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Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
Stuart Lane on SORRY
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Stuart Lane on SORRY

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Stuart Lane takes saying sorry seriously. Seriously seriously. To the extend he's nearly finished his PhD on it. Listen to this fantastic talk, watch the slides and add comments your comments on …

Stuart Lane takes saying sorry seriously. Seriously seriously. To the extend he's nearly finished his PhD on it. Listen to this fantastic talk, watch the slides and add comments your comments on www.intensivecarenetwork.com.

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  • What we are not doing. Tick box exercise, and can they remember them
  • Thesis title after several alterations
  • Purposive sampling. Establishing a baseline of interns in their first year of practice
  • The simulation part of the thesis
  • The follow up from the simulation session
  • How the simulation woks
  • Transcript

    1. Sorry seems to be thehardest word: Or is it? Stuart Lane Sydney Medical School Nepean Hospital
    2. Overview• ODC• Qualitative research• PhD thesis – structure• PhD thesis – results and interpretation• Conclusions
    3. Background• 1987 VA Hospital, Lexington, USA,• ‘To maintain a humanistic, care-giving attitude with those who have been harmed• Rather than respond in a defensive and adversarial manner’• Ten years later - drop in court cases and claims• OD now forms part of health reform across the world
    4. Background• November 1999, the Institute of Medicine (IOM) issues a report ‘To err is human’• Almost 100,000 patients each year die in US hospitals due to preventable medical errors.• Up to 67% of all patients admitted to hospital are exposed to a medication prescription error.
    5. Open disclosure communication• The principles of ODC – Be open and timely with communication – Acknowledge the error – Express regret – Recognise the reasonable expectations of the patient, or their support person – Ensure support for health staff and confidentiality
    6. Is it working?• Reports of decreased litigation• Lots of policies and documents• But not much evidence of teaching• Even less evidence of evaluation• Anecdotes • People have little understanding of it • People are not aware of the policies • But they probably practice it to some degree
    7. Findings• 30% did not agree with disclosing medical errors to patients• 20% did not agree that a physician should never tell the patient something untrue• 40% did not agree that they should disclose financial relationships with drugs and devices• 11% said they had told a patient something untrue in the previous year
    8. Why?
    9. Qualitative vs. Quantitative• A finding or result is more likely to be believed if it is expressed as a number• Many of these numbers are biased and reductionist• The numbers are the convincing part• Quantitative research is powerful amongst the medical profession
    10. Qualitative researchers• Seek a ‘deeper truth’• Or just a different truth• Really a different question• Study things in their natural setting• Attempt to make sense of, or interpret, phenomena in terms of the meanings people bring to them• Human behaviour is complex
    11. Questions• How many parents would consult their general practitioner when their child has a mild temperature?• Why do parents worry so much about their childrens temperature?• What proportion of smokers have tried to give up?• What stops people giving up smoking?• Asthma and epilepsy as social conditions
    12. PhD thesis• Saying Sorry: Doctor’s experiences of open disclosure communication (ODC) following medication error?
    13. Initial thoughts• Doctors receive little or no communication education • Medical school • Hospital practice• It forms a significant part of their clinical practice.• Find their own way during their careers, to help them develop strategies to assist them in dealing with difficult communication scenarios• Simulation has shown promise as an adult learning tool• Simulation with facilitated debriefing can assist in the learning and teaching of ODC
    14. Mind mapping
    15. Question 1• Intern experiences of open disclosure communication with patients and their families?
    16. Question 2• Final year medical students experiences of a simulation session focussing on open disclosure communication with a patient’s family
    17. Question 3• Intern experiences of open disclosure communication with patients and their families after a simulation experience
    18. Methodology• How can we go about acquiring knowledge?• Research design and justification of methods• Phenomenology• Intentionality• The study of the ‘lived experience’• What is it like to be ..?’ ‘How do we make sense of ..?
    19. Theoretical perspective• The philosophical stance informing the methodology• Interpretevist• Meanings are constructed by humans as they engage with the world they are interpreting.• Humans make sense of the world based on their historical and social perspective.
    20. Epistemological stance• The theory of knowledge / the knowing of knowing• Constructivism• Social phenomena develop in particular social contexts.• Learners construct mental models to understand the world around them
    21. Data collection methods• Interviews• Focus groups
    22. Data collection methods• Audio interviews • Illuminate the person’s experience• Focus groups • Concentrated data collection to an immediate event • Exploring reasoning and debate on the topic
    23. Sampling• Purposive for JMO interviews • Repeat sampling till thematic and theoretical saturation• Purposive for simulation scenarios • Expected to have an opinion
    24. The simulation aspect• 8 final year medical students• 2 groups of 4• Mannequin with deterioration• Team-leader speaks to family• Facilitated focus group after watching
    25. Analysis• Interpretive Phenomenological analysis• IPA (Johnathan Smith) – Try to make sense of the participant trying to make sense of…• Also grounded theory analysis for focus group data (Kathy Charmaz)
    26. Reflexivity• Needs to be happening • At all times • Throughout all processes’ • Not just reflection but true analysis• True reflexivity is almost impossible• Needed to discover my views on the subjects and how they may influence• CMS Harvard/MIT • Trial run of data collection • Prospective learning pathways grid
    27. Results• Provisional results• Still working through the final conclusions• Four areas to highlight• SVU; We are sorry for your loss• The hardest word - mistake• Apologetic justification, ‘it’s the patient’• The development of professionalism
    28. SVU apology• Easy to say sorry • ‘It is expected of us’ • ‘It is what I would want to hear’ • ‘I would say it even though I don’t really feel it’• Can’t stop saying it enough• Minimal empathy around sorry • Genuine for the situation • But not for the saying sorry part
    29. The hardest word• Mistake / error is the stumbling block • This is what worries people litigation wise • Do people actually see it as an error? • Can they be sorry if they see no error?• Dialogue of prefixes and sentence fillers • ‘A little bit too much’ • ‘Slightly excessive’• Frightening regularity • It is expected • It is the culture
    30. Does this matter?• Why is theory important• Bullying (Prof Helen McGrath) – Self esteem vs. Self respect• Theory of apology• Is our ODC template good enough?• What does an apology mean in society• “Tuesdays, Thursdays and Fridays are tricky for me, I’m sorry.”• “Best days for meetings are Mondays and Wednesdays.”• “Sorry to bother you.”• “Is now an okay time to talk for five minutes?”• This needs to be personal, not via the system
    31. Famous apologies
    32. Famous apologies
    33. Famous apologies
    34. Apology
    35. Apologetic justification• Its not me, it’s the patient • ‘It was her heart than was not strong enough for the medication’ • ‘She would have died anyway’ • ‘It was OK because they got her back with Naloxone’ • ‘He could not handle the side-effects of the morphine• Can the system always be to blame? • Side-effects vs medication error • Where does the cognition of error lie? • Opinions changed after reflection
    36. Learning from simulation• Constructivist approach appears justified• It is beyond either behaviourism or cognitivism• Creating a reflective environment that goes beyond the simulation centre and the simulation session• This can not be assessed by conventional means• We need to move away from the obsession of validation
    37. Notions of professionalism• Professional identity vs. professionalism• Professional identity is constructed at the level of the individual. The reality might not be ideal• Professionalism is constructed by the community and medical profession as a whole of the idealized professional. The ideal may not be a reality
    38. Notions of professionalism• This needs to be a personal characteristic• Blaming the system does not help• If it is not personal, how can one reflect?• We don’t want a culture of blame• But is making people feel accountable and responsible what is really needed?
    39. So did simulation affect this• People reflected far more• They thought about the development of their practice• What they concluded was up to them• We need to help them draw the right conclusions• And then reinforce them• The education needed is far bigger than most anticipate
    40. Take home messages• Doctors are quite happy to say sorry• They still struggle to admit to errors / mistakes• Their communication can appear to rationalise it as a patient problem rather than a practitioner problem• Many of the errors that occur are not even seen as errors since they happen so frequently• We need to instil the desire to develop professionalism at a personal level, by forging the development of the appropriate professional identities.• A beurocratic template based on decreasing litigation is not what is needed
    41. Take home messages• This is about the sort of doctor that you are and you want to be• This is about what you say and do when you have family conferences• This is about what effect you want to have and have had• This is about how you learn, keep learning, and want to keep learning• This is about the professional identity you have moulded for yourself, and how you develop you professionalism• CICM provides a template and others provide guidance – you fill in the rest
    42. Questions?
    43. Questions?

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