A Key to Patient Safety — Don’t Just Listen, Solicit Input

New blog post in BMJ

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suzanne_gordonWant to be a better physician or nurse leader? Enhance patient safety? Effectively lead teams? One of the current consultant prescriptions is the recommendation that leaders spend more time listening than talking. Whether in the larger management literature or in the articles and books that specifically target healthcare, listening is portrayed as a key to leadership.

I am all for listening. Of course people have to listen to each other rather than silence, ignore, dismiss, or denigrate one another. When it comes to the implementation of genuine teamwork and patient safety within the hierarchical environment of health care, I don’t think listening is enough. As Amy Edmondson has written in her book Teaming, “Research shows that hierarchy, by its very nature, dramatically reduces speaking up by those lower in the pecking order. We are hard-wired, then socialized, to be acutely sensitive to power, and to work to avoid being seen as deficient in any way by those in power.”  READ MORE

Hey Manners Matter: Say Hello My Name Is Not Just to the Patient

Why Introductions Matter Is a New Post I did at the BMJ

suzanne_gordonThe other day, I was invited to give a seminar on interprofessional teamwork to a group of residents and attendees at a prestigious university medical center in Europe. The first thing people did when they trooped into the room was introduce themselves to me. Since there were about 25 people in the room, no one really expected me to remember their names. But each and every one of them went through the drill.

These introductions did more than convey instrumental information about who we all were and what roles we had. At the most fundamental level, what people are doing when they acknowledge a stranger walking down a street or shake the hand of a person whom they have just met is create a psychologically—not to mention physically—safe environment. Read More


New Blog Post about VA at BMJ

This was just posted on the BMJ blog.  

Hope people will read and pass it on.

suzanne_gordonBy the end of this year, the US will have a new president as well some new members of Congress. The results of the 2016 election will not only effect the further implementation of the Affordable Care Act (Obamacare), but the future of the country’s largest healthcare system—the Veteran’s Health Administration. That’s because most of the Conservative Republicans running for President—as well as many of those running for or already serving in Congress—are not only determined to repeal Obamacare. They are also committed to dismantling the largest and only publicly funded, fully integrated healthcare system in the US—the Veterans Health Administration (VHA). Even many Democrats are not fully supportive of the VHA. While Hilary Clinton says she does not support privatization of the VHA, only Bernie Sanders (D. VT) has demonstrated a deep understanding of what the VHA does and how it actually works.

The Veterans Health Administration grew out of Abraham Lincoln’s Civil War pledge “To care for him who shall have borne the battle and for his widow, and his orphan.” Since World War Two, the VHA has become the largest and only fully integrated, publicly funded healthcare system in the United States. Its 1700 sites of care include more than 150 medical centers, 1000 community based outpatient clinics (CBOCs), and other mental health, nursing home facilities, and in and outpatient facilities.

The VHA has over 260,000 employees, over a third of whom are veterans. Its tripartite mission includes the delivery of clinical care, research, and teaching. Since 1946, the VHA has affiliated with major academic teaching hospitals and now trains over 70% of American physicians as well as students and trainees in 40 other healthcare professions. It’s vast research arm has produced innovations that have improved the health of veterans suffering from illnesses like Post Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI), as well as spinal cord injury. VHA research has also produced innovations that help all patients. To name only a few, the VHA developed the first implantable cardiac pacemaker, performed the first successful liver transplant, helped to test the Shingles vaccine and develop the nicotine patch.

Republicans have consistently refused to adequately fund the VHA and have resisted expanding its services to all veterans. The VHA only serves veterans who have some form of honorable discharge and who have service related disabilities and/or low incomes. The result is that the system takes care of the oldest, sickest, and poorest veterans. The average VHA patient is 62 years old, has multiple physical co-morbidities and a higher percentage of mental health problems than the average patient in the private sector. In spite of this significant challenge, an Independent Assessment of the VHA’s record on care delivery, mandated by the 2014 Choice Act, documents that the VHA outperforms the private sector on many measures, is equivalent on some, and marginally worse on only a few. Despite variability in the VHA system, the Independent Assessment repeatedly reports that the private sector healthcare system provides care with even more variability than the VHA. The Association of VA Psychologist Leaders recently posted yet another review of the scientific studies on VHA care which document similar outcomes.

Ignoring the VHA’s record of care delivery, congressional conservatives are exploiting the wait time problems and delays uncovered in 2014 in Phoenix and some other VHA facilities to argue that the entire VHA system is broken and that the VHA should no longer pay for and provide healthcare services. They want to eliminate the VHA and transfer veterans to the private sector healthcare system, with the government serving as payer, rather than also the provider of care.

Needless to say, this would be a huge boon to private sector hospitals, which is why many support this plan. It is also favored by large pharmaceutical and medical equipment companies. Big Pharma has long chafed at the fact that the VHA—unlike say Medicare or other US health plans—negotiates lower pharmaceutical prices through its drug formularies. Since VHA physicians and other staff are on salary, they have little financial incentive to either over or undertreat their patients and thus use medical equipment and treatments much more judiciously than their counterparts in the private sector. They have also developed more integrated mental health, primary care, geriatric and palliative care services than other US health plans.

Finally, the VHA has long been anathema to conservatives. As Alicia Mundy has recently reported in an article in The Washington Monthly, the Koch brothers have funded a group called the Concerned Veterans of America—a veterans’ service organization that has no veteran members and provides no veteran services.

The CVA has been lobbying for partial and ultimately full privatization of the VHA. The mainstream media have been filled with stories about VHA dysfunction. Media outlets have promoted this narrative and ignored continuing evidence that the VHA—in spite of wait time delays and top heavy management—continues to deliver high quality care to veterans.

As a result Congress is now considering two bills that could pave the way for the privatization of the VHA. At the same time, a congressionally mandated Commission on Care tasked with strategizing about the future of the VHA, is also dominated by discussions of VHA privatization.

Seven of the commission’s members have written a proposal entitled “The Strawman Document” recommending the total elimination of the VHA. The Strawman document has produced an outcry from veterans’ service organizations (VSOs). Eight of the nation’s largest veterans services organizations—including the American Legion, Disabled American Veterans, and Paralyzed Veterans of America, have written a formal letter to the commission to express their concern about the report. These groups support proposals, like that put forth by VA Undersecretary of Health David Shulkin, that would strengthen the VHA, give veterans the choice to see outside providers if necessary, but maintain the VHA as provider and coordinator of healthcare services.

The fate of VHA will affect more than America’s 24 million veterans and their families. With its research, teaching, and innovative models of team-based integrated care, the VHA serves as a model for quality healthcare delivery that should be emulated rather than dismantled.

Suzanne Gordon is a healthcare journalist and co-editor of The Culture and Politics of Healthcare Work Series at Cornell University Press. Her latest book is Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.

Competing interests: SG is currently writing a book about the VHA. 

New Blog Post in BMJ on The Difficult Patient

I just had this blog post published on the BMJ.

Suzanne Gordon on the difficult patient

22 Mar, 16 | by BMJ

suzanne_gordonToday it’s hard to find a healthcare professional who doesn’t want to “put the patient first,” practise “patient centered care,” or make the patient “part” or even “the centre” of the healthcare team. When you discuss any potential or actual bureaucratic, governmental, insurance company, or even internet interference in clinical practice, clinicians complain that non-healthcare professionals fail to understand the sacred trust that exists between clinician and patient and the duty to “first do no harm,” and protect the patient. 

When, however, the conversation moves from the abstract patient to the real life patient whom clinicians meet in their daily practice, it’s amazing how quickly we, as patients, can slip off our sacred perch and be categorized as  “difficult.”  The rapidity of our descent into difficultness has always intrigued me. Who exactly is “the difficult” patient?  What exactly do you have to do to move from worthy to difficult? Call the physician at home every couple of hours?  Scream at nurses in the hospital or sit on the call bell? Be, god forbid, “non-compliant?”

When I talk to ER docs, or surgeons, or even primary care physicians (the ones who are supposed to be extra-special caring) I also hear many complaints about their “difficult patients.” “You see a patient whose chart is the size of a dictionary, and you run in the other direction,” one internist told me recently.  (I cringed when I heard this. What happens when I’m 80 and my medical chart is as thick as my wrinkles are deeply etched?) Another ER doc (like so many ER nurses) complained about all the “frequent flyers”—patients who repeatedly visit the ER, often with chronic conditions—coming to his institution. OMG! I thought, would that be how they talk about me if I had sickle cell anemia, or repeated falls from dementia, or some other chronic physical or mental problem?  I’ve heard nurses complain about patients who are simply anxious about a procedure, or ring the call bell once too often.  Comparing them to patients who are much worse off, they wonder what this person has to complain about.

Most non-healthcare professionals would heartily agree that screaming, using abusive language, punching, and other violent behavior falls into the category of “difficult.” But it’s a bit frightening to hear healthcare professionals label patients as “difficult” only because they are anxious and terrified at being in an alien land—i.e. a hospital; ask too many questions when the nurse or doc is busy; ring the call bell because illness has reduced them to the status of an infant who can’t do anything for herself; or express a slight doubt about treatment.

I understand that many healthcare professionals may lack empathy because they are overworked, exhausted, hungry, and perhaps even depressed and anxious themselves. Some would also insist that they are caring with their patients no matter how “difficult,” these patients prove to be. Nonetheless, I worry that using the term “difficult” establishes a framing effect—a cognitive bias—that may result in poor communication and tense patient-clinician relationships. Well-intentioned healthcare professionals may convey their feelings about so-called difficult patients to those patients and to other people who will care for those them. This will color the behavior of other caregivers and turn the patient record into a kind of rap sheet—the proverbial gift that keeps on giving. (Just say the word “difficult patient” to yourself and consider how you would respond to that person. Does your stomach clench, your blood pressure rise, and your mind race to the most negative image when you contemplate interacting with that person?  Then think about how a  nurse, told by her manager that she is about to care for a “difficult patient and family” has been set up to approach them? Framing patients as “difficult” can lead practitioners to convey subtle signs of impatience, lack of sympathy, negative judgments about the patient or his or her behavior, among other things.  As Dominck Frosch and his colleagues have documented in a study in Health Affairs, this can, in turn, lead patients to fear asking questions of, discussing concerns about treatment with, or even concealing critical information from their caregivers.

The potential to create unproductive and unsafe relationships could, perhaps, be reduced if the terms used to describe patients changed: if clinicians talked about the “difficulty” they had dealing with a particular patient or situation rather than characterizing the patient as “difficult.” Such a reframing might make it more possible to search for options, alternatives, and solutions to those “difficulties.” Conceptualizing the patient as difficult, on the other hand, makes that process very hard once the problem is almost defined as someone else’s character rather than one’s own response to a challenge or individual.

The point here is that words matter. If we can shift the clinical and relational terrain by adding a y, or ies to the word difficult, isn’t it worth a try?

Suzanne Gordon is a healthcare journalist and co-editor of The Culture and Politics of Healthcare Work Series at Cornell University Press. Her latest book is Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.

Medicine’s F Word from BMJ

suzanne_gordon“The patient failed” this or that therapy.

I first heard medicine’s F word almost 30 years ago when I was having a casual conversation with an oncologist in a break room on the hematology/oncology unit. The oncologist—an earnest man devoted to his patients—was talking about a man who was dying of cancer. “Well,” he said with grim resignation, “he failed six rounds of chemotherapy and there’s nothing else we can do.”

The last time I heard the F word was at a morbidity and mortality round. A group of physicians were discussing a case that had gone badly. The patient had contracted Guillain-Barré syndrome. As the resident was presenting the case, he reported that the patient “had failed” several rounds of antibiotics and was now completely paralyzed. People in the room nodded sagely. No one but me—who thinks of herself as a potential patient or sometime patient—seemed to think there was anything wrong with this formulation.

And why would they? The F word is everywhere in medicine. It’s used when professionals are talking about patients who are in trouble or are dying, when they describe a treatment that has not worked, or when a patient has experienced a set back. Consider the following examples:

Oncology attending to resident– “I put the patient on Taxol and Adriamycin and the patient failed Taxol/Adria.”

ER physician to hospitalist, “Mr Y is a morbidly obese patient with a terrible infection on his left leg. He failed oral antibiotics and needs to be admitted for IV antibiotics.”

An attendant in the neonatal intensive-care unit (NICU) talking to a NICU nurse—“The baby has a congenital diaphragmatic hernia and has pulmonary hypoplasia. We started nitric oxide and the baby failed the nitric oxide therapy course.”

With variations, notes in charts use the same language, as do reports in research journals.
Many healthcare professionals with whom I’ve spoken about the F word think it is purely descriptive—almost neutral in its content and connotations. They don’t recognize that the verb to “fail,” used with the noun “patient” as a subject always implies blame.

Here, for example is how, Ask Dictionary.com defines the word fail:

“to be or become deficient or lacking; be insufficient or absent; fall short:
to fall short of success or achievement in something expected, attempted, desired, or approved”:

Failure is always an act that is accomplished by an agent. When you fail at something—particularly in competitive Western cultures—you have done something wrong. You have not studied hard enough so you failed the test. You did not run fast enough, so you failed to win the race. When one says that a patient failed a therapy, the patient is, by definition, not doing something right or efficient. They are lacking, absent, falling short or—to follow the dictionary definition—setting him or herself up for the medical equivalent of bankruptcy. When a patient is said to have failed something, the unavoidable implication is that the patient—not the disease process, the limitations of contemporary treatments, or of the state of current scientific knowledge—is responsible for his or her own suffering, deterioration, or demise. Unless the patient actively compromised their own treatment, using the term “the patient failed,” ascribes agency or action to someone who, in most cases had very little ability to influence the outcome. When clinicians use these terms, they are infecting the patient experience with the same burden of shame and blame that they so often shoulder. Only this time, they are transferring part of that burden to suffering patients. As Mardge Cohen, an internist and HIV-AIDS specialist puts it, “It’s almost as if nothing is patient-centered except the patient’s failures.”

When I’ve talked about this phenomenon to different healthcare providers, many respond that this terminology is only used when physicians or other healthcare professionals communicate with each other—either verbally or in their charting. They insist that they would never, ever tell a patient—to their face, that they had “failed a therapy” and were about to suffer the consequences. They wouldn’t be so callous as to sit down with the patient and inform him that he’s dying because he failed his treatment.

They somehow believe that we, as patients don’t know that they, as providers, consistently refer to our setbacks in language that makes it seem like they think we are responsible for any poor outcomes we experience. “I always tell my residents that if we use the term the patient failed in our case meetings, this language may slip out of our mouths when we are in front of patients,” says Glenn Bubley, chief of Genitourinary Oncology at the Beth Israel Deaconess Medical Center.

Bubley is right. The F word slips out when physicians-in-training fan out around a patient’s bed and inform their attending doctors that Mr X has “failed four rounds of chemo.” Or when a parent sitting next to their desperately ill child on a NICU overhears rounding physicians tell one another about that poor baby who failed the course of nitric oxide.

I myself was told that my bladder failed when it somehow acquired—all on its own—a urinary retention injury after surgery. After having heard these comments over and over again for the past thirty years, it is hardly reassuring to think that the people caring for me will consider that I may have failed in some therapeutic enterprise and blame me for the poor outcome of my medical journey.

If healthcare is to be truly patient centered, then those who care for the sick cannot continue to use language that ascribes blame to suffering human beings—whether in conversation, through notes in the chart, or discussions in the scientific literature. Medicine, nursing, and all other healthcare disciplines have perfectly good options when discussing poor patient or treatment outcomes. Consider some of the following:

  • The bacteria was resistant to multiple antibiotics,
  • The cancer was refractory to treatment.
  • Taxol/Adria failed to put the cancer in remission.

The patient failed is just not one of them.

Suzanne Gordon is a healthcare journalist and co-editor of The Culture and Politics of Healthcare Work Series at Cornell University Press. Her latest book is Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.