Self-monitoring, medical errors and professionalism: A challenge for ...

Promoting Self-Monitoring as a Core CompetencyRonald Epstein, Craig Hassed, Carol-Anne MoultonAAMC San Francisco Nov 2012

Ronald Epstein MDProfessor of Family Medicine, Psychiatry, Oncology and NursingDirector, Center for Communication and Disparities ResearchDirector, Deans Teaching Fellowship ProgramUniversity of Rochester Medical Center, New York, USACraig Hassed MDSenior Lecturer, Dept of General PracticeSchool of Medicine, Monash University, Melbourne, AustraliaCarol-Anne Moulton MD PhDAssistant Professor, Department of SurgeryScientist, Wilson Centre for Educational ResearchUniversity of Toronto, Ontario, CanadaAAMC San Francisco Nov 2012

Physicianwell-being(resilience vs.burnout)Quality of care(vigilance vs.mindless errors)Quality of caring(presence vs.abandonment)Shanafelt, T. D., et al. (2002). Burnout and self-reported patient care in an internal medicine residency program.Ann Intern Med, 136, 358-367; Shanafelt, T. D., et al. (2005). Relationship between increased personalwell-being and enhanced empathy among internal medicine residents. J Gen Intern Med, 20, 559-564.

Key pointsSelf-monitoring is a professional obligation of physiciansand contributes to quality of care and well-being.Self-monitoring is enacted haphazardly and inconsistently.It is possible to develop habits of self-monitoring, whichinclude intentionality, attentiveness, curiosity, beginner’smind and presence.Teaching self-monitoring is a primary task of medicaleducators.No one can self-monitor alone.

Since completing your training…• How well do you assess your own strengths and weaknesses?• How aware are you of your moment-to-moment performance during patientcare?• How aware are you of your blind spots when diagnosing and treatingpatients?• How often do you see a challenging situation from more than oneperspective?• How often do you respond to anxiety-provoking situations with curiosity andpresence rather than avoidance, rigidity and distance?• How often do you make mid-course corrections based on new information?• How did you learn these skills of awareness?

Are you a good driver?

1009080706050403020100actual scoreperceived abilitycompared with peersbottomquartile2ndquartile3rdquartiletopquartileKruger and Dunning, 1999

Unguided and uninformed self-reflectionsIs it possible to “know oneself?”SELF-ASSESSMENT OR SELF-DECEPTION?Eva & Regehr 2005

Qualities of mindful practitionersAttentive observationCritical curiosityBeginner’s mindPresence

Physicianwell-being(resilience vs.burnout)MindfulpracticeQuality of care(vigilance vs.mindless errors)Quality of caring(presence vs.abandonment)

Ronald Epstein MDProfessor of Family Medicine, Psychiatry, Oncology and NursingDirector, Center for Communication and Disparities ResearchDirector, Deans Teaching Fellows ProgramUniversity of Rochester Medical Center, New York, USAMINDFUL PRACTICE ANDMINDFUL COMMUNICATION

Francesc Borrell-CarrioKevin EvaBrian HodgesGlenn RegehrJoan SargeantDan SiegelJordan SilbermanArnold P Gold FoundationArthur Vining Davis FoundationJohn W Kluge FoundationMannix FundPhysicians FoundationACKNOWLEDGMENTS

Change blindness

Looking but failing to see“The blue kidney”

ClinicianfactorsHabitsSituationalPatientFactorsMutableImmutableErrorsLarger systemFactorsFinancialRegulatoryMicro-systemfactorsTeamsEnvironmentEpstein RM 2011

PerceptualdistortionStereotypingFailure of curiosityUnexaminedemotionsOver-concretenessInadequate dataMisinterpretation of findingsPremature closureSituational cognitive impairmentIneffective communicationLack of self-monitoringBurnoutEpstein et al 2008 JCEHP

“DELUSION”“The tendency of the mind to seek premature closure...…that quality of mind that imposes a definition on thingsand then mistakes the definition for the actual experience”**Epstein M. 1995

Apter M. 1989

“… could this be something serious?”

Mindful practice =cultivating the observing selfMoment-to-moment purposefulattentiveness to one’s own mentalprocesses during every day work with thegoal of practicing with clarity andcompassionEpstein RM 1999

Qualities of mindful practitionersAttentive observationCritical curiosityBeginner’s mindPresence

Can we learn to pay attention?Top-down (“alerting”)Bottom-up (“orienting”)Executive = reconcilingcompeting demandsGusnard DA et al 2001

Seeing information as novel, seeing “facts” as conditionalSeeing situations from multiple perspectives simultaneouslyTemporarily suspending categorization/judgmentSelf-questioningLowered reactivityMental stabilityLanger EJ 1997, James W 1895, Fitzgerald FS 1945,Borrell-Carrio F & Epstein RM 2005

Formal practiceInformal practiceReflective questionsNarrativeAppreciative inquiry interviewsDiscussionMINDFUL PRACTICEPROGRAMS

Seven minutes of redFor the next 7 minutes, record in writing thename of everything red that you see;Feel free to roam around, but do not talkSource: Maue K. Three days of red. In, Water in the Lake: RealEvents for the Imagination, 1979, New York: Harper and Row

Reflective questions to promote mindfulnessAttentive Observation“If there were data that you ignored, what might they be?”“What did you notice?” “What were you unable to see?”Critical Curiosity“What are you assuming that might not be true?”“What was surprising or unexpected?”Beginner’s Mind“What would a trusted peer say …?”“Can you see the same situation/patient with new eyes?”Presence.“At what points did you feel present and connected? Disconnected anddistracted?”

Using narrativeFocus on a time when you made an error …Take 5 minutes to jot down a few key elements of thestory before telling it

Take 10 minutesFor the storyteller, address:What happened?What helpful qualities did youbring to that moment?Who else was involved, and howdid they contribute?What aspects of the context madea difference?What lessons from this story areuseful to you?For the listener:Be attentive, don’t interruptAsk questions to help yourpartner clarify and providedetailsDon’t talk about your ownideas or experiencesUse reflective questions andempathy when appropriate©Mindful Practice Programs, University of Rochester, 2010

Appreciative inquiry interviewsFocus on a difficult moment in which you wereat your best…Describe the event in detail, including personalattributes and contextual factorsReflect on how those attributes will be appliedin future situations

ThemesMeaningful experiencesDismissing patientsSurprisesSelf-careBurnoutDeath and dyingAttractionConflict

70 Primary care physicians, 46% Female, 49% Internists, mean of15.9 years in practiceSignificant improvements in:well being (burnout, mood)quality of interpersonal care (empathy, ps orientation)personality (emotional stability, attentiveness on NEO-FFI)MEDIATED BYimprovements in mindfulnessKrasner MS et al JAMA 2009

What did participants say?Interviews (n = 22) from among 46 participantswho completed >1/2 of phase 1 and >1/2 ofphase 2Analyzed thematically, coded, quotes extracted

Qualitative resultsCommunity“The most meaningful part was being with other physicians,sharing and discussing some of our experiences and beingable to have the immediate understanding of peers withrespect to the struggles that we all have.” (Participant #16)

Qualitative resultsSkills“I am much more attuned to listening. I put a mental stop watchin my head. I am much more attentive to non-verbal behaviorand letting patients express their thoughts… I found out,without realizing it at the time, I wasn’t necessarilycommunicating well before. I [now] have a heightenedawareness and sensitivity to people’s conversation. I look atmy own communication and pay much more attention tothat. I pay much more attention in general.” (Participant #5)

Qualitative resultsPermission“In one of the classes we had to describe a traumatic experience,realizing that this was the first time I talked about it outside ofthe event that it happened, probably 2 years later. This was thefirst time I really expressed anything realizing that this mustreally mean something, having it all bottled up. That was anenlightening moment. (Participant #1)

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