The Role of Talking (and not Talking) in Helping Physicians

Cope with a Medical Error

Natalie B. May, PhDMargaret Plews-Ogan, MD

University of Virginia

Study funded by the John Templeton Foundation

Wisdom in Medicine Study

Part of larger, mixed-method study We interviewed 61 physicians who had

been involved in a serious medical error. They also completed questionnaires

measuring PTG, wisdom, forgiveness, gratitude, and personality characteristics.

Research Questions (A few)

Can medical error be a catalyst for growth? How can we help physicians not only

survive but also grow in face of trauma? What role does talking play in physician

coping with error & fostering wisdom? How can we create a culture that supports

this learning & growth?

Open-ended Interviews

We asked 61 physicians to share their story of coping with a medical error, including what helped and what hindered their journey.

We used questions and prompts reflecting the research literature on coping with adversity (e.g., sharing story, journaling, therapy, spirituality, meditation)

Today’s focus

The role of talking about medical error in fostering growth & helping physicians cope

What did not help What did help (Beyond disclosure)

Importance of Narrative

Organizes major life events causing distress

Provides sense of predictability & control Facilitates a sense of resolution Helps us prepare to deal with it should it

happen again Pennebaker JW, Seagal JD. Forming a story: the health benefits of narrative. J Clin Psych 1999.

55(10):1243-54.

Did not help - Silence

Silence from colleagues Silence from superiors, attendings

“The chairman of family practice, the guy who’d recruited me to come there, never said a word to me. Not a single word. And nothing could make you feel more abandoned than that. Sure, don’t talk about the case, but wouldn’t it have been nice to have heard from the chairman who’d recruited you to come to say, ‘Listen, I heard about that case, I’m really sorry, it’s a bad situation, of course we can’t talk about the medical details but I want you to know that we think a lot of you and we’ve got your back.’ It would have been nice to have heard that.”

Did not help – Not talking

To colleagues Shame, legal advice

To spouse Didn’t want to burden or upset her

To patient or patient’s family Shame, fear, legal advice

No one to talk to

“I was too ashamed to tell any of my colleagues, so I suffered in silence for probably a week or two. Because I thought, if I tell them, they’re not going to trust me to cover their patients, they’re not going to think I’m smart anymore, all of those things go through your head. I mean, you really feel defective, you feel like you’re not up to standards, you know?”

“She’s an artist, she’s wonderful. But, you know, she already has enough of a hard life living with my hours and schedule and through residency and all this and I just felt like it wasn’t very fair to put her through all this. So I just pretended like nothing was going on and I’m pretty transparent so it really wasn’t very good. It was a huge mistake, so in this study you might point out that was not a really good coping mechanism.”

Did not help – Difficult Conversations

Cruel comments, blaming“It was my first month of internship and we just killed this person and I was pretty upset, and I took the resident aside and said, ‘I don’t know if I am suited to medicine or not,’ and my resident said, ‘Yeah, you’re right. Maybe you aren’t.’”

Insensitive, uncaring comments Self-serving comments Dishonest conversations

Did not help – Talking with well-intentioned colleagues

“Because everybody else was minimizing it, probably to protect me, I couldn’t really talk to anybody at work about this. I could have talked about it more freely had everybody else thought that it was as serious as I did. So everybody tries to, I think, protect their friends and their trainees and their coworkers whenever they have a complication like that. But, I think the downside is it doesn’t allow people to get the support that they need because they themselves truly feel that something went wrong."

“It reassured me a little bit from a technical, malpractice standpoint that I was fine, but it still didn’t help me shake the feeling that if I had listened better I could have intervened.”

Other unhelpful talking

With patient’s spouse “It felt terrible to seek absolution while she was grieving.”

With physician’s spouse, parents“That only goes so far.”“They don’t understand what I do.”

With risk management

Did help – Talking with Patients & Families

Disclosure Receiving forgiveness Apologizing Explaining what went wrong Assurance about preventing future errors Honesty Conveying love for the patient

“Initially I broke the bad news to him, and like I said, he was very angry. ‘How could you do this to me, and you know I’m just going to die now because you didn’t follow up on this fast enough.’ So he was pretty angry, and that really hit me hard. And it took all the courage I could muster to go back and see him again, but I felt such a strong need to ask him to forgive me and to check on him and to let him know that I care about him and that I would never mean him any harm. I wanted to apologize.”

Did help – Talking with Colleagues

Peer support groups, shared experience“I think the turning point for me was really when 2 of my colleagues and I each shared our story. I think that was the most emotionally fraught occasion where, where I didn’t share just a story; I shared the feelings. It

was, just the feelings came out, all the regret and the loss.” Disclosure & Reassurance

“He was asking me how I was doing, and at one point he says, ‘You know, everybody thinks that you are a good doctor,’ and that really helped me. That was so important, because I was still carrying around so much shame and guilt.”

“I would be driving down the highway and think about it, see horrible, gross images. I mean, it was like a war scene. Then we brought the Healer’s Art to our hospital, and we each shared a story of loss. I fell apart. They asked me questions which I answered. It was just a way of being listened to. And after that I could feel this burden lifted off of me. I really did feel like everything lifted off of me, and I stopped having those flashbacks, so it was a very powerful healing thing. But obviously it never goes away, but you start by thinking about it and talking about it.”

Did help – Talking with mentor or specialist

To learn about and from the error What did I do wrong? To receive reassurance

“But I needed to tell somebody who was not going to be protective of me that I had screwed up. He was helpful. He told me the two essential things I needed to hear: ‘Yes, you did wrong. Yes, this is something to learn from and no, you didn’t kill this person you loved.’ And so those were actually really important things that helped me.”

Did help – talking with residents or team

Processing event medically Processing event emotionally

“So we processed it medically but we also processed it emotionally. You know, “How are people doing?” Just validated the emotions. I remember the MICU resident was crying. I’m surprised we all weren’t crying.”

Teaching others, prevention“That’s right, it’s not just about systems but also talking about that we all make mistakes at some point and I have, too, and telling them stories like this, which has opened things up.”

Did help – Talking with own Spouse or Family

Emotional support If spouses or family members were

physicians, they could provide reassurance.

Did help – Talking to God, Prayer

Grace“It was during a prayer. I just felt a sensation and I felt a calming, it was a definite event. I felt calm, and I just felt a sense of peace, you know I didn’t hear a voice or anything, but I just had this inner knowledge of, be still and know I am God and I give you my grace.”

Forgiveness Reminder of medicine as a calling

Did help – Talking to Researcher

Never talked before“You’re the first person I’ve talked to about it since my colleagues in ’94.”

Want to help others“Because I think it’s a really important study. Because I had experiences that I thought were relevant and that I’m more than willing to talk to people about. Because I think it helps to talk about these things. It doesn’t just help other people to know, so that they’re ready when they make their mistakes, but it also helps to disclose our humanity.”

How can we help?

Skills training – how to talk to colleagues, how to be helpful, supportive

Peer support Mentor coaching Team leader training Develop resilience

Questions?