Teaching Error Disclosure to Residents: A Curricular Innovation and Pilot Study Rachel A. Bonnema, MD, MS Gabriella G. Gosman, MD Robert M. Arnold, MD Abstract Objective To compare change in obstetrics and gynecology residents self-efficacy in disclosing medical errors after a formal educational session. Methods This was a retrospective postintervention survey to assess change in perceived preparedness to disclose medical errors. We used a 4-hour educational seminar that included a didactic component (30 minutes) and experiential learning with a trained facilitator (3 hours). Change in self-efficacy was measured using a 5- point Likert-type scale (1 is lowest, and 5 is highest) and was compared using sign test (a 5.05). Results In our pilot study, 13 of 15 residents reported having previously participated in error disclosure. After the session, residents considered themselves more prepared for the following: to know what to include in and how to introduce error discussions, to deal with a patient s emotional reaction, to respond to a patient s questions regarding how an error occurred, and to recognize one s own emotions when discussing medical errors. Residents believed that they would be likely to use the skills learned in the remainder of residency and in their future career. Conclusions This curriculum was associated with improvement in self-efficacy regarding error disclosure. Given the unique malpractice issues that obstetricians/ gynecologists face, it seems particularly useful for residents to learn these skills early in their career. In addition, this topic represents an ideal educational opportunity for residencies to improve patient care and to address other core competencies in resident education such as communication skills and professionalism. Introduction The issue of errors, particularly disclosing errors to patients, is an uncomfortable and often anxiety-provoking topic for physicians. Physicians may recognize cognitively that adverse events and errors are a reality in medicine; however, the practice of error disclosure to a patient remains difficult. Since publication of the Institute of Medicine s report on medical errors, 1 guidelines regarding communication of errors with patients have emerged. 2 When medical errors occur, effective physician-patient communication is Rachel A. Bonnema, MD, MS, is Assistant Professor of Medicine, Section of General Internal Medicine, University of Nebraska Medical Center; Gabriella G. Gosman, MD, is Assistant Professor, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh School of Medicine; and Robert M. Arnold, MD, is Professor of Medicine, Chief of the Section of Palliative Care and Medical Ethics, Assistant Director of the Institute to Enhance Palliative Care, Director of the Institute for Doctor-Patient Communication, and Leo H. Criep Chair in Patient Care, University of Pittsburgh School of Medicine. This study was supported by the Department of Obstetrics, Gynecology & Reproductive Sciences and the Department of Medicine, University of Pittsburgh School of Medicine. This study was presented as an oral abstract at the 2008 Council on Resident Education in Obstetrics and Gynecology & Association of Professors of Gynecology and Obstetrics Annual Meeting; March 6, 2008; Lake Buena Vista, Florida. Corresponding author: Rachel A. Bonnema, MD, MS, Section of General Internal Medicine, University of Nebraska Medical Center, 985185 Nebraska Medical Center, Omaha, NE 68198-5185, 402.559.2439, rbonnema@unmc.edu DOI: 10.4300/01.01.0019 essential. The literature indicates that patients want to know when errors occur and desire full disclosure of not only major errors but also all errors that cause harm. 3 Ethical and professional guidelines and patient safety organizations advocate disclosure of medical errors. Studies 3,4 show that physicians also support disclosure, yet evidence also demonstrates that frequently disclosure does not occur after a medical error. 5 Physician uncertainty about what to say and lack of skill in disclosure 6 contribute to the rarity of routine error disclosure. The medical literature on error disclosure in obstetrics and gynecology (OB/GYN) is sparse, although the topic of error disclosure has been well documented in internal medicine and surgery. 3,5,7 It is a particularly important area of investigation given the professional liability climate of OB/GYN practice. Despite the lack of OB/GYN-specific data on error disclosure, the American College of Obstetricians and Gynecologists 8 published a committee opinion in 2007 on the importance of error disclosure and the need for health care providers to undergo specific training in error disclosure to understand how to best disclose adverse events. Much of the literature regarding error disclosure education among trainees deals with the emotional aspects to the trainee; sparse literature exists regarding the best way to teach error disclosure to residents, with no literature to date existing on this topic within the clinical specialty of OB/GYN. It seems that much of the 114 Journal of Graduate Medical Education, September 2009
INNOVATIONINSBPANDPBLI teaching and learning surrounding medical errors is informal and that many learners are unsure whether to disclose errors and what to say. 9 We believe that the topic of error disclosure represents an ideal educational opportunity for residencies not only to improve patient care but also to address other domains of resident education such as communication skills and professionalism. Therefore, we describe an innovative curriculum and pilot study for OB/GYN residents with the following 2 primary curricular objectives: (1) to develop verbal and nonverbal communication skills targeted to effective medical error disclosure and (2) to teach basic knowledge about the disclosure process using didactics and experiential learning. Methods Curriculum We designed a 4-hour educational seminar for fourth-year OB/GYN residents on error disclosure. We directed our educational session to more experienced trainees to optimize learning. Session attendance was mandatory for all fourth-year residents, but participation in this pilot study was optional. Our educational session included a 30-minute didactic component, followed by a 3-hour standardized patient (SP) practice session with a trained facilitator. Before developing the didactic portion of the curriculum, we performed a literature review to identify key elements of medical error disclosure thought to be important to patients (TABLE 1). 5,10 12 These were included in the didactic session. We then led a brief discussion of a physician s emotional reaction and response to errors, common patient reactions to hearing about errors, verbal and nonverbal responses to emotion such as the NURSE mnemonic (name the emotion, understand, respect, support, and explore) (TABLE 1), 13 and hospital and Pennsylvania state policy for disclosing an error in writing (http://www.mcare.state.pa.us). These discussions were followed by a small-group SP practice session for learners to disclose hypothetical errors. We developed 3 scenarios based on real-life cases. OB/GYN faculty, communication faculty, and SPs collaborated on case development for medical accuracy and ability to meet the learning objectives. Communication faculty had received master s degree-level training in teaching communication skills and are local and national experts, in one case serving as the Director of the Institute for Doctor- Patient Communication at the University of Pittsburgh School of Medicine (RMA). Residents were provided with information about patient background, medical issues in the case, and the timing and setting of disclosure. Standardized patient and facilitator cases contained this information, an in-depth description of the patient, and specific emotional directives for the SP. Each resident practiced error disclosure in a small-group setting composed of a communication expert, content expert (OB/GYN faculty), TABLE 1 Patients want Components to Include in Error Disclosure An explicit statement that an error occurred (use the word mistake or error ) To know what the error was To know why the error happened To know how recurrences will be prevented An apology NURSE mnemonic statements (verbal responses to patient emotion) Name the emotion Understand ( I can understand why you might be feeling ) Respect ( You ve always managed to cope in the past when ) Support ( We ll work together to ) Explore ( Is anything going on now that is contributing to ) SP, and 2 to 3 other residents. The communication faculty member was responsible for directing the didactic session and facilitating the small group, with the content experts present for any practical questions that arose. The basic tenet of the communication skills teaching method in this curricular intervention uses a learnercentered approach in a safe small-group environment allowing learners to experiment with new skills. This model asks learners to self-reflect on how they performed, what problems they may have encountered in the session, and what help they would like from the group. The teaching method is aimed at addressing learners needs and making the learning relevant to their current situation, as well as ensuring that they have received practical help in overcoming stumbling blocks. 14 As in other communication skills training, communication faculty used individual and group debriefing to apply this problem-based approach to teaching error disclosure. Evaluation We have used this curriculum with 2 consecutive residency classes. We included a retrospective postintervention survey to assess change in perceived preparedness to disclose medical errors. This was an anonymous survey distributed by one of us (RMA), who has no ongoing contact with the OB/GYN residency program. The survey asked residents to assess their preparedness to perform several skills before and after the session (score ranges from 1 [not at all prepared] to 5 [very well prepared]). The survey was based on a previously published instrument that was designed to evaluate the effect of a curriculum on breaking bad news 13 ; Journal of Graduate Medical Education, September 2009 115
TABLE 2 Self-Assessment of Error Disclosure Preparedness Among 15 Residents Variable Before Session Score a After Session Change in Score No. of Residents Improved P Value Know what to include 3.00 4.20 1.20 12.01 Introduce the topic with a patient Deal with a patient s emotional reaction 3.07 4.27 1.20 13,.01 2.87 4.13 1.26 12.01 Express empathy 3.73 4.47 0.74 8.20 Respond to a patient s questions Address patient concerns about consequences of error 3.20 4.20 1.00 13,.01 3.07 3.80 0.73 9.12 Deal with legal questions 2.47 3.00 0.53 7.20 Recognize your own emotions 3.13 4.27 1.14 12.01 Keep your emotions in check 3.33 4.13 0.80 9.12 a Score ranges from 1 (lowest) to 5 (highest). therefore, questions were modified to focus on the practice of error disclosure. Our assessment of the curriculum consisted of the following 4 components: self-efficacy regarding the skills used in disclosure, self-efficacy regarding response to emotion, a control question for validation, and evaluation of the perceived usefulness of the curriculum. Answers to these questions were based on a 5-point Likert-type scale (1 is lowest, and 5 is highest). Last, we obtained basic information on residents prior experiences with error disclosure. The number of residents who improved in perceived preparedness (after the session relative to before) was analyzed using sign test (a 5.05). Results are reported as raw data, with P values where appropriate. Likert-type scale items are reported as mean values. The institutional review board at the University of Pittsburgh reviewed the study protocol and designated the project as exempt under IRB PRO07050182. Results All 15 participants in this pilot study were fourth-year OB/ GYN residents at a single institution. Six of 15 residents reported some prior training in error disclosure. Thirteen of 15 residents reported having previously participated in a discussion with a patient about a medical error. TABLE 2 gives the results of the postintervention survey. The results indicate that the residents rate their abilities in 5 of 9 areas of error disclosure as improved compared with what they perceived their abilities were before the intervention (P,.05 for all). Residents showed a nonsignificant trend toward improvement in perceived abilities to address patient concerns about consequences of error and to keep their emotions in check. The areas of disclosure that did not show improvement were self-efficacy in expressing empathy and preparedness to deal with legal questions, which functioned as a control question. Residents valued the training and gave high ratings on the usefulness of the didactic session (mean score, 4.33) and the communication skills practice session (mean score, 4.50) (1 is poor, and 5 is excellent). Residents believed that they would be very likely to use the skills learned in the remainder of residency (mean score, 4.73) and in their future career (mean score, 4.80) (1 is not at all likely, and 5 is very likely). Overall, the educational quality of this session was highly rated, with a mean score of 4.64 (1 is poor, and 5 is excellent). Discussion Our experiential curriculum in this pilot study demonstrates a model for enhancing resident communication skills about error disclosure. In this setting, physicians are often uncertain exactly what to say or how to say it, and they often receive mixed messages about appropriate content in medical error disclosure discussions. 11 This curriculum was designed in part to meet increasing expert and professional organization recommendations regarding error disclosure training. We suggest that the use of this curriculum to teach 116 Journal of Graduate Medical Education, September 2009
INNOVATIONINSBPANDPBLI medical error disclosure represents an opportunity for residencies to potentially improve patient care and to address other core competencies in resident education such as communication skills, practice-based learning, and professionalism. Previous authors have described the skills necessary for error disclosure as having many similarities to those used in giving patients bad news and in physician-patient communication in general. 10,11 To provide residents with adequate skills in error disclosure, our curriculum method used basic tenets in communication skills training. Previous research has demonstrated that didactic training of communication skills alone is not enough to change learner behaviors, but the use of small-group experiential learning with the opportunity to practice learned skills and receive feedback has been well documented as a tool for teaching communication skills. 11,14 The curricular innovation described herein builds on previous knowledge about teaching communication skills by specifically using these methods to teach error disclosure. The use of experiential learning to teach communication skills is occurring more frequently in resident education; its use specifically to teach error disclosure is just beginning to be reported. 15 Our curriculum design used small-group learning theories and a supportive setting to provide a chance to practice new skills in a safe environment. In our study, almost half of the participants indicated previous training in the realm of error disclosure. All of these residents were in the same class who received a lecture on error disclosure during their intern year that is no longer part of the residency program curriculum. Despite this prior training, we were still able to show improvement in self-efficacy in many areas of error disclosure. This pilot study has some limitations. We restricted our learners to fourth-year residents; therefore, we have few participants on which to report at this time. Senior residents are skilled in basic communication skills and exercise a high level of responsibility as team leaders on many rotations. By this stage in training, residents have often encountered adverse events or cases of medical error and are invested in learning the skills of disclosure. The fact that we limited this pilot curriculum to senior residents may also explain the lack of improvement with regard to expressing empathy. It may be that residents already are skilled in this area at this point in training. Last, these are physicians who will be leaving residency shortly and will be responsible for error disclosure in the near future. Given this, we believed that this group would offer an optimal learning climate for this educational intervention. We did not have a control educational intervention with which to compare the changes seen in resident attitudes. Another limitation with regard to study design was the use of a retrospective postintervention design, which biases our findings because we asked residents to recall their abilities after an intensive educational session. This pilot study only assessed self-efficacy and not actual skill or behavior. Certainly, future iterations of this curricular assessment would be improved by using a mini-clinical evaluation exercise, an objective structured clinical examination, or other observation tools to directly measure skill. Assessment of long-term effects of the curriculum would also be important for further evaluation. Our method is resource intensive and requires a half-day of faculty and resident time away from clinical duties. However, when teaching communication skills, it is imperative that residents have the opportunity to practice the learned skills and receive directed feedback; therefore, maintaining a small-group environment and having skilled SPs are ideal for a curriculum in communication. This session did not address legal issues and possible implications surrounding error disclosure. Our goal for this curriculum was to improve specific error disclosure communication skills; legal and professional liability issues are covered elsewhere in our residency curriculum. This pilot study demonstrated that at our institution residents are already participating in error disclosure discussions. This curriculum fills an existing gap in resident education in our training program and in the OB/GYN residency education literature. The future direction for this pilot study includes continued training and evaluation of postgraduate year 4 OB/GYN residents at our institution. Improved behavioral evaluation, which was beyond the scope of this pilot study, will be helpful in determining longitudinal change in practice. In addition, translation of this curriculum to other specialties will be important to expand the program and to address core competencies in residency training. References 1 Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine, National Academy Press; 2000. 2 Gallagher TH, Lucas MH. Should we disclose harmful medical errors to patients? if so, how? J Clin Outcomes Manag. 2005;12(5):253 259. 3 Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients and physicians attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001 1007. 4 Gallagher TH, Waterman AD, Garbutt JM, et al. US and Canadian physicians attitudes and experiences regarding disclosing errors to patients. Arch Intern Med. 2006;166(15):1605 1611. 5 Mazor KM, Simon SR, Gurwitz JH. Communicating with patients about medical errors. Arch Intern Med. 2004;164(15):1690 1697. 6 Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med. 2006;166(15):1585 1593. 7 Chan DK, Gallagher TH, Reznick R, Levinson W. How surgeons disclose medical errors to patients: a study using standardized patients. Surgery. 2005;138(5):851 858. 8 ACOG Committee Opinion No. 380: disclosure and discussion of adverse events. Obstet Gynecol. 2007;110(4):957 958. 9 Fischer MA, Mazor KM, Baril J, Alper E, DeMarco D, Pugnaire M. Learning from mistakes: factors that influence how students and residents learn from medical errors. 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