In March 2018, The Collaborative for Healing and Renewal in Medicine (CHARM) published an article titled “Charter on Physician Well-being” in JAMA. The piece describes guiding principles and lists recommendations for promoting well-being among physicians. The charter successfully pulls together, in a 2-page document, a comprehensive approach to preventing burnout and fostering well-being among physicians.
One recommendation especially caught my attention. “Anticipate and Respond to Inherent Emotional Challenges of Physician Work.” A tenet of addressing physician burnout is that some amount of stress is inherent to the practice of medicine. The supporting text suggests that, “Organizations could aid physicians by integrating regular protected opportunities for debriefing within the workday and by building professional support systems to address the influence of adverse events on physicians and other members of the health care team.”
Why did this portion of the document intrigue me?
It resonated with a commentary I read recently by Jo Shapiro, MD, director of the Center for Professionalism and Peer Support and a surgeon in the Division of Otolaryngology at the Brigham and Women’s Hospital (BWH) in Boston and an Associate Professor of Otolaryngology at Harvard Medical School. Shapiro identified the Brigham and Women’s Center for Professionalism and Peer Support as a key organizational strategy for preventing burnout. As I read about disclosure coaching, one element of the program, I found myself wondering: How does it work? How common are programs like this? How can other health care organizations start a similar program? Shapiro generously found time in her schedule to fill me in. Here’s what I learned…
National data suggest that physicians generally do not excel at having conversations with patients and family members after an adverse event occurs. According to Shapiro, they tend to use jargon, omit saying, “I’m sorry,” and speculate on what happened before sufficient information is available. Plus, physicians are, understandably, emotionally affected when an adverse event occurs, which reduces their ability to communicate well during these challenging conversations. In addition, for any particular physician, adverse events occur infrequently, making it difficult to learn and apply best practices regarding communication.
The disclosure coaching program at BWH involves just-in-time support provided by Shapiro. She is contacted when an adverse event occurs and clinicians need help preparing for a conversation with the patient and family about the occurrence. (She is usually contacted through a referral from the risk management department but occasionally via direct contact from a clinician.) She meets with the care team and asks them to consider the questions that the patient and family might ask. She assists them in identifying who will lead the conversation and in deciding on the best way to structure it.
According to Shapiro, the two most important principles to remember in these situations are compassion and transparency. She mentioned these specific best practices:
- Meet with the patient and family members as soon as possible after preparing for the conversation
- Ask for questions
- Allow time for processing of information
- Be empathetic and transparent
- Don’t speculate on uncertain information, as it can be upsetting and confusing
- Don’t withhold information that is certain
- Tell the patient and family if there are actions that you and your organization will take to prevent a similar adverse event in the future
The goal of disclosure coaching programs is to reduce the intense stress associated with an adverse event, especially those involving an error or harm to a patient. According to Shapiro, among physicians who have made an error and recovered after the event, the actions they identified as most helpful were speaking with physician colleagues, learning more about the event, and teaching others to make the health care system safer in the future.
Unfortunately, disclosure coaching programs are not common, perhaps because they require an investment of resources. To wit, 70 percent of Shapiro’s time is supported by the hospital to serve the Professionalism and Peer Support program—one component of which is disclosure coaching. For clinicians or executive leaders interested in beginning a program at their organization, Shapiro suggested making sure to partner with patient safety and/or risk management personnel in establishing a program. For anyone interested in more information on disclosure coaching, Shapiro and colleagues wrote an article on this topic (“Disclosure Coaching: An Ask-Tell-Ask Model to Support Clinicians in Disclosure Conversations”), which was recently published in the Journal of Patient Safety.
Solving clinician burnout requires a multifaceted approach. Systematic support for clinicians who are experiencing extreme stress after an adverse event is an absolute necessity. As Shapiro stated in her commentary, “Through the Center for Professionalism and Peer Support, we have multiple programs to help create a culture of trust in the organization, in service of improving clinician wellness and patient quality.” Our colleagues and our patients deserve nothing less.
Photo credit: Sam Dennis