A Bittersweet Farewell to IPEP’s Interns

As another semester passes, we bid a bittersweet farewell to our amazing interns, many of whom are graduating from their respective programs at Simmons College and Northeastern University, or continuing their education in fields related to public health and research. We are grateful for their diligence and hard work on their Institute related projects throughout the year. These projects and initiatives have greatly benefited from our interns’ contributions. Projects on which the interns contributed included the Aligning Expectations During Surgical Consent, Advancing Relational Learning Worldwide, Disclosure and Apology after Medical Error, and Patient Centered Anesthesia Informed Consent projects.

Each of the interns brought their unique background, skills, and knowledge to their roles within these projects and initiatives, enhancing each project’s continued success. As we bid this cohort of interns farewell, we wish them nothing but the best of luck and success in their future endeavors. Thus far, these endeavors include:

-Taking a position at our partner institution SIMPeds
-Potentially taking a position at a public health research facility in Australia focused on Aboriginal health.
-Continuing their education into graduate school with the intention of becoming a Child Life Specialist
-Accepting a position within the Harvard Public Health research branch
-Continuing their education into medical school
-And continuing their degree in Public Health to later receive a degree to become a Physician Assistant from Northeastern University.

IPEP has developed a unique, interprofessional method of teaching the intricacies and nuances of holding difficult conversations among clinicians, families and patients. We can say with pride that our interns have brought this concept to life right here in the office, contributing their unique perspectives, ideas, and collaborations with our team as a whole. In effect, we’ve learned as much from them as they have from us. We hope you’ll join us in congratulating our intern cohort on their hard work and dedication, their graduation into their new chapters in life, and thanking them for their contributions to IPEP’s initiatives.

Posted in IPEP Team

Tips for Preparing to Disclose a Medical Error or Adverse Medical Event

Speaking with patients or their families after a medical error or an adverse medical event is one of the most difficult conversations a clinician can have. Rather than taking a deep breath and walking into this stressful event unprepared, being thoughtful about how the meeting might progress and what the priorities might be is well worth your time. Preparing for a difficult  conversation, in fact, can greatly support the interactions between the patient and clinical team and help to reduce the anxiety felt by all. Here are some tips for preparing to have such a conversation:

Tip 1:  Purpose 

Remember that the meeting with the patient and family is for their benefit.

Tip 2: Team Members

Determine which clinician/provider(s) should be present for the initial conversation and assess who should be available to support the patient and family.

Tip 3: Present a Unified Voice

Before meeting with the patient or family, discuss the need for the team to present themselves in a sincere, unified, and professional manner. This is not the time for the team members to debate about the event.

Tip 4:  Avoid Blame

Avoid blaming others. For example, saying, “the lab always does this,” or blaming the system.

Tip 5:  Be Honest

Think about what you will say to the patient or family about what has happened. Honestly share the facts of the situation, as they are known, with the patient and family. But, resist the temptation to speculate beyond what you know for certain at this point.

Tip 6:  Try to Anticipate the Patient or Family’s Needs

Anticipating the patient’s and family’s needs and being prepared ahead of time, even practicing the conversation in role play, can be very helpful. Speak with an institutional coach or other resource and the team beforehand to anticipate potential questions and emotional reactions from the patient and family and how you might respond.

These tips are based on the “Guidelines and Tips for Disclosure and Apology Conversations” video narrated by Dr. Elaine Meyer in collaboration with OpenPediatrics

Posted in Disclosure and Apology

“Doctor, the Family is Here”: The Challenges of Communicating Difficult News in the Emergency Department

By Gabriela Toutin Dias, MSc

This was his first shift as an attending. Fresh out of emergency medicine training, he felt an overall sense of relief and satisfaction; it had been a good shift. As night fell, his thoughts increasingly turned to the moment he would arrive home, hug his wife and son and wind down. He was interrupted by a nurse; motor vehicle accident coming in, 17 year-old boy, multiple fractures, intubated at the scene, blood pressure dropping. He quickly stood up and made his way to the emergency room, it was go time.

As the patient was rushed into the emergency room, the entire team was ready. In his mind, he read off a checklist of all the steps in assessing and managing a trauma case: airway, breathing, circulation, all the letters and acronyms clearly organized; he had seen this so many times and wondered if it should feel automatic by now. It didn’t. He was sweating, heart pounding in his chest. Severe trauma, young patient, he had to get this right; the odds were against him.

He could see all his team members focused and rapidly working their way to make sure this kid survived. He wondered if they were as worried as he was. In front of him, a text book case of hypovolemic shock and a Patriots jersey, his favorite team. Hands moved in a quick, almost orchestrated manner, lots of voices at the same time as he led the case and a palpable tension in the air; they had to move faster. Fluid, blood, voices in the room becoming louder. Cardiac arrest. He stepped up and quickly began compressions, he could not let this one go, he was too young and there was too much life ahead of him. He tried to push away images of his son, but they kept popping in his head. He had to focus, but as his arms became weaker, somebody took over. As he wiped the sweat from his face, he felt a sinking feeling in his stomach and took a step closer to the patient; he didn’t even know his name. He resumed compressions for what felt like a confusing mixture of time standing still and time flying past him; he was in a zone and all he could think of was saving his patient. Someone touched his shoulder and told him 50 minutes had gone by; they had to call it. Everything around him froze. As that person, kindly but firmly, removed his hands from the patient, an unfamiliar voice broke the silence in the room, “Doctor, the family is here”.

The case illustrated above, although fictional, is a realistic representation of what transpires inside an emergency department (ED). During the four years I worked as a clinical psychologist inside the ED of a tertiary teaching hospital in Brazil, I experienced on a daily basis the feeling of working in a high-energy and fast-paced environment. The crisis nature of emergency care often results in healthcare professionals working under constant time pressure and the uncertainty of managing unpredictable situations.

In this context, communication between physicians and patients or families acquires unique aspects in the ED. The task of delivering difficult news is routine and extremely common, yet it is still perceived as one of the most difficult responsibilities in medicine. Furthermore, this particular type of communication is a common source of distress for physicians and, in extreme cases, burnout, fatigue and depression-related symptoms (Brown et al., 2009).

On the other hand, a visit to the ED can also be an overwhelming experience for patients and/or family members when, in many cases, news of a serious illness or, as our case scenario illustrates, death may come up. This news, often given in an abrupt manner, may lead to feelings of abandonment, loneliness and loss of control. Many will forever remember the moment in which bad news was given to them (Takayesu & Hutson, 2004).

In the ED, most encounters between physicians and patients (or family members) occur for the first time, neither party entering this relationship by choice, a set-up that can potentially favor mistrust or negative stereotyping. In addition, assessment, rapport building and patient education tend to happen simultaneously rather than sequentially because of the rhythm in which care is provided. With these elements in mind, it becomes clear that communicating effectively with patients and families is a core skill for emergency physicians. The effective management of communicating difficult news results in patients’ better comprehension of information, satisfaction with medical care, level of hopefulness, and subsequent psychological adjustment (Toutin-Dias et al., 2016).

So, what can we do to achieve the effective communication of difficult news? Here is where simulation-based training becomes a powerful ally. Communication is a skill that can be enhanced by training, therefore it is essential that we offer the opportunity for every professional involved in patient care to experience the event of communicating difficult news in a controlled and psychologically safe environment. With the help of standardized patients, we can design realistic and engaging interprofessional scenarios that ultimately lead to the creation of individual “skill set archives,” or mental resources that can rapidly be accessed when faced with real-life situations like the ones seen inside the simulation center. As for our attending, wouldn’t it be ideal if he could reflect on lessons learned from previous experiences with simulated pediatric death notifications before stepping in to talk to the patient’s parents?

Gabriela Toutin Dias, MSc is a psychologist from Sao Paulo, Brazil where she worked in the emergency department of the Hospital das Clinicas (tertiary teaching hospital affiliated with the University of Sao Paulo’s Medical School) as a clinical psychologist and simulation educator. Currently, Gabriela is a fellow in the Institute’s Faculty Fellowship for Leaders in Collaborative and Humanistic Interprofessional Education. In addition, she works alongside staff, faculty, and leadership on several projects and initiatives within the Institute.

Posted in Simulation

PERCS Rounds: A Clinical Ethicist’s Reflections from the “One-Room Schoolhouse”

by Kerri Kennedy

How does one learn the art of navigating difficult clinical encounters with compassion and skill?  Thankfully, IPEP has developed an innovative approach to teaching this art, sometimes referred to as the “one-room schoolhouse” which creates a space for diverse practitioners to learn from and alongside each other.  The Program to Enhance Relational Communication Skills (PERCS) Rounds at Boston Children’s Hospital is one example of this educational approach. The monthly, hour-long forum is conveniently held on patient care units and draws interdisciplinary professionals together to discuss and explore challenges they face in everyday practice. In my role as a clinical ethicist at Boston Children’s Hospital, I regularly participate in the NICU-based PERCS Rounds. I would like to share a few reflections about what I find so valuable about them:

We’re all in this together.  PERCS Rounds is a safe forum for staff to take a brief pause from their work to join with colleagues and discuss the myriad challenges they face in day to day practice. Because the topics are selected by unit staff members themselves, attendees typically find them highly relevant and useful to their practice. The PERCS Rounds discussions are wonderfully engaging and create a sense of shared experience which fosters a sort of camaraderie (“I’m not the only one who finds this challenging…”). And these discussions are far from vent sessions. Those who participate are rewarded with new ideas and strategies for addressing the difficult conversations and clinical challenges they are facing. It is especially gratifying to see junior staff members learning from more senior ones…and vice versa!

“None of us is as smart as all of us.” This famous quote by Kenneth H. Blanchard, an IPEP favorite, nicely captures the spirit of the “one-room schoolhouse.” During PERCS Rounds planning, great care is taken to consider who to invite to a given Rounds that can bring expertise best matched to the topic at hand. This gives participants access to the knowledge and talents of a wide range of hospital professionals, from interpreters to child life specialists, even experts in meditation. In the same vein, I often find that PERCS Rounds is a natural forum for providing ethics education, and in a manner that is responsive to the real time needs and questions that participants have.

These people inspire. People sometimes ask how I cope with the sadder aspects of my work. My reply is simply, “I find the people so inspiring.” The patients, the parents, the clinicians – they are profoundly resilient. PERCS Rounds creates a space where this resilience can be seen, shared, and further cultivated. Recently, members of IPEP’s family faculty have begun regularly participating in PERCS Rounds. This inclusion of the patient/parent voice adds a crucial layer of richness to discussions and helps to keep the focus on the patient, who is always at the center of our care. Time and again, I am moved by my colleagues’ dedication to providing the best care for patients and families, and I have often reflected that this work truly draws out the best of the human spirit. I think that’s pretty inspiring.

 

Kerri Kennedy MA, RN is a clinical ethicist at Boston Children’s Hospital.  There, she coordinates and facilitates ethics consultations, conducts unit-based ethics rounds, and assists with the development and implementation of ethics-related institutional policies.  In addition, Kerri is an active member of the Boston Children’s Ethics Advisory Committee, participates in the Harvard Clinical Ethics Consortium, and serves on the Harvard Task Force on Ethical Issues in Emergency Preparedness.

 

Posted in IPEP Team

Informed Consent Prior to Surgery: It’s Not Just About Signing a Form

Featured in Boston Children’s Today
By: Adena Cohen-Bearak

As the sun rose on a cold November morning, 20 surgeons and 3 nurse practitioners from the Department of General Surgery at Boston Children’s Hospital gathered for the PERCS: Aligning Family-Team Expectations During Surgical Consent workshop developed by the Institute of Professionalism and Ethical Practice (IPEP). (PERCS is IPEP’s signature program, the Program to Enhance Relational & Communication Skills.)

Many surgeons and nurse practitioners are trained to understand the informed consent process as a legal exercise: there is a discussion with parents about the details of their child’s upcoming surgery, a presentation of the informed consent information to the family (risks, benefits, alternatives, etc.), and then responses to any questions. Then, right before the surgery itself, the family signs an informed consent document.

Done? Not so simple.

Research shows that patients only tend to absorb half of surgical informed consent information that they receive. This can result in the misalignment of expectations of the family compared with the expectations of the surgeon pertaining to the goals of the surgery and the process of post-op recovery, among others.

This risk of causing a family’s dissatisfaction about their child’s medical experience, even if the surgery was successful, is great, and can have a long-term impact on the family. In response to Boston Children’s Hospital’s focus on the Patient Care Experience, IPEP is doing something about this.

Through a combination of didactic learning, case simulations with trained actors posing as parents, experiential learning, use of everyday ethics and debriefing, surgeons and nurse practitioners learned to appreciate the importance of increasing their family focus during surgical consultations at November’s workshop.

When asked about the most valuable skills and information that they acquired, participants reported learning how to relay information to the family, communicating with children, and learning multiple ways to recognize family emotions and establish connections.

At the workshop, Craig Lillehei, MD, senior associate in Surgery and the project’s co-principal investigator, along with IPEP’s Director of Patient Safety and Quality Initiatives Sigall Bell, MD, took on the role of lead facilitators. The faculty and facilitators also included Adena Cohen-Bearak, MEd, MPH; Pam Varrin, PhD; Lisa Burgess and Lauren Mednick, PhD.

When asked about what they might do differently in the future based on their learning in the workshop, participants reported:

  • (Changing their) tone with families
  • Trying to make a personal connection with families
  • Recognizing/addressing parents’ and patients’ emotions
  • Asking the family for their baseline level of understanding

Family facilitator Lisa Burgess, a Boston Children’s parent and member of the Family Advocacy Council, commented: ”What an amazing day! This IS history in the making. Thank you all for all you are doing to make this work happen! It is a true privilege to be a part of this team.”

Aligning Family-Team Expectations During Surgical Consent has included the participation of surgeons and nurse practitioners in the departments of General Surgery, Neurosurgery, and Urology. IPEP is in the process of scheduling the last workshop with the Department of Neurosurgery to take place this spring 2017.

This work has been made possible through a generous grant by CRICO’s Patient Safety Risk Management Grants Program, and through funding from the Program for Patient Safety & Quality (PPSQ)

Posted in Aligning Expectations

An IPEP Actor’s Experience

By: Jessica Webb

Jessica Webb, IPEP actor, was moved to write based on her participation at the South Shore Hospital PERCS launch.jessica-webb-hudspeth

I have had the honor of working as an actor with PERCS for 6 years. In that time, I have had the opportunity to share and represent the experience of all kinds of families: high income, low income, supportive and communicative, divorced and aloof, single parent, working parent, and so many more. But for the first time in all my years working with IPEP’s PERCS initiative, I was finally able to portray my family—a family of two moms. While same-sex parents may not seem groundbreaking for those of us lucky enough to call New England our home, for my moms who raised me in Michigan, raising a family as two gay women was a defining factor of my upbringing and their daily lives.

My mother spent many years in the closet due to the fear of what her identity could cost her: her job, her livelihood, or losing custody of me, all because she way gay. Because of the intense pressure my mother experienced to remain closeted for so long, my mothers and I never truly experienced what being a family felt like outside of our loving and unconditionally accepting home. In one instance when I was 5 years old, I had to go the hospital to receive stitches. I clearly remember hearing my mother lie during my intake and call her partner, my mom, Colleen, her sister. Colleen was not allowed to be with me unless she was “family.” In this heartbreaking instance, while only one of many, my mother had to bend our family’s truth to fit the outside world’s limited understanding of what “family” means in order to include her partner, my mother, in my care.

My mother, who still lives in Michigan, is now working as an advocate for LGBTQ rights within the senior community, as well as faith-based organizations in an attempt to encourage both Jewish and Christian congregations to institute open, affirming and anti-bullying policies for their members. During this particular PERCS workshop simulation, I was the one who got to be the advocate, just by being a clear, unconstrained representation of my family. Naturally, I called my mother after the simulation to tell her about my experience. As she asked me how it went, I began to explain all the details of the scenario, including the fact that I represented a member of a family with two moms. It was then that she began to cry—not because of the issues that were at play in the simulation, but because the issue that had defined the struggle of her entire life was suddenly not an issue at all.

Thank you, PERCS, for letting me experience here what I was never able to where I grew up: my family.

Posted in IPEP Team, LGBTQ, Simulation

Aligning Expectations: Where We Started, Where We Are Now

by Adena Cohen-Bearak

Back in the spring of 2015, when our project team learned that our grant proposal for our new project Aligning Family-Team Expectations During Surgical Consent had been funded, we believed that surgical informed consent was a simple process. Our thinking went something like this:  a family would come to Boston Children’s Hospital, meet with a surgeon to discuss their child’s upcoming surgery, and the surgeon would describe the surgery, present the informed consent information to the family (risks, benefits, alternatives, etc.), answer any questions, and that would be it. Done. Finished. All the I’s dotted and the T’s crossed. Simple.

We decided to start our project by looking deeply into parents’ experience of surgical consultations by asking parents whose children had recently undergone surgery a series of questions:  What did they remember most about their discussion with the surgeon? What did they think of the way the surgeon spoke to them? Did they get the information they needed? And how about after the surgery? Was the recovery experience what they expected? Were their expectations aligned – and by that we meant, did the experience of the surgery mesh with what they expected what would happen?

Through this process, we realized that there was nothing simple about informed consent. Not only was informed consent not a simple, one-time conversation, it was actually a complex process that took place in many locations, with many participants, and still sometimes left families feeling confused.

No wonder it was difficult to align expectations between families and surgeons!

Though our initial exploration –  utilizing focus groups and interviews – was with a small number of parents, we found out many important things. Parents find the surgical consultation to be a very emotional event. They rarely remember everything that they heard in the discussion. Parents often don’t know what questions to ask, even though providers ask if they have questions. They feel that they need more information about the recovery process, and what possible complications might occur. They don’t know who to go to with questions. Parents do not really know what informed consent is  –  they see it as the form that they sign before surgery, and they pay it little heed.

We also looked into the literature about informed consent, and what we found fit with what we learned from parents. Research shows that patients only tend to absorb half of surgical informed consent information that they receive. Patients often give clues about their social and emotional concerns, but surgeons often miss the opportunity to acknowledge patients’ feelings. When a patient asks “is this something serious?” surgeons often revert to a comfortable response for them – biomedical inquiries –instead of expressing empathy or uncertainty. While surgeons excel in providing details about surgical conditions and approaches, the literature shows that surgeons could improve in their assessing of patients’ understanding, in discussing risks, and in discussing uncertainties.

These initial discoveries set the tone for the project, and have informed all our decisions moving forward. By basing our project on the actual experience of parents and families (backed up by relevant literature), we are able to offer surgeons and other surgical staff suggestions on ways to improve their communication with families prior to surgery that are immediately applicable and realistic.

Posted in Aligning Expectations

From the Viewpoint of a Research Assistant

By John Scott, IPEP Intern

John Scott, Co-op Intern

Being at the hospital with a sick child is never a parent’s idea of a good time. Add to that a complete stranger convincing you to take part in a study, and you can imagine how the parents may feel. But this isn’t any average study; we want to explore how surgeons communicate with families by recording the consultations our families invite us to be a part of. Expectations of medical procedures can vary greatly between physicians, patients, and their families. To understand why, you only have to consider the variety of factors that go into making a decision, such as the difficult process of deciding whether your child should undergo surgery. Making this decision, much the same as any other medical decision, is complicated by understanding the procedure, anticipating the outcome of the procedure, and figuring out what “improvement in your child’s condition” realistically looks like.

Obtaining informed consent to record the consultation is a small role in the grand scheme of the project, but in that moment, talking with the families, it felt like the most important. I’ve seen this talk happen several times, yet I can’t help but feel my heart racing while I wait for the family to settle into their seat where in a few moments it will be my turn to speak with the family. I’ve prepared my speech, went over what I plan to say in my head several times, and even had a checklist of items I needed to cover if, for some reason, I lost my place. Even with all this preparation, I can’t help but feel anxious when I approach any family.

I spoke with one father both before and after their appointment after I obtained his consent to be in the study. It had been a journey to get his child in to see the doctor, which began at least a year prior to our conversation. He was the textbook example of being an advocate and champion for your child. I heard his story, understood the reasons why he kept pursuing different opinions, and finally saw that he was pleased with his visit and the care that his child would be receiving. We spoke for a short while before they left for some final tests and then for their home several hours away. The last thing I remember I told him was “you’ve done everything for your child, you were his advocate and pushed to make sure he received the care he deserves, and I would be lucky to have someone on my side like you”.

Posted in Aligning Expectations

Elizabeth A. Rider, MSW, MD, Honored by European Society for Person Centered Healthcare

Elizabeth Rider, MSW, MD

Congratulations to Boston Children’s own Elizabeth Rider, MSW, MD, who was recently awarded the 2016 Platinum Medal for Excellence in Person Centered Healthcare by the European Society for Person Centered Healthcare (ESPCH). Rider was selected from a pool of 397 nominations to receive the award, which recognizes excellence in person-centered health care advocacy, scholarship, research and teaching.

Rider is a member of the Division of General Pediatrics and the director of Academic Programs for the Institute for Professionalism & Ethical Practice (IPEP), where she creates and directs programs to enhance the relational skills and professionalism of health care leaders, faculty, trainees and clinicians. She is a founder of and currently directs Boston Children’s and Harvard Medical School’s first Faculty Education Fellowship in Medical Humanism and Professionalism and the first Faculty Fellowship for Leaders in Collaborative and Humanistic Interprofessional Education.

In addition to her work at Boston Children’s, Rider caught ESPCH’s attention for her leadership of the International Charter for Human Values in Healthcare. The Charter is an interprofessional collaborative of individuals, organizations and institutions around the world working to restore human values to health care including Compassion, Commitment to Excellence and Justice in Healthcare.

When ESPCH President and Chairman of Council Sir Jonathan Asbridge, DSc, presented the award to Rider at the organization’s annual conference in London, he acknowledged the Charter as a “major contribution to the development of more person-centered healthcare system globally.”

ESPCH is not first to recognize Rider’s work. In 2009, Boston Children’s named her Community Pediatrician of the Year for her work at the hospital and in the community. And in 2012, she received the National Academies of Practice’s Nicholas Cummings Award, a national award for extraordinary contributions to interprofessional health care education and practice.

Posted in IPEP Team

Aligning Expectations between General Surgery and the PreOp Family

By Adena Cohen-Bearak, IPEP Project Manager

As the sun rose on a cold November morning of this year, twenty surgeons and three nurse practitioners from the Department of General Surgery at Boston Children’s Hospital gathered with Aligning Family-Team Expectations during Surgical Consent faculty and staff at a workshop developed by the Institute of Professionalism and Ethical Practice (IPEP). At the state-of-the-art BCH Simulation headquarters, IPEP’s Director of Patient Safety and Quality Initiatives Sigall Bell, MD took on the role of lead facilitator. The rest of the stellar faculty and facilitators included Craig Lillehei, MD, Adena Cohen-Bearak, M.Ed., MPH, Pam Varrin, PhD, Lisa Burgess, and Lauren Mednick, PhD. The workshop case enactment, which featured IPEP veteran actors Lewis Wheeler and Susan Lombardi-Verticelli as the case’s child “Max Miller’s” fictitious parents, was particularly engaging to this group, and workshop faculty allowed extra time for the debrief of a very complex surgical consultation.

In their post-workshop evaluations, many participants described their appreciation of the importance of increasing their family focus during surgical consultations. When asked about the most valuable thing they learned, participants reported learning how to relay information to the family, communicating with children, and learning multiple ways to recognize family emotions and establish connections. When asked about what they might do differently in the future based on their learning in the workshop, participants reported:

• (Changing their) tone with families
• Trying to make a personal connection with families
• Recognizing/addressing parents’ and patients’ emotions
• Asking the family for their baseline level of understanding

Workshop faculty also commented positively on the experience: “Thanks to the actors for not only a stellar performance,” commented Dr. Sigall Bell, “but also, as always, delivering the key take homes with ease and power.” Lisa Burgess, a BCH parent and FAC rep, commented: ”What an amazing day! This IS history in the making. Thank you all for all you are doing to make this work happen! It is a true privilege to be a part of this team.”

IPEP is in the process of scheduling the last workshop with the Department of Neurosurgery to take place in January 2017. This work has been made possible through a generous grant by CRICO’s Patient Safety Risk Management Grants Program.

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