Working together with, and for our patients (and other musings).

Reflecting over the events of the past week I can say that for sure it has been one of the most unique and enriching experiences of my medical career. Our group was incredibly diverse, not only from different parts of the world but also from different backgrounds from first year medical students to nurses to residents and fellows. Each brought a unique perspective to the conference with their experiences.

Too often we are blinded by the “Tribes” we belong to. Doctors interact with doctors, nurses with nurses and so on. Only when one “tribe” needs the services of one of the others does cross communication take place. Each have their own reports or sign-outs and do their own tasks during their shift. The concept of hierarchy complicates matters further as both within and between tribes there are those that traditionally have been expected to be subservient, quiet and revere those “higher in the food chain”.  This is catastrophic for patients as it makes it near impossible for someone of lower status to speak up.

One of the highlights I took from the novel we read was that to improve the quality of care we provide to our patients we all need to be on the same team, and medical practice under the old hierarchical way of thinking is not sustainable and incredibly dangerous. It’s not easy to throw this way of thinking aside. Even during the hiking event the concepts of certain tasks being “a nurse’s job” was lightheartedly brought up. Reflecting on how many times I’ve personally left the room when something unpleasant has occurred, or having “let me go get your nurse” as part of my vocabulary shows that even early on in my training I’ve also adopted this way of thinking. As the shirtless man video demonstrated, even one person can start a significant movement and while there most definitely are job specific tasks, it’s wrong of us to not pitch in when we can.

Right from the start our group threw away our labels of doctors, nurses, medical students and worked together as an equal group of health professionals to brainstorm ideas and share our opinions on how to improve practice and ourselves to better serve the people we are charged with taking care of. Not only did this change the entire dynamic of the week, creating what surely will be lasting friendships, it allowed us to appreciate every different perspective each discipline had to offer in a fantastic, safe and energizing atmosphere.

We heard multiple patient stories and while each had their own unique emotions and medical failures, one of the overlying themes I felt across all videos was a sense of these patients and families being alone, confused, let down not just by the medical errors, but the failure of the providers to listen and failure to explain. It’s difficult to put yourself in the patient’s shoes. What seems simple to us as health providers might as well be written in a foreign language to most of our patient population. I would imagine that what an informed consent form looks like to a patient is similar to what my tax return looks like to me. Without the help of a professional I surely wouldn’t be able to navigate this process, and yet my patients look to me for similar guidance for something that is much more important. We put our trust in the professionals that help us, and it’s scary how easy it is to betray that trust.

We learned about leadership and the qualities and traits of a leader. One of the traits not mentioned was that of courage. Reflecting back on all of the videos, courage, or lack thereof, also played a very important role in all of them. How might the stories have played out had the physicians had the courage to tell the families that something was wrong? If a nurse, medical student or junior resident had the courage to speak up before something happened? If after the fact the physicians had the courage to step up and take responsibility for what they did? On the other side of the coin, I sensed a feeling of guilt from the families for not having the courage to speak up themselves when they noticed something was wrong or when they didn’t get enough information from the medical team taking care of their family.

Taking the time to reflect on my own practices I now find myself wondering how many times I’ve gone through an informed consent form with a patient and have them not completely understand what I’ve told them. How many times have I rushed through the process to provide them the treatment I think they need, but that they might not and are just too confused or scared to say anything back. How many times have I took stock in the almighty paper with the patient’s signature on it without understanding the importance of the process behind it. I wonder how many of the patients had questions regarding my level of training and were too scared to ask. It’s not something I even considered as part of an informed decision process until now. What we do as physicians needs to be more than just a doctor-patient relationship, but rather a doctor-patient partnership in which we work together to develop a plan of care.

Several important pillars to this partnership are communication, mindfulness and transparency. We need to be mindful of the fact that most of our patients do not understand what is happening to them or why they are sick. Even at the best of times medical jargon is confusing for people, sometimes even between professionals. We need to be able to be effective communicators, able to talk to a level that patients can understand.

It takes skill to be able to effectively communicate with patients, and it’s something that I feel very passionately about. During my medical school interviews in Canada, I had been essentially told that I have the skills and smarts for the job, but was unable to sound professional enough to effectively communicate with my peers and therefore their schools were not the right place for me to learn. I feel that attitudes like that are the reason patients are so confused about their care. Who is the patient population these schools serve? Other health professionals? I think there is a fine balance, and a lot of practicing physicians cannot effectively communicate with patients because talking like a normal person has little role in medical training.

We also need to be transparent about our practices. Every step of the way the patient should be informed and updated whether the outcome is good or bad, and especially if a medical error had occurred. This will not only build trust between the equal partners in the relationship, but also keep the plan of care in focus. Honest and open communication can be extremely difficult to achieve, especially if you know that a medical error has caused your patient harm. Even more difficult will be moving forward with a patient that no longer respects you or the partnership. I think this point was illustrated very well in the patient stories we saw. Over the first half of the week, the stories were more based on the lack of transparency, and then as the week continued there was more of a shift to open and honest communication, and there was a clear difference in the outcomes.

Sometimes, despite everything we do, errors will still happen. It is important to disclose these errors with honesty and openness, and as quickly as possible. Unfortunately, the fear of persecution is real, and often justified. It’s often easier to single out a scapegoat than to look at the evidence and make a system change. It was refreshing to see everything that has been done with CANDOR and how much more can be learned from mistakes if we create an open and safe environment. In a just culture, where the fear of persecution is passed over for a much more constructive environment. Treating someone who has made a medical error with respect and working with them to identify system errors brings a plethora of knowledge to the case that can ultimately lead to system changes. It is not fair to put people in a system that sets them up for failure and then punish them when something goes wrong. By engaging with families immediately after the fact with “Go Teams” we can begin the healing process immediately and, as a patient story demonstrated, with good outcomes for both the patient and the physician responsible for the medical error.  

In order to really generate a culture of change, everyone needs to be on board. The walls that have been erected between us and our patients and colleagues need to come down. We need to all work together as equals, regardless of our occupation or level of training. This week for me has shown that when the walls come down, and we are just a group of people with a common goal, we really and truly can accomplish great things. As we learned, all it takes is one person willing to do something different (be that with or without a shirt).