Thursday, 7 September 2017

What's in your attic?

This blogpost weaves together 4 threads:
1) In Oscar Wilde's only novel, "The Picture of Dorian Gray", Dorian sells his soul to ensure that a portrait of him ages while he remains young. 

2) In his must-read book "Safe Patients, Smart Hospitals" Peter Pronovost argues that healthcare professionals are very good at hiding mistakes from themselves. They compartmentalise mistakes and explain them away because of a belief that "doctors don't make mistakes."

3) In a very good lecture, Scott Weingart argues that:

"The difference between bad doctors and good doctors is not that the bad ones make a bad decision every single shift or even every single week. The difference between a bad doctor and a good doctor may be one bad decision a month. And that's really hard to get self-realised feedback on. There are not enough occurrences of real, objective badness to learn from one's mistakes."

4) Lastly, if we take the numbers from the Instititute of Medicine's "To Err is Human" as correct then we can postulate the following: 
  • There are approximately 100,000 deaths due to medical error per year in the US (1)
  • There are approximately 500,000 doctors in the US (2)
  • Therefore a given doctor will be involved in a death due to medical error once every 5 years
  • Let us make the assumption that only 50% of these deaths are recognised as having been caused by medical error. Then a given doctor will be aware of a patient who died in part due to his/her medical error once every 10 years.  Or 4 deaths per career.

Now for the weaving. 

For a number of reasons healthcare professionals will not be able to have a good understanding of their actual performance. Partly this is because our involvement in errors leading to death is (thankfully) rare and partly because the feedback loop in healthcare is often very long or non-existent. 

We are also, because we are human, very good at rationalising our poor performance. Lastly many of our jobs require confidence, or at least an outward confidence, in order to believe that we can do the job and to put patients at ease. 

This means that, like Dorian Grey, we have a public persona which is confident, capable and error-free. But we also have our "true" selves hidden away, perhaps not as pretty as we might like to think. 

If this is a problem then what are the solutions? 

Unsurprisingly perhaps, given that this is a simulation & HF blog, one solution is immersive simulation. The simulation has to be realistic enough to trigger "natural" behaviour and actions. Realisation of the differences between one's imagined and actual performance  often emerge as the simulation progresses. The simulation can also create the conditions under which poor decisions are more likely to be made. This means rather than waiting a month for a sufficiently stressful real-life event to occur, twelve stressful scenarios can be created in a day.

However it is during the debrief that the two personas, the portrait and the person, can be compared. The use of video-based debriefing means that the participant can see their own performance from an outsider's perspective. The facilitator helps the participant see the metaphorical wrinkles and scars that have accumulated over time. The skilled facilitator provides help in taking ownership of the blemishes and advice on how to work on reducing them.

Simulation remains overwhelmingly the domain of the healthcare professional "in training". Consultants, staff grades, registered nurses, midwives and other fully qualified professionals rarely cross the threshold. Perhaps this is because in training the portrait of ones true self is constantly being exposed. It hangs, as it were, above the fireplace or in a prominent position where many people can and do comment on it. Upon completion of training it is with a sense of relief that the portrait is relocated to the attic. And the longer it stays up there, the greater the fear of the horror we will be faced with if we take it back down.

Face your fears, attend a simulation session and let's clear out that attic together. 

1) DONALDSON, M. S., CORRIGAN, J. M. & KOHN, L. T. 2000. To err is human: building a safer health system, National Academies Press.
2) Number of active physicians in the U.S. in 2017, by specialty area (Accessed 7/9/17)