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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
response to Dr Pace
Individuals vs Systems: Other issues also important
First, know thyself
response to Dr Saba's letter
To Err is Human; To Be Aware is Preventive…
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Ronald M Epstein, Rochester, NY, USA Professor of Family Medicine and Psychiatry, Francesc Borrell-Carrio
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To the editor, We thank Dr. Pace for his comments, with which we agree, up to a point. We tend to see two types of potential errors in medicine. Errors based on systems inadequacies that do not require complex judgements or interactional skills are the “low hanging fruit” of medical errors. They include medication errors, operating on the wrong limb, and other situations where physician training is not the issue. These might be amenable to simple systems changes without any need for personal transformation, such as creating an error-free computerized drug ordering system, and a means of marking the affected limb. Even these might be more complex than we think. Unlike the air traffic control (1), with which medical errors are often compared, the “substrate” of these errors is not a mechanical object carrying people, but the people themselves. Many medical errors occur in open systems of outpatient practice rather than the relatively closed systems of the operating room or the ICU. While changing the procedures in the operating room might be straightforward, changing outpatient health care delivery is not easy nor is it cheap. The second type of errors are more complex, and could be considered errors in phronesis, or practical wisdom. These are often errors in judgment which arise as a confluence of unique conditions, such that the nature of the error cannot be anticipated. We know much less about these errors, including the toll that they take in terms of patient morbidity and dissatisfaction. Karl Weick describes how “mindful” systems can effectively deal with the unexpected problems that complex systems can create (2. These systems tend to promote and reward vigilance, resilience, flexibility, and openness. These mindful systems, though, depend on wise judgement of the individuals that comprise it, and the same qualities of vigilance, resilience, flexibility and openness. Systems do not create such individuals; rather they selectively reinforce skills and habits that are cultivated during years of training. While not impossible, it is not yet clear how an inexpensive systems change, for example, might prevent the errors in judgement made by an unobserved practitioner in the middle of the night – just those situations where clinical practice guidelines instruct the clinician to use judgment or consider the context of the situation. Just like error-prone systems, medical training can undermine habits of self-observation, self-questioning, and flexibility. One could even view the “medical education system” itself as an error-prone system. It produces some “products” that would rather follow inadequate heuristics than reframe a problem. Rather than assuming that we already know how to accomplish the necessary changes, we are proposing a theory that might guide those subtle systems changes in focus in the process of training physicians. The principles we oulined, though, could apply equally to the training of individuals and to the design of systems. In our view, systems change without parallel changes in the training of physicians are not likely to be successful in dealing with these complex problems. There is no need for an either-or mentality in the prevention of errors. Simple systems changes that promote vigilance are clearly superior to complex individual interventions, when they actually work. Recognizing the limits of systems interventions is crucial to avoiding self-deception. We would welcome systems-wide error-reduction and patient safety initiatives that would help to prevent the consequences of individual cognitive distortions that we report in our article. We need to study interventions at all levels of the system to determine which will produce the greatest gain at the lowest cost. Dr Pace expressed skepticism about change in medical education. At our institution, we face the issue of medical errors in a radically redesigned medical student curriculum that promotes the kind of self- awareness and teamwork that is required of practitioners in the 21st century. We have all seen medical schools, hospitals and health systems that are hopelessly entrenched. We cannot share his pessimism about medical education, any more than pessimism about any systems change. It is never easy, but is possible. Sincerely, Ronald Epstein, MD Francesc Borrell-Carrio, MD (1) Weick KE, Roberts KH. Collective Mind in Organizations - Heedful Interrelating on Flight Decks. Administrative Science Quarterly 1993; 38(3):357-381. (2) Weick KE, Sutcliffe KM. Managing the Unexpected. San Franscisco: Jossey-Bass, 2001. Competing interests: None declared |
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Margaret A Kirkegaard, MD, MPH, Downers Grove, IL, USA Predoctoral Program Director, Midwestern University, Department of Family Medicine
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Drs. Borrell-Carrio and Epstein certainly present a cogent counterpoint to the prevailing tendency to focus exclusively on systems issues in patient safety. Indeed, the development of self-awareness by individual clinicians and addressing systems issues are likely to be complementary strategies for reducing medical errors. The external conditions that push physicians outside of the optimum work zone can be reduced by addressing systems factors such as interruptions for pages, design of work stations, ability to access clinical information and management of fatigue and workload. In addition to examining the polar extremes of individual cognition and global systems, a third area of research that can impact patient safety is communication. Recent studies have documented that communication failure is a significant contributor to medical error. (1) Current systems-based strategies to reduce communication failures focus on improving the accuracy and timeliness of the transmission of clinical information through devices such as electronic sign-outs and electronic medical record. These strategies focus on the *content* of communication. However, “communication failure” is often more complex than a simple failure to transmit clinical information. These issues often involve medical hierarchies and ambiguous roles reflecting difficulties in the *process* of communication. Team training, a strategy borrowed from aviation, has focused on improving team interactions and has been effective in reducing medical errors.(2) But team training has focused more on the acute settings and static team roles. Many clinicians move in and out of multiple “teams” as they move from one care setting to another or from one patient to another. Team training thus far does not translate into improved overall communication skills. In much the same way as Drs Borrell-Carrio and Epstein are advocating for increased awareness of the physician’s internal cognitive processes, increased awareness of communication processes may also reduce medical errors. “Habits of self-questioning” might also include such questions as: How might my previous interactions with this other care provider affect my communication now? What am I assuming in this conversation that might not be true? What surprised me during this communication? How did I respond? What interfered with my ability to observe, be attentive or be respectful with the other care provider with whom I am communicating? How could I be more present and available during this communication? Were there any points at which I wanted to end the communication early? If there was relevant information that the other care provider was attempting to transmit to me, did I ignore it? Medical errors are a significant concern in our health care delivery system. Improvement must include a wide range of targets from the narrow focus of a clinician’s cognition process to the broad-based systems interventions and every process in between including the processes of communication. 1 Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures; an insidious contributor to medical mishaps. Academic Medicine 2004;79:186- 194. 2 Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, Berns SD. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the medteams project. Health Services Research 2002;37:1553-81. Competing interests: None declared |
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Wilson D. Pace, MD, Aurora, CO Professor, University of Colorado Health Sciences Center, and the ASIPS Collaborative
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The article by Borrell-Carrió and Epstein calls on clinicians to be aware of their thought processes, particularly when relying on automatic decision making in the face of incomplete or contradictory information. They suggest that training can improve self-awareness and perhaps reduce some clinical errors through an internal check process. Our error database supports the contention that the processes described in this article lead to errors and harm. One perspective on these errors is to consider these individual acts can be improved through individual provider educational activities. This call is an ancient one: “First, know thyself.” From an alternative systems perspective, this can be viewed as a call to the medical education system to improve its processes and for the creation of individual internal quality improvement feedback loops. Many medical schools are moving in this direction, understanding that teaching people how to think and how to seek answers is more important than imparting “knowledge” in the form of facts. Some post graduate training programs routinely combine self evaluation with external feedback and correction to improve internal performance assessments. Translating this to error reduction, we agree that the first step towards a safer medical system is for every health care worker to recognize they are both part of the problem and part of the solution. We have repeatedly witnessed this transformation when an individual realizes that routine slips in a system (missing consultants reports, failure to notify patients of normal lab results or missing radiology reports) are errors that will eventually lead to a bad outcome. This recognition typically changes individual behavior, while striving to improve the system. Safety activities based on improving systems and “blame free environments” do not ignore an individual’s contribution to the instigation and perpetuation of errors. These environments use error recognition to improve systems to help people do the right thing, instead of relying on re-education of the individual. System changes perpetuate safety across multiple individuals and over time, whereas individual educational efforts must be repeated as people are added to the work force or are lucky enough to be identified making an error. In Borrell-Carrió’s scenario, retraining the world’s medical providers to improve self-awareness is a daunting task which would overwhelm available financial and personnel resources. While medical education has proven remarkably difficult to reorganize, if the system can be successfully realigned so that providers will truly “First, know thyself,” then the improvements should be sustainable. Competing interests: None declared |
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Ronald M Epstein, Rochester, NY, USA Professor of Family Medicien and Psychiatry, University of Rochester, Francesc Borrell-Carrio, University of Barcelona
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8/18/04 To the editor: We thank Dr. Saba for emphasizing that supervision and reflective exercises can promote self-awareness. Methods that are used in the moment -- during clinical practice -- have the advantage of creating a habit of questioning that often cannot be accomplished by other means. We believe that Dr. Saba's suggestions are in the right direction. But, our model emphasizes the ability to recognize justifications that practitioners generate when tired, distracted or distressed, which cause them to abandon their better judgment. The goal is to promote a line of defense against what we have called the "failure of heuristics." It is a small step to apply the strategies that we promote for individual practitioners to group or individual supervision of live, recorded or recalled clinical encounters. However, not all supervisors help trainees recognize points at which errors might have occurred, or specifically identify somatic markers of emotional and cognitive interference in clinical reasoning. We would hope that our approach would help supervisors provide the trainee with tools to avoid the next error. There are many additional ways of fostering mindfulness in action (1-4). Fortunately, medical educators and researchers have arrived at a new level of sophistication in understanding the inner lives of clinicians. Future research should delineate the specific contributions of each approach; it has become impossible, in a short article, to describe it all. Sincerely, Ronald Epstein, MD Francesc Borrell-Carrio MD 1. Epstein RM, Mindful Practice in Action (II): Cultivating Habits of Mind. Families, Systems and Health 21(1):11-17; 2003. 2. Epstein RM. Mindful Practice. JAMA. 282(9):833-9, 1999. 3. Novack DH, Epstein RM. Paulsen RH. Toward creating physician- healers: fostering medical students' self-awareness, personal growth, and well-being. Academic Medicine. 74(5):516-20, 1999. 4. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA. 278(6):502-9, 1997. Competing interests: None declared |
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George W Saba, San Francisco, California,USA Clinical Professor, University of California, San Francisco, Family and Community Medicine
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“The First Law of Robotics: A robot may not injure a human being, nor, through inaction, allow a human being to come to harm.” I Robot, Isaac Asimov (1) In I Robot, Asimov grapples with what makes us human, exploring the role of emotion, reason, and responsibility and asking “Can robots be self aware?” (1) While we would never want physicians to operate in a robotic fashion, we often expect them to work flawlessly, governed by reason above all else. Borrell-Carrió and Epstein provide a remarkable reexamination of the role of the individual physician in clinical errors. As we shift from a reductionistic, biomedical approach to a systems-oriented paradigm, we are at risk of focusing only on large systems and neglecting the interconnectedness of all subsystems. (2) The authors correct this epistemologic error by reminding us that the individual physician is a subsystem in context, with its own rules and responsibilities. Focusing on the cybernetics of the interaction within the physician, they provide an exquisite conceptual map and a “human scale” technology to diagnose and alter unproductive sequences of thought and behavior. In contrast to a biomedical perspective on clinical errors which elevates reason over emotion and devalues the person of the physician, Borrell-Carrió and Epstein argue for: • Examining the interconnection between reason and emotion in clinical decision-making, • Utilizing emotion and other personal qualities of the physician (e.g., intuitive thinking) as strengths to enhance care rather than viewing them as dangerous forces to be controlled, • Mastering ambiguous, clinical situations and resisting premature closure by being mindful in the moment. Self-aware practitioners must think “outside the box” in complex, stressful, non-textbook situations. (3) To gain this competence, the authors suggest habits of self-questioning and learning reframing through simulated clinical situations. (4) Additional training methods5 include: 1) Live supervision-While observing a clinical encounter, a supervisor can stop the action at any point to talk with the learner about their thoughts and feelings and suggest changes in unproductive interactional sequences in real time. 2) Stimulated Recall-A supervisor facilitates a learner’s review of their videotaped clinical encounters to articulate thoughts and feelings, activate tacit knowledge, and strategize future behaviors. 3) Model of Medicine-A group of trusted colleagues reflects on their personal models of medicine to reveal beliefs and values that influence their clinical practice. To prevent errors over a career, we must create forums that foster physicians’ self-awareness in the context of their practice settings. The first law of robotics echoes the familiar physician dictum, “First, do no harm.” Borrell-Carrió and Epstein remind us that self- awareness, a uniquely human trait, will help us reach that goal. References 1. Asimov I. I robot. New York: Doubleday/Gnome, 1950. 2. Kohn LT, Corrigan JM, Donaldson MS. Institute of Medicine. Committee on quality of health care in America. To err is human: building a safer health system. Washington, DC: Academy Press, 2000. 3. Schön DA. Educating the reflective practitioner. San Francisco: Jossey-Bass, 1990. 4. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287:226-235. 5. Saba G. Preparing healthcare professionals for the 21st century: lessons from Chiron’s cave. Fam Syst & Health. 2000;18:353-364. Competing interests: None declared |
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