Ezekiel Emanuel, a bioethicist with the National Institutes of Health and brother of White House Chief of Staff Rahm Emanuel, put into perspective the more than $2 trillion spent on healthcare in the U.S. every year.
"People don't have any idea of what a trillion is," said Emanuel, pointing out that healthcare's steady increase will theoretically consume the entire economy one day.
He gave a shocking math lesson:
How long ago was a million seconds?
Less than two weeks ago.
How long ago was a billion seconds?
About the time when President Richard Nixon resigned from office in 1974.
How long ago was a trillion seconds?
30,000 B.C., which was 15,000 years before the first human stepped foot on North America.
With all the wrangling going on in Washington, D.C. over healthcare reform, wouldn’t it be nice if all of our elected officials took the time to set aside their political differences and read the following simple, yet powerful, poem by William Arthur Ward, and then, more importantly, took its words and meaning to heart? I know I’m being idealistic, and there’s not a snowball’s chance in hell it’s going to happen, but what if?
Believe While Others...
By William Arthur Ward
Believe while others are doubting.
Plan while others are playing.
Study while others are sleeping.
Decide while others are delaying.
Prepare while others are daydreaming.
Begin while others are procrastinating.
Work while others are wishing.
Save while others are wasting.
Listen while others are talking.
Smile while others are frowning.
Commend while others are criticizing.
Persist while others are quitting.
How to apologize
After deciding that an apology should be offered, it is essential to do it well. A badly done apology can make things worse for both the patient and the professional. A well-done apology involves at least four parts: acknowledgement, explanation, expression of remorse and reparation.
The high emotion surrounding an apology warrants that it occur at the right time and place. If you do it too soon, you won't know enough facts. If you wait too long, you might be suspected of deception or disregard. Ensure sufficient time, a comfortable physical layout and adequate privacy so that a meaningful, and likely emotional, conversation can take place. Consider who should be present: Who would the patient like in attendance? Should other members of the care team attend? Does someone from your organization's patient relations staff need to participate? Having more people participate increases the chance that all relevant concerns will be aired, but it also raises the risk that the moment will be less personal and, perhaps, less effective.
Be aware of your body language as you get ready to begin your apology. First, sit down and maintain an open and receptive posture (no crossed arms or speaking over the shoulder). Maintain eye contact, and speak in a professional and empathic manner. Avoid jargon, defensive statements or angry rebuttals. Facial expressions and body language will likely be remembered as much as words.
Focus on listening. Begin by asking the patient - and, if present, family members - about their understanding of what happened. This will provide insight into their interpretation of the facts and will highlight potential gaps in their knowledge or possible misperceptions. After their explanation, describe in chronologic order what happened when and why various interventions were taken, or not taken, at each step. Explain the error that occurred, let them know that you share their frustration that the mistake happened, and express your sincere remorse.
It is especially important to patients to find meaning in their experience. To the extent possible, describe what their outcome will mean for them, what can be done to prevent similar errors from occurring and how others may be helped by what was learned. If possible, offer restitution. Obviously, any monetary amounts would need coordination with and possible approval by institutional or insurance carrier representatives, as appropriate, before discussing them in specific terms.
Who apologizes
The patient's personal physician often is in the best position to explain what happened and to express sorrow over the outcome; a long-trusted relationship goes a long way toward helping the healing. If the personal physician was not responsible for the error, then the person who made the mistake should apologize, perhaps with the personal physician in attendance. When a trainee (e.g., a resident physician or a medical student) has committed the error, that person should be accompanied by the attending physician when making the apology. When the error is due to systems or institutional failure, it might be an administrator who should apologize. Should the responsible person not be identifiable, or able or willing to apologize, then the personal physician or organizational leader should make the apology.
Time for reflection
Learning to give a skilled apology without improving on patient safety is like perfecting firefighting while ignoring fire prevention. Start by practicing reflective medicine. Think about each hospital admission as a possible failure in outpatient management. This develops the habit of doing root cause analysis of why your patient deteriorated to the point of requiring hospitalization. This, in turn, can lead to changes in practice routines (e.g., arranging for a nurse call the day after an office visit for a chronic obstructive pulmonary disease exacerbation). Many larger groups now have patient safety officers who are responsible for overseeing safety practices. Create an "oops" box - known in hospitals as a repository for incident reports - that allows staff to report events or routines that caused, or could have caused, error.
Beware the handoff. The transfer of responsibility for care from one clinician to another is one of the high-risk moments in health care. Electronic sign-outs or communication through unit clerks or paging services may suffice for stable patients, but a real-time conversation in person or by phone is usually needed for patients who are fragile, critically ill or high risk (e.g., their cases involve social issues, including problems in previous care).
Electronic records offer great potential to improve the safety of care by eliminating illegibility, making more information available more easily, providing warning signals and reminder prompts, and facilitating easier identification of practice patterns and potential problems (e.g., notifying patients on a specific medication of newly released drug alerts or recalls). At the same time, however, poorly designed electronic records may allow clinicians to dump huge volumes of text that obscure the important data, document histories or exams that were less complete than represented, or generate so many warning messages that they become an ignored blur.
Perfect care is an ideal that can only be pursued, not achieved. Individual effort can assist in that pursuit, but the most substantial improvements will occur through system redesign, which requires a reflective approach to care and the commitment of all members of the care team. In the journey to better care, missteps and trips will occur. Meanwhile, skill in the art of apology will be needed.
The aftermath
One potentially vexing decision for a family physician who commits an error and apologizes is whether to continue as the patient's personal physician. Like most difficult questions, the answer will depend on the circumstances and the people involved. Continuing the professional relationship may be too emotionally difficult for the patient or the doctor. Yet, terminating the relationship, if not handled properly, may leave the physician vulnerable to allegations of abandonment. If the patient or family is unable to forgive the doctor, then they will likely answer the question themselves by seeking care from another physician. Even when there seems to be genuine forgiveness, it may not be appropriate for the doctor to continue as the patient's physician if the doctor cannot maintain the necessary professional objectivity in future stressful situations involving the patient. Doctors who have erred in the care of a patient may attempt to compensate by over-responding when the patient develops subsequent problems.
Should the relationship continue, the patient will expect, and deserve, extra-attentive care in order to validate the essence of an apology ("I am sorry for what I did, and I will do my best to avoid future mistakes."). Giving the patient special attention is also the right thing to do; when someone has been injured by another's error, there is a duty to prevent further harm from happening.
An apology puts the health care professional in the unfamiliar and vulnerable position of being dependent on the patient for something that only the patient can provide: forgiveness. Thus, it represents a shift in power and a kind of role reversal. A sincere apology cannot heal all wounds - it will not immunize the professional against litigation or other retribution. It is, however, the right thing to do and is considered an ethical duty for the professional. For the patient, it begins the healing. For the professional, it allows forgiveness.
If a medical mistake in your practice is worthy of an apology, make sure you offer it skillfully.
Mistakes happen. What happens after a mistake can be as, or even more, important to a patient's ultimate outcome and satisfaction with care. This article discusses how to decide if an error has been made in your practice and how to offer an apology when one is warranted. It also recommends strategies to avoid future errors.
What is an error?
Not everyone defines error the same way. An often-cited 1999 Institute of Medicine (IOM) report defined error as a "failure of a planned action … or the use of a wrong plan." Some patients include rudeness or prolonged waiting time when describing medical error. With the literature offering at least 25 definitions of error, how do you decide whether an occurrence rises to the level of an error and whether it should be disclosed to the patient?
Whatever definition you use, it is clear that healthcare professionals have frequent opportunities to learn from, and answer for, their mistakes. The IOM report estimated that between 44,000 and 98,000 Americans die annually in hospitals because of errors. A review of 11 studies found between five and 80 errors per 100,000 primary care visits. Another study asked family physicians to identify errors in their practice; they disclosed errors in 24 percent of their office visits, with 24 percent of those errors causing (usually minor) harm.
From a systems perspective, every error - large or small - offers an opportunity for improvement and may be worth identifying, correcting and tracking. Yet, disclosing every error, no matter how trivial or benign, chips away at patient confidence, while failure to disclose erodes patient trust. From a patient perspective, there is a preference for full disclosure, although patients appear to agree with professionals when deciding if an error was committed - they tend to rely on whether professional standards were breached and whether harm occurred.
Even when the care is blameless, a caring professional will show empathy when a patient has an undesired or unanticipated result, or appears unhappy or offended. (Here are some examples: "I am sorry things turned out this way." "How are you holding up?" "This must be difficult for you." "Thank you for waiting.")
Empathy, however, is not an apology.
When to apologize
An apology acknowledges responsibility and reflects remorse. It should be offered when an error has occurred and harm or potential harm has resulted.
As with most judgment calls, determining whether the error's magnitude and harm, real or potential, merit an apology will depend on the circumstances. For example, a misspelled word in a progress note would not usually be cause for an apology. However, if the misspelling was a medication that was similar in name to another drug, and a subsequent prescriber refilled the misspelled medication, which in turn caused harm to the patient, then an apology would be in order.
When the outcome is unwanted or unexpected, people are unhappy, or errors are suspected, an apology should be considered. Before concluding that an apology is needed, it is first necessary to get the facts: What happened, exactly? What are the perspectives of the other members of the care team? What was the proper procedure for the condition in question, and was it followed? Was there an error? If the patient - or very often, a family member - demands an explanation or apology on the spot, before you have a sufficient understanding of what happened, it is appropriate to reply, "I don't know, but I will find out." When things go bad, clinicians may jump to premature conclusions about whether an error occurred, perhaps feeling a need to offer some explanation of what happened or to cope with their own emotions over a bad outcome.
Consider the example of an infant with cerebral palsy who had a worrisome electronic fetal monitor tracing before a difficult vaginal birth. The cord blood gas at delivery showed a pH of 7.34. Feelings of grief, guilt or empathy with the distraught parents may cause the clinician responsible for the delivery to attribute the cerebral palsy to brain damage due to perinatal asphyxia and to consider an apology for not delivering the infant sooner by cesarean section.
Before offering an apology, however, it is important to reflect on the facts of this case and on what is known about cerebral palsy. The infant's cord gas pH was not consistent with the acidemia expected in a newborn diagnosed with perinatal asphyxia. Moreover, electronic fetal monitor tracing has not been shown to improve or predict long-term birth outcomes. Fewer than 10 percent of children with cerebral palsy are thought to have developed the handicapping condition as the result of their birth process. While cerebral palsy may be related to prematurity or perinatal infection, in most cases no one knows why the cerebral palsy developed or whether it could have been prevented.
In the spirit of full disclosure, the clinician might refer back to the worrisome electronic fetal monitor tracing, acknowledge the potential for cerebral palsy to be caused by asphyxia in a small proportion of affected babies and explain that the cord gas results made asphyxia unlikely in this case. While it might not sound as professionally confident or be as satisfying for those desperate for the certainty of definitive answers, the correct explanation to the parents in this case is most likely, "I don't know why your baby has cerebral palsy, but we'll continue to work on trying to find out." At the same time, the clinician should offer more than just science. The emotional aspects of the diagnosis must also be addressed: "How are you coping? Having a child diagnosed with cerebral palsy can be overwhelming for families. I am sorry you and your family have to deal with this difficult time."
To be continued...
This posting may be short on content, but it's long on marketing strategy!
1. Patients do not buy your services-they buy solutions to their problems. This old adage never fails: promote the sizzle, not the bacon. Your patients are looking for what the nose job, breast augmentation, chin augmentation, etc. will do for them. They are looking for the best (highest quality, safest, least expensive) way to get that sense or feeling they desire. Focus on that.
2. How your staff feels is eventually how your patients will feel. No matter how much you try, the bottom line is your patient will have more contact with your staff than with you. How your employees feel about their situation at work will ultimately be translated into how your patients perceive your practice. Fill your practice with happy, positive and motivated people and you will increase the opportunities for your patients to have a positive experience.
3. If you are an underdog, only compete in market segments where you have or can develop strengths, avoid head-to-head competition with dominant competitors, emphasize profits rather than volume, and focus on specialization rather than diversification.
I recently attended a seminar on the use of overhead rates as a financial indicator of practice performance. Numbers are important in managing a business. But never confuse fixating on numbers as managing the business.
Numbers are data. What a manager needs is information. In many clinical situations, the numbers are information. In business situations, most numbers are data – the value a manager brings to the business is applying knowledge, experience and judgment to turn data into information, information that is the basis for decision making.
For the smaller of small businesses, which would encompass most physician practices, cash is king. On a weekly basis, know what your cash position is – the cash available for use by the practice. You should be budgeting cash each week for payables and payroll. Payroll is pretty fixed, so you have to pay the bills that are starting to get closer to the due date. While you don’t have to pay bills the moment they come in, you do need to be setting aside cash and paying every one to two weeks to stay current.
On a regular basis – usually monthly, but for solo practices on a quarterly basis – look at actual revenue and expenses compared to your budget. Items that are over budget are not a cue to be upset, stop spending or cut other budget items. You have to ask questions – why is an item over budget? Many times, there are seasonal variations (such as utilities), sometimes you order a quantity of supplies in order to gain discounts.
In addition to financial performance, you also want to look at productivity, such as: how many patient visits (office versus hospital), how many diagnostic tests or other in-house services provided, and the percentage of available time is booked for patient services.
All of these numbers are most useful when put in a context. My first approach is always to look at variations over time. I want to see two years worth of monthly data before I am comfortable making a lot of significant decisions or changes. Usually, the practice hasn’t been capturing data, so we have to start recording data on a monthly basis and build from there. Once we have the basic building block of monthly data, I can look at changes on a quarterly basis. Looking at a data on a quarterly basis smoothes out the month to month variations that occur because of number of days worked (20, 21 or 22), weather, vacations and other factors that impact the workload. Pretty soon, we can see patterns emerge and compare one year to the one past, and then two years and so on.
Data. Information. One leads to the next, but they are not the same thing, as the example below clearly indicates.
Physicians
(A) Approximate number of physicians in the U.S. is 700,000.
(B) Approximate number of accidental deaths caused by physicians per year are 120,000.
(C) Approximate number of accidental deaths per physician is 0.171.
(Statistics courtesy of U.S. Dept. of Health Human Services)
Guns
(A) Approximate number of gun owners in the U.S. is 80,000,000. Yes, that is 80 million.
(B) Approximate number of accidental gun deaths per year, all age groups, is 1,500.
(C) Approximate number of accidental deaths per gun owner is 0.000188.
Statistically, doctors are approximately 9,000 times more dangerous than gun owners.
Remember, "Guns don't kill people, doctors do."
FACT: NOT EVERYONE HAS A GUN, BUT ALMOST EVERYONE HAS AT LEAST ONE DOCTOR.
Please alert your friends to this alarming threat. We must ban doctors before this gets completely out of hand!
Out of concern for the public at large, I have withheld the statistics on lawyers for fear the shock would cause people to panic and seek medical attention.
Recently, I spoke at a gathering of physicians and mentioned the new profession of patient advocate. It is an indication (as if we needed more indications) that the healthcare system is falling apart.
Most doctors might not recognize the term “patient advocate”, but they’ve probably already fulfilled its function many times for relatives and friends. If you’ve ever informally evaluated a relative’s care, called the doctor of a friend for a clarification, or suggested to someone that they ask their doctor for a specific test, you have acted as a patient advocate.
Theoretically, there should be no need for a patient advocate, since doctors, by the very nature of their job, are already advocates for their patients. Unfortunately, the need for a patient advocate arises all too often, because patients don’t understand their diagnosis, can’t figure out their treatment, don’t comprehend the results and implications of tests, can’t get their doctor to return phone calls, etc. In my experience in dealing with doctors, there are several reasons for this.
First, doctors are extremely pressed for time. When you know that you have a waiting room full of patients, it’s very difficult to engage in an open-ended conversation with one patient. It’s much easier to announce the results or diagnosis, pronounce the treatment and send the patient on his or her way. We are all pressure to be more “efficient” and it is very clear that insurance providers do not consider patient discussion to be efficient at all. They won’t reimburse for it, so obviously they don’t even think it is necessary.
Second, doctors often forget the impact of their words on patients, or that patients may not understand the explanation. The doctor might think he/she has gotten the job done, when the reality is that the patient was so shocked by the diagnosis that he/she could not hear or process the information that followed. Or even if the patient is listening attentively, he/she might not understand the language that the doctor is using. Unfortunately, many physicians have trouble modifying medical terms to straightforward English. I have seen this in clinical practices when doctors are rushed, but also in medical writing when they have ample time to choose words carefully. I have edited materials written by doctors specifically for patients. Even when I sent things back with express instructions to modify the language, some doctors just couldn’t seem to do it.
Finally, many doctors are simply not paying attention the way they should. They don’t order the right tests, they don’t look at all the results and they don’t listen to what the patient is telling them. These doctors can often become very motivated and attentive when they realize that another doctor is monitoring a patient’s care, even if that other doctor is a relative or friend. Obviously, you shouldn’t need another doctor looking over your shoulder to force you to pay attention to what you are supposed to pay attention to in the first place. Sadly, it has become all too necessary with the advent of “managed” care.
Despite the sentiment in some quarters that equates the death of a patient with the failure of a physician, doctors shouldn’t shy away from attending patients’ funerals, a family doctor wrote recently in the British Medical Journal.
“There’s a bit of a reluctance to go,” the author, Bruce Arroll of the University of Auckland, told a physician client of BAC Medical Marketing in a phone interview recently. “You may not know many people there. You may not think it’s appropriate. But I think the opposite — the family is honored that you’re there.”
Going to funerals may be especially appropriate for family doctors, who are likely to have other patients at the funeral, Arroll suggests. In the article, he mentions two cases in which close relatives of deceased patients came to visit him at the clinic soon after seeing him at a funeral. “I was left with the impression that my attendance at the funeral was contributing to the resolution of grief in those two people,” he writes.
Arroll isn’t suggesting that all doctors go to patients’ funerals, or that any doctor go to every patient’s funeral. In the article, he notes dryly that “it may be wise to avoid funerals when the family is unhappy with care.”
But when we spoke on the phone, he mentioned a case where he had put a patient he was close to on a cholesterol-lowering drug. The man later died of liver cancer, and Arroll heard through the grapevine that the family thought the drug he’d prescribed had contributed to the man’s demise. Arroll didn’t go to the funeral, but he still wonders if he could have mended the rift with the family by doing so.
“I thought it might have been quite a healing thing for me to attend the funeral,” he said. “In retrospect, it would have been worth a gamble to ask their permission to go.”
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