Communication and patient safety
I am embarrassed to admit that it was a cardio-thoracic surgeon in Hebron, Palestine, who reminded me about the importance of including patient safety in discussions about health care communication. In Fall 2022, I led a communication workshop for the medical students at Hebron University. The charismatic dean, a surgeon, asked to kick off the session and focused on the importance of the checklist and surgical staff communicating honestly and thoroughly with each other. He spoke eloquently about learning how airline pilots took off and landed a jet at a conference and realizing how he needed to use a checklist in surgery.
Meeting with Hebron University faculty of Medicine and Foundation for Family Medicine in Palestine team, October, 2022
Of course, you have probably read or watched Atul Gawande describe the importance of the Checklist. As I listened to the dean, a light went off – I need to include this angle in my workshop and the Communication in Health Care class back at Brown. How could I make it fun and engaging and applicable for undergrads with medical school and other health profession aspirations?
This is my 4th year teaching the Communication in Health Care class. I inherited it from a PhD in education: 7-week long summer semester, two hours of lecture three times a week. Content focused on patient-centered vs. doctor-centered care communication, health belief model, culture, listening well, using silence and the difference between open and closed questions. The course was popular; the professor loved to lecture, was funny, and an easy grader. Students spent 6 hours shadowing in clinics, which were the setting for their research projects.
When I took over in 2020 all teaching was virtual – thank you COVID. As I planned for the 2021 class, now 14-weeks in the spring, teaching styles had changed and a reverse classroom format was preferred, where students do preparatory work and class time is spent applying what they read. The content also needed to be updated to include more on anti-racism and bias, trauma informed care, and tele-medicine. The Debra Roter text, revolutionary in its day and updated in 2006, was out of date showcasing research based on immigrant populations from Europe.
Considering patient safety, there are now 20 years of publications and research since the report To Err is Human by the then Institute of Medicine, now National Academy of Medicine, which pointed out the honest mistakes occurring in our medical system, both revolutionary and startling at the time. A clever 5-minute video by IHI on safety efforts at a Florida zoo looks at what caring for poisonous snakes teaches us about communication and safety, stressing its importance and the continuous quality improvement approach, but I thought students needed more of a health care focus as an introduction. My web search eventually led me to TEAMSTEPPS – thank you AHRQ – and their 1 minute animated videos applying different communication tools: SBAR, CLC, Handoff, Brief, Huddle, Debrief, CUS, etc.
The class and I worked through the SBAR framework–a method to communicate about an urgent situation – background, assessment, recommendation. Using this method can be clunky. I remember thinking that when I first used it in my rural clinic in the mid-2000s. Apologies to Lori the head RN. At the time, I was still learning the value of huddles which interfered with my ability to run over to clinic last minute. Thankfully, I’ve mended my ways and even evaluated the value of huddles in clinic transformation research.
Students counted off and worked in groups of 2 or 3 with the assignment to view the animated videos and create a skit to present their tool to the class. The skit’s content could be inspired by school, family, or work activities; it didn’t have to be about health care.
The fun began.
CLC close-loop-communication did a correct and incorrect version of a minor surgery scenario. In the incorrect skit one of the students got the giggles.
Two female coaches briefed the basketball team pre-game on the offensive and defensive plan. As a non-title 9 teen, I never had the opportunity to participate in team sports and was pleasantly surprised by their practical application of the brief concept to their lives in basketball.
The two students doing huddle and the two assigned to debrief asked if they could work as a team. They presented two skits. EMTs assessing an intoxicated student and the friend who shared her worry about some kind of drug consumption, the EMTs huddling to share the information they were getting from the friend and planning to transport the patient. The medical team debriefed after managing the intoxicated student in the ED and successfully admitting her to the hospital.
The CUS skit was a female resident discussing with her male supervising physician a patient just seen where he failed to separate a mother and an ill teen: “I am concerned; I am uncomfortable; this is a safety issue.” I am worried we might be missing child abuse.
The students applauded themselves and each other and I was thrilled that I had made patient safety communication fun and applicable to what they know and do.
And I had successfully implemented continuous quality improvement with my communication course. I am reminded that there are always opportunities to learn and improve if we are open.