Health care is slowly, but surely moving towards more transparency and openness. Safety in healthcare is often compared to airline safety and physicians are often compared to airline pilots. However, there are some key differences between physicians and pilots. One difference is that pilots fly planes to a known destination whereas the ‘destinations’ or the ‘flight path’ in patient care are not often clear particularly when the patient’s diagnosis is unknown or very ill at the time of hospital admission. Pilots do not ask passengers for consent before a plane ride. Physicians obtain informed consent from patients before complex therapies and surgical procedures. In fact, when my brother asked his 80-year old patient to consent for surgery during his internship, she asked him with a sweet smile whether his parents signed permission for him before he begin his residency. Another difference is that in the event of a plane crash, the pilot goes down with his or her passengers whereas a physician doesn’t experience similar harm in the case of a safety event. Lastly, pilots don’t stand in front of passengers and explain them any errors or ‘adverse events’. Many physicians do, and the rest are expected to.
No physician goes to work expecting he or she would make a mistake. Clinical adverse events tend to be particularly serious in surgery and disclosing them to patients is arguably one of the stressful patient care activities. The surgeons are often the ‘second victim’ of these adverse events. The article by A. Rani Elwy and colleagues earlier this month shines light on the topic ‘Surgeon’s Disclosure of Clinical Adverse Events’ (JAMA Surg. Published online July 20, 2016. doi:10.1001/jamasurg.2016.1787). The study team enrolled 67 of the 75 eligible surgeons across a dozen specialties in three Veterans Affairs medical centers. At the time of enrolment, they surveyed baseline positive attitudes (e.g., feeling an obligation to disclose) as well as negative attitudes (e.g., perceived risk of malpractice claim with disclosure) of the surgeons towards disclosure to patients in response to a vignette representing high harm and a second vignette representing low harm.
Over the subsequent three-year period, the surgeons were asked to complete a confidential web-based survey for up to three adverse events and disclosures during the study period. The surgeons were asked their experience of the adverse event, their perceived seriousness of the event, and whether they discussed the eight elements of disclosure. Per the guidelines from the National Quality Forum and the VA, the eight elements are 1) explain why the event happened, 2) whether the event was preventable, 3) how the event will be prevented from happening again, 4) express regret for what happened, 5) express concern for the patient’s welfare, 6) apologize for the event, 7) disclose the event within 24 hours, and 8) discuss steps taken to treat subsequent medical problems. The surgeons were also given a third type of survey, whether and how the disclosure affected them. The questions were related to the impact the disclosure may have had on their job satisfaction, professional reputation, anxiety about future outcomes of events and their ability to sleep.
The study found that at baseline, the surgeons reported more positive attitudes toward disclosure in the high-harm scenario. There were no differences in negative attitudes between high-harm and low-harm scenarios. During the three years of the study, 62 surveys on adverse event and disclosure were completed (out of 201 (=67×3) possible total number of surveys) by 35 surgeons (52% of the study participants). Sixty percent of the surveys reported the surgeons being moderately, quite a bit, or extremely affected by the event. About a fourth of them reported anxiety about future events or outcomes. Most did not report significant effects related to job satisfaction, confidence, professional reputation, or ability to sleep. Most of them used 5 of the recommended 8 components of a complete disclosure. Approximately half of them discussed whether the event was preventable, a third discussed how repeat events could be prevented in the future, and 55% apologized to the patient during disclosure even though it’s not a VA requirement. Another key finding of the study is that the surgeons are more likely to be negatively affected if the event is more serious, if the experience of disclosure was very difficult, if the event was preventable and recurrences could be prevented. Surgeons with more negative attitudes in response to the low harm scenario in the baseline survey were more likely to express anxiety about future outcomes or events.
The 52% response rate in this study is higher than other published surveys of surgeons. The authors are right in concluding that future quality improvement efforts on implementation of open disclosure programs need to factor in potential for surgeons being negatively affected after adverse events and disclosures, and the association between attitudes, perceived seriousness of the events, and surgeons’ experiences with disclosures, so that we may ensure a healthy surgeon workforce.
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