Feb 15, 2010

Being Honest: Ducking Out from Under the Table

My adorable dog, May, has her flaws. Her bark and temper are infamous in our neighborhood. If the toy is not made of rubber, it will become an unrecognizable ball of mush within days. However, when it comes to going out to do her business, May almost never has accidents. On those rare occasions she makes a mistake, she slowly greets us with her head ducked down rather than her normal energy-filled charge when we arrive home.

We understand why these accidents happen. Most medical errors, as discussed in the IOM report, To Err is Human, are a result of poorly designed systems that do not give providers the best chance possible to care for patients in the way that they would like. May's accidents are also systems error. We only find a pool of pee in the house when we leave for a long period of time without allowing her to go out before we leave. May was not being negligent or purposefully filthy; the system she lives in simply does not allow her to successfully avoid these accidents. With these system constraints in mind, we do not blame her, but continue to work on scheduling improvements to prevent future occurrences.

Clinicians never want to intentionally harm their patients and are often emotionally impacted by a mistake. Similarly, as far as we can tell, May deeply regrets her accidents. Since she cannot use words to express her regret, she hides under the dining table and avoids eye contact as we clean up the mess until we say, "It's okay, May." Sometimes, she will even circle the "biohazard" zone slowly, as if admonishing herself. May's actions demonstrate her acknowledgment of the accident and we accept her apology--a courteous exchange that occurs between people all the time.

Medical malpractice is one of the few bipartisan goals of the current health reform battle. However, how to reform this messy process that is hard on all participants (physicians, hospitals, patients and families, and insurers) emotionally and financially is not as clear. Focusing on how to minimize costly lawsuits through caps on financial damages awarded to patients further complicates the fundamental courtesies that should occur when a mistake happens: acknowledgment, understanding, acceptance, and forgiveness.

In a paper published in the NEJM in 2006, then Senators Hilary Clinton and Barack Obama discuss how to improve patient safety and the medical liability climate through open communication between physicians and patients. The paper cites that the most important factor in people's decisions to file lawsuits is not negligence, but ineffective communication between patients and providers: lawsuits occur when "unexpected adverse outcomes are met with a lack of empathy from physicians and a perceived or actual withholding of essential information."

For those of you who are Grey's Anatomy fans (click here to read a Grey's Anatomy Obsession confessional), episode 13 of season 6 titled, "State of Love and Trust," touches specifically on medical liability reform and being honest with patients. A patient, later discovered to have a form of cytochrome P450 that unexpectedly allows her to metabolize anesthesia faster than normal, wakes up from anesthesiology in the middle of her bowel surgery and is traumatized by the violence of surgery and the panicked yelling from the surgical team. Emotionally disturbed by the experience, the patient wishes to press charges against the hospital. Dr. Shepherd, interim Chief of Surgery, is deep in thought about the threat of a lawsuit on his first day as Chief, when Dr. Miranda Bailey talks to him about open communication between physicians and patients in situations of medical error (see clip above). By apologizing to the patient, Dr. Shepherd is acknowledging the mistake and the patient's concerns, is providing the patient with the opportunity to understand and accept the mistake, and is working with the patient to reach an agreement that allows both sides to accept the mistake and attempt to reach forgiveness.

As then Senators Clinton and Obama explain in the paper, open communication allows for improvements in patient safety. The proposed National Medical Error Disclosure and Compensation (MEDiC) Bill was based on model disclosure programs such as those in place at the University of Michigan Health System (Go Blue!) and the Veterans Affairs system. These programs have given both patients and physicians protection while successfully reducing administrative and legal costs for providers, insurers, and hospitals. Surveys from these successful programs have also showed greater trust in and satisfaction with health care providers. On the cost side, the disclosure programs have resulted in the filing of fewer malpractice suits, a reduction in litigation costs, accelerated provision of compensation to patients, and increases in the numbers of patients who are compensated.

It is a remarkable feat that the University of Michigan Health System has reduced litigation costs from $3 million to $1 million in four years with its disclosure program. Though isn't it ironic that at the heart of the solution to such a complex problem are the basic principles of being honest and communicating openly with patients?

Telling patients the truth at times may be harder, but it is the most respectful thing to do. My dog, May, would bark in agreement.

Understanding the Incomplete Medical Diagnosis

*names and some details have been changed to maintain and protect privacy*
If multiple sclerosis was an anatomy review item, I can just imagine Dr. Zeller pointing at the spinal cord and asking me, “Eva, what is the clinical presentation of multiple sclerosis?” After overcoming the anxiety of being “pimped,” my response would probably include symptoms such as: muscle weakness, difficulty in moving, difficulty with balance, visual problems, fatigue, and pain. Before meeting my patient volunteer, Casey, that’s how I characterized multiple sclerosis. The mental image in my head also included a wheelchair. This snapshot of multiple sclerosis is the medical mold that physicians give to their patients upon diagnosis, which I used to think was complete and scientifically correct.

After almost six months with Casey, I now understand that this sort of medical mold is incomplete. This medical mold is analogous to giving an unknowing sculptor a headless cast of Michaelangelo’s David and telling him that this represented Michaelangelo’s complete masterpiece. What was missing in the medical mold of multiple sclerosis (MS)?

What was missing was Casey. Her empowering and encouraging relationship with Dr. Osuco, the optometrist who made her initial diagnosis; the negative recommendations she received from physicians that told her to quit nursing school because she had MS; her steady and rapid inability to walk up flights of stairs; the finality and fear she felt when researching more information about her condition; the shame of losing the ability to spell simple words; the unbearable embarrassment of urinary incontinence; the feeling of helplessness as her right side got weaker; the difficulties of maintaining a treatment regimen that seemed to fundamentally change her personality; starting every date with “I have MS”; shopping for life insurance plans along with her elderly mother; the loss of friends because they just couldn’t handle it; designing a plan for “when things get to that point”; doctor shopping and coming across the kind and comprehensive care that Dr. Richardson provides; temporarily losing hearing in her right ear and worrying about its implications on her MS; letting go of managing the disease on her own and instead working with Dr. Richardson's team; navigating how others view her given her very normal appearance but serious condition, trying not to mention her occupation as a nurse unless it means better care for her and her family; meeting other MS patients at varying degrees of disease progression who are all fighting and living quality lives; negotiating the risks and benefits of a high-risk drug that drastically improves quality of life but can cause a deadly brain infection; being the primary caretaker for her elderly mother who is surviving on an oxygen tank and two developmentally challenged foster children; working as a nurse nearly full time; her strong beliefs to advocate for quality and patient-centered care; and lighting up the room with her warm smile. That is the complete picture of MS.

How can we as future physicians learn how to see the complete picture of a disease? We need to be aware that our list of symptoms is only a subset of factors that can instigate tremendous challenges and change on another life, learn how to talk to patients about their values and greatest concerns, and integrate those values and concerns with the treatment plan. By laying a foundation of trust and building a strong partnership with patients, we can begin to cross the gap between the stigma that we create and the reality of illness in an individual. My experience with Casey has taught me these important lessons and I hope to never forget them as I continue in my training.

Many thanks.