physical harm

I have to admit, I was skeptical when I was first asked to attend this conference. As a psychiatry resident in my last year of training I have been confronted on a daily basis by patients placing themselves and others in unsafe environments and situations. Between seeing patients who heavily abuse substances and then get into arguments with loved ones or god forbid get into a car, to patients who shun the comforts of home because of profound paranoia about their home environment, I have always thought of the hospital as a safe place for psychiatric patients.

However, on a daily basis we are faced with a patient population who all to often cannot advocate for themselves or when they attempt to do so are written off or unfortunately flat out ignored. In a bigger way, patient safety is integral to good patient care because by allowing our patients to… Continue reading

On tribal hierarchy

On tribal hierarchy

On day one of the “Academy of Emerging Leaders in Patient Safety” conference, we started by watching a video featuring a patient’s mother who brought up the tribes of healthcare (doctor tribe, nursing tribe, etc) and the role that the element of hierarchy played in her son’s unfortunate outcome. In healthcare, we often witness two of mankind’s most primitive motivators – the desire to care for others and the drive to survive. The “doctor tribe” is predominated by competitive, type A, detail-oriented individuals, and deference to the hierarchy is one of our tribe’s oldest traditions. In the patient safety community, the need to address this specific tribal tradition is frequently discussed. Knowing that old habits die-hard brings up a number of questions: Is hierarchy still alive and well? How can it be addressed? How receptive will the tribe be to solutions proposed by external parties?

Take a… Continue reading

That Creeping Feeling…

First of all, I want to say that Richard’s presentation was so phenomenal today. I distinctly remember hiking up the San Juan mountains in Colorado at last summer’s Telluride conference after a great session the day before thinking, “I’ve found my people.” It really is a special thing. I still see one of the other alums every now and then at hospital meetings and it literally warms my heart to hear his name and that he is doing great things at his home institution.

We talked a lot about informed consent and a patient’s understanding of their own experience in the healthcare system. As a primary care physician, I couldn’t help but wonder how Patty’s son’s primary care doctor felt about the horrific outcomes of his patient at the hands of a surgeon who probably didn’t need to operate in the first place, someone he tried to… Continue reading

I Have A Question…Is That OK?

Throughout today’s discussion various moments truly hit home to me, especially in regards to communicating with patients and families. People come to hospitals often in their most dire time of need, not to simply chat and sip coffee. Stress, fear, anger, and uncertainty mar the face of these individuals, leaving them to appear disfigured in comparison to their standard facade…leaving them at their most vulnerable. As healthcare workers it is our duty to identify that these people are hurting and understand that communication can assist in stopping the hemorrhage of “what if’s” and begin to help with the healing process.

Bringing to light that it is normal for individuals to have questions, I feel, is so important. As it was examined today, asking patients and families “what concerns you?” or “what bothers you about this?” truly provides an opportunity for individuals to stand up for themselves without feeling the pressures… Continue reading

Day 2 Reflection: Michael Skolnik and the problems we have with the process of obtaining informed consent

Today we discussed Michael Skolnik’s story and really touched on the process of informed consent. As a nurse I am a witness of informed consent and I have been identified by some as to “who not to ask to be a witness to an informed consent” form by some physicians in my practice. Often times, as many of the residents in the program identified, informed consent is one of the many tasks that physicians have to check off their list throughout the day. First off, I will not sign an informed consent if I was not in the room during the process of obtaining an informed consent. I also want to make sure the patient’s, or their families/POA, are able to state the procedure in their own terms, and every risk or benefit that accompany each procedure. If they cannot, I will have the physician restate or rephrase whatever part… Continue reading

Informed Consent and Shared Decision Making

Yesterday we began the morning by watching a film about Michael Skolnik, a young man who died from the aftermath of an unnecessarily aggressive brain surgery for what was ultimately an incidental imaging finding. This case highlighted several errors in the delivery of his care, but the most obvious was the absence of shared decision making. The Skolnik family was not given a complete picture of the risks of their son’s surgery as well as the alternatives available to them. Following the film we discussed several problems with the existing informed consent process. Many people noted that the current function of informed consent documents is to provide legal protection to the hospital and providers rather than truly inform the patient or obtain their consent in any meaningful sense of the word. Others noted the inherent conflict of interests that underlie the process: when hospitals and proceduralists rely on volume to… Continue reading

Informed Consent as a Dynamic Process

Our group had a really great discussion about informed consent after watching “The Faces of Medical Errors… From Tears to Transparency: The Story of Michael Skolnik”.

Even though all of us agreed that the importance of informed consent has been appropriately emphasized throughout our education, many of us were unclear on the practical aspects of the “ideal” version of informed consent. A distinction that was highlighted by the film is that informed consent is a dynamic process, not a singular event, and does not merely end with the patient’s signature on the consent form. One conversation would not suffice regardless of how comprehensive it might be.

The consideration that, at any point in time, circumstances driving the patients’ decisions can change and they can withdraw their consent should remain at the forefront of caregivers’ minds.
Not only does maintaining this collaborative process prevent harmful outcomes, but it improves patient satisfaction… Continue reading

First day at Telluride Napa 2015

It’s hard to be more impressed after our first day at Telluride Napa 2015. The first set of sessions spanned the gamut from stirring personal patient stories, to workable and translatable sets of tools to take home to New York, to fantastic conversations with both faculty and medical student participants.

I have to say, my favorite (and most challenging) segment so far was the impromptu exchange between our lucky guest, the mother and inspirational patient advocate, and the CEO of The Doctors Company (a malpractice insurance provider). Their remarks touched on the candid, the taboo, and the important. The tension between “CYA medicine” or “defensive medicine” and doing absolutely right by the patient will be ever-present in our clinical practice (and that’s not to mention the central role of cost-effectiveness in the equation). So to see these boundaries being hashed out by two extremely invested experts was a privilege. I… Continue reading

Helping with the dialogue for informed consent

The discussion about informed consent following the tragic story of Michael Skolnik was very insightful. It is the physician’s job to obtain the consent after explaining the procedure, the alternative choices along with the pros and cons. It is a meaningful dialogue where the patient and the family members have the option to clarify their doubts and even have the option of seeking a second opinion.

It was worrisome when scenarios like mailing informed consent to the patients, letting physicians make the decision, and  not provide a consult before the signing of the informed consent for certain procedures in some contexts were brought up. This does not appear to be heading in the right direction because the meaningful dialogue or parts of the dialogue are not taking place and the patient’s level of comprehension about the risks and benefits are being overlooked. This got me thinking how I could… Continue reading

It’s the system…

It was great having a session on human factors. I had a great review and also learned a lot of new things. I love data, so having all of the results from the various studies made me smile. In thinking about outcomes to look at for my project it will be important to see if I can capture how interruptions/disruptions affect communication, patient care, and patient clinical outcomes.

I also gained more appreciation and received validation for my beliefs that the patients and health care professionals must have a partnership. This relationship relies on mindfulness and we must include the family because they are the patient’s advocate(s).

Nakia

Telluride Experience 2020 Dates

BRECKENRIDGE, CO:
CMF Session One*: 6/8 – 6/11
Bennathan Session Two: 6/15 – 6/18
Session Three: 6/22 – 6/25

WASHINGTON, DC/MD:
Session Four: 7/22 – 7/25

*Session exclusive to the COPIC Medical Foundation Residents.