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.

1. Sorry seems to be the
hardest 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.

7. 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

8. 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

10. 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

11. Why?

12. 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

13. 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

15. Questions
• How many parents would consult their
general practitioner when their child
has a mild temperature?
• Why do parents worry so much about
their children's temperature?
• What proportion of smokers have tried
to give up?
• What stops people giving up smoking?
• Asthma and epilepsy as social conditions

16. PhD thesis
• Saying Sorry: Doctor’s experiences
of open disclosure communication
(ODC) following medication error?

17. 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

18. Mind mapping

19. Question 1
• Intern experiences of open disclosure
communication with patients and their
families?

20. Question 2
• Final year medical students experiences
of a simulation session focussing on open
disclosure communication with a
patient’s family

21. Question 3
• Intern experiences of open disclosure
communication with patients and their
families after a simulation experience

22. 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 ..?

23. 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.

24. 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

25. Data collection methods
• Interviews
• Focus groups

26. 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

27. Sampling
• Purposive for JMO interviews
• Repeat sampling till thematic and theoretical
saturation
• Purposive for simulation scenarios
• Expected to have an opinion

28. 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

29. 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)

30. 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

31. 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

32. 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

33. 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

34. 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

35. Famous apologies

36. Famous apologies

37. Famous apologies

38. Apology

39. 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

40. 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

41. 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

42. 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?

43. 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

44. 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

45. 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

46. Questions?

47. Questions?