Social Media and the Health System
Ted Eytan, MD, MS, MPH; Jeffrey Benabio, MD; Vince Golla;
Rahul Parikh, MD; Sara Stein, MD
Winter 2011 - Volume 15 Number 1
You know institutions tend to become static; they build walls around
themselves to protect themselves from change, and eventually die.
You should fight that by opening up your thinking and your ideas,
and work for a change.
-Sidney Garfield, MD1
As early as 1960, Sidney Garfield, MD, the co-founder of Kaiser Permanente (KP), foresaw how computers would become powerful tools to help patients.2 It is in his maverick spirit that we examine the potential for social media to be powerful tools to help our patients today.
Social media, or content created and exchanged within virtual communities through the use of online tools, are used by millions of people to converse and to connect.3 Health systems can use social media to engage members and potential members by building trust and making large organizations more accessible and approachable.4 Social media can help patients manage their chronic conditions and make healthy choices; it also can accelerate knowledge acquisition and dissemination for patients and clinicians.
Health and health care organizations are popular topics in social media conversations, and both positive and negative stories shared through online networks can have an enormous reach. KP experienced this in 2006, after unfavorable media coverage of the KP HealthConnect® electronic health record system emerged on social media sites.5 Positive messages can also spread as has been the case of the KP Thrive advertisement “When I Grow Up,” which was hosted on the social network video site YouTube. The video portrayed images of active women seniors alongside a message promoting mammography that attracted more than 125,000 views garnering significant attention from repeat viewers and women in the target demographic of 55 and older.
Although there are risks for health systems to participate in social media, there are also risks in not participating. In a patient-centered model of health care, absence from social networks that are important to patients might lead to a gap between patients and clinicians. In this article, we will focus on the promise of social networking and review potential risks of both participation and abstention.
Social Networking and Social Media
Social networking is not a program or a Web site; it is a community of people who share similar interests and activities who interact through online and mobile technologies. Facebook, Twitter, and blogs are Web platforms used to connect people and transform the publishing of media from broadcast media monologues into social media dialogues.3 The rapid and extensive penetration into society of these sites is related to their ability to facilitate talking as well as listening, consuming as well as participating. Whereas it took nearly 40 years for computers to become mainstream, it took Facebook less than 6 months to add 100 million people.6 Today more than 500 million people use Facebook regularly.7 Among adults in the US, 42% use social networking sites. Among young adults (age 18-29 years), the figure is an impressive 86%.8
Building Trust and Understanding
Because of the “no advertising rule” in the American Medical Association’s code of ethics, which existed from 1847 to 1975, health care organizations were barred from communication that could subject physicians to allegations of “soliciting” patients. In the post-“no advertising rule” era, however, health care organizations have begun to adopt best practices of the public relations and issues management field. One key concept is the “bank of good will.” Good news generated by an organization strengthens its reputation in the marketplace and among policymakers and influencers. Good news also protects against potentially harmful messages. When this bank is depleted because of the absence of positive mentions, organizations face reduced effectiveness as the result of a damaged reputation. Adding to this understanding, large media outlets and organizations no longer generate all news and messaging. In today’s world of democratized influence, consumers generate news. A 2010 report by the Pew Internet and American Life Project9 confirms this reality: 37% of Internet users have actively contributed to the creation, commentary, or dissemination of news. In addition, 75% of online news consumers get news forwarded through e-mail or posts on social networking sites.
In practice, a successful organization tracks positive, neutral, and negative media “mentions.”
Data show that KP has internalized the bank of good will best practice.
Figure 1 demonstrates the visible change in media mentions (defined as a reference to the organization in print publications, television, and the Internet) from KP’s work.
Twitter and other social media exert leverage by using positive network effects. This means that one message reaches the direct followers, who then share the original message in an exponential fashion, increasing the value of the network to the individuals who participate in it. The positive network effect provides fast and free distribution of messages to health consumers. A recent demonstration of this effect occurred with the media release of KP’s electronic health record collaboration with the Department of Veterans Affairs in January 2010.10 Through the use of social networking tools such as Twitter, an audience of hundreds was expanded to an audience of over 75,000 within 48 hours, with 92% of the reach created by individuals not affiliated with KP.11
An example that examines the reach of just one physician demonstrates the potential of building the bank of good will. In Figure 2, the content generated by a single KP physician, in this case coauthor Jeffrey Benabio, MD, a dermatologist, (“Tweet Type” pie chart), is compared to the reach of each piece of content, copied and forwarded, and tracked through the Internet.
Following on this analogy, each impression equals a deposit to a bank of good will. The conservative approach to social media participation has typically been to use social media “handles” and profiles that avoid mention of organizational affiliation, as is the case above. The significant impact of positive mentions and the dominance of user-generated content in media mentions has changed this view, however, turning what was once thought of as a liability into an asset in the positioning of a care system as the model for the future. If the physician instead is identified as part of a Medical Group in their social media handle or profile, the deposit of good will goes to the organizational “account” in addition to the individual “account.” Combined with the network effect of multiple physicians participating, their impact in support of the health system’s efforts to support patient, family, and community health is multiplied exponentially.
Studies of the impact and accuracy of health information disseminated via social networks are only beginning to be published.12 Statistics clearly demonstrate a demand for social media in medicine, which provides an opportunity for clinicians and health care organizations to engage their patients. During the H1N1 outbreak of 2009, the Centers for Disease Control and Prevention (CDC) turned to social networking site Twitter to communicate with clinicians across the US. The CDC employs a Twitter feed for emergency information (more than 1.2 million followers) and also for flu information (46,000 followers).13 There are numerous examples of individual physicians using social media to educate and support patients in preventing and managing chronic illness. Additionally, we are seeing a growing effort within the health sector to embrace social media as evidenced by the creation of the Mayo Clinic Center for Social Media. Physicians involved in these efforts cite the use of social media as the enabler of societal purpose in their professional work, whether it is to “realign families with science”14 or “tap into the reason we all went into medical school, to make a difference in people’s lives.”15
A recent legal review of social media concluded, unsurprisingly, that “in the health care context, complex situations can arise.”16 For example, a physician unaccustomed to mass communication might be misquoted or contribute to negative perceptions of his or her practice or health system, intentionally or not. In addition, a broader perspective of risk must include the actions of physicians, staff, patients and their families. Employees have been terminated for tweets that violate the Health Insurance Portability and Accountability Act (HIPAA); discovered Facebook and MySpace conversations have led to insurance coverage litigation; civil complaints have been filed alleging libel/defamation of clinicians in the use of online rating sites.16 The protection of patient privacy is paramount and requires special attention. Multiplying the number of communicators and the number of environments can increase the risk of harm to those we serve and of harm to the organization’s integrity and ability to carry out its mission. Paul Levy, former CEO of Beth Israel Deaconess Medical Center in Boston, points out in his social media work that “any form of communication (even conversations in the elevator!) can violate important privacy rules.”16p13 For this reason, an approach to social media that is applicable across all forms of communication is fitting.
An organizational social media policy is a first step in acknowledging employee activity and managing risks, “to keep them and your company safe as well as responsive.”17 KP’s social media policy,18 ratified in 2009 has been freely available for organizations to learn from and is considered a model in the health care industry.19 Greater actualization of benefits, including maintaining and growing a bank of good will, requires a transition in thinking from prohibiting all social media activity to active, guided engagement of all who wish to participate.20
Although health care’s understanding of the potential of social media is still in its infancy, more innovation is inevitable. Health care organizations and individual physicians are already using social media regularly to build trust, promote management of health and wellness, and disseminate knowledge. For health care systems and physician groups with a tradition of innovation and responsible growth, organized social media participation can extend the benefits of excellent communication with patients and potential consumers to enhance their relationship with us and promote achievement of their life goals through optimal health.
In an August 2010 conversation with the author (TE), Jack Cochran, MD, Executive Director of The Permanente Federation, the national umbrella organization for KP’s 15,000 physicians, stated: Today’s health system leaders are beginning to appreciate social media as “another societal asset that we need to be conversant in, and imagine how it will all link to a better future, instead of imagining that it will go away.” Leadership in the use of social media is an opportunity and a challenge for a health system to engage with a changing stakeholder group. On the basis of current life expectancy, it is possible that an individual over the age of 50 today could be cared for by a physician who is not yet born, and both these physicians and their patients will have different expectations for interaction than exist today.
“Social media is already integral to how people now live their lives and, increasingly, it plays an important role in how they manage their health,” says Holly Potter, Vice President of Public Relations at Kaiser Foundation Health Plan. “If we want to be relevant partners, helping our members and their families manage their health, it is our obligation to learn how to engage—safely, respectfully, and authentically.”
A sustained educational effort will be required to address gaps in understanding, manage fears, and mitigate tangible risks. We see the enormous potential of these tools to help a care system fulfill its purpose. At the same time, we are mindful of the benefits of learning from and teaching colleagues about this significant change in the way we will interact, with encouragement from medical leaders:
“Social media is very formidable, very real. It’s all around us and gaining momentum. We need to become savvy enough to help direct our colleagues to understand its potential, negative and positive.” Dr Cochran related to the author (TE) in their August 2010 conversation.
It may be normal one day for every physician and nurse to maintain a social media presence as health professionals committed to the health of individuals and populations. We are hopeful that this article will continue conversations already started about this future and the way we will shape it, in the interest of moving ahead together for the benefit of those we serve.
The author(s) have no conflicts of interest to disclose.
1. Debley T. The story of Dr Sidney R Garfield: the visionary who turned sick care into health care. Oakland, CA: The Permanente Press; 2009. p 119.
2. Garfield S. The delivery of medical care. Sci Am 1970 Apr;222(4):15-23.
3. Social media [monograph on the Internet]. San Francisco, CA: Wikipedia; 2010 [cited 2010 Aug 3]. Available from: http://en.wikipedia.org/wiki/Social_media.
4. Understanding the role of the Internet in the lives of consumers [monograph on the Internet]. St Louis, MO: Fleishman-Hillard; New York: Harris Interactive: Digital Influence Index; 2010 Jun [cited 2010 Aug 3]. Available from: http://digitalinfluence.fleishmanhillard.com/.
5. TECH/HEALTH PLANS: A Permanente Group executive speaks [monograph on the Internet]. San Francisco, CA: The Health Care Blog: 2006 Nov 13 [cited 2010 Dec 4]. Available from: www.thehealthcareblog.com/the_health_care_blog/2006/11/techhealth_plan_1.html.
6. Smith J. Facebook crosses 250 million user mark, adds 100 million new users in 6 months [monograph on the Internet]. Palo Alto, CA: Inside Network; 2009 Jul 15 [cited 2010 Aug 3]. Available from: www.insidefacebook.com/2009/07/15/facebook-crosses-250-million-user-mark-adds-100million-new-users-in-6-months/.
7. Press room: Facebook factsheet. Palo Alto, CA: facebook; 2011 [cited 2011 Jan 4]. Available from: www.facebook.com/press/info.php?statistics.
8. Madden M. Older adults and social media [monograph on the Internet]. Washington, DC: Pew Internet and American Life Project; 2010 Aug 27 [cited 2010 Sep 3]. Available from: http://pewinternet.org/Reports/2010/Older-Adults-and-Social-Media.aspx.
9. Purcell K. Rainie L, Mitchell A, Rosenstiel T, Olmstead K. Understanding the participatory news consumer [monograph on the Internet]. Washington, DC: Pew Internet and American Life Project; 2010 May 1 [cited 2010 Sep 3]. Available from: http://pewinternet.com/Reports/2010/Online-News.aspx.
10. Doherty T, Kahn R, Roberts K. Veterans Affairs and Kaiser Permanente share electronic health information to improve care for veterans [press release on the Internet]. Oakland, CA: Kaiser Permanente News Center; 2010 Jan 6 [cited 2010 Aug 26]. Available from: http://xnet.kp.org/newscenter/pressreleases/net/2010/010610vamedexchangepilot.html.
11. TweetReach for va, Kaiser Permanente [data on the Internet]. San Francisco, CA: Appozite; 2011 [cited 2011 Jan 8]. Available from: http://tweetreach.com/reach?q=va%2C+kaiser+permanente.
12. Scanfield D, Scanfield V, Larson EL. Dissemination of health information through social networks: Twitter and antibiotics. Am J Infect Control 2010 Apr;38(3):182-8.
13. CDCemergency: Twitter profile [Web page on the Internet]. San Francisco, CA: Twitter; 2011 [cited 2011 Jan 4]. Available from: http://twitter.com/CDCEMERGENCY.
14. Eytan T. “The more we change the world”—Blog-ter-view with Wendy Sue Swanson, MD, about physicians and social media [blog on the Internet]. Washington, DC: Ted Eytan, MD; 2010 Aug 8 [cited 2011 Jan 10]. Available from: www.tedeytan.com/2010/08/10/6078.
15. Brown M. The doctor will see you now?? Comment by Sara Stein, MD [blog on the Internet]. Knoxville, TN: Pershing, Yoakley and Associates; 2010 Aug 13 [cited 2011 Jan 10]. Available from: http://healthcareblog.pyapc.com/2010/08/articles/healthcare-reform/technology-social-media/the-doctor-will-see-you-now/.
16. Coffield RL, Joiner JE. Risky business: Treating tweeting the symptoms of social media. AHLA Connections 2010 Mar;14(3):10-4.
17. Bernoff J, Schadler T. Empowered. The Harvard Business Review 2010 Jul-Aug:94-101.
18. Kaiser Permanente social media policy [monograph on the Internet]. Oakland, CA: Kaiser Permanente 2009 Apr 30 [cited 2010 Aug 3]. Available from: http://xnet.kp.org/newscenter/media/downloads/socialmediapolicy_091609.pdf.
19. Li C. Open leadership: how social technology can transform the way you lead. San Francisco: Jossey-Bass; 2010. p 336.
20. Owyang J. Breakdown: The five ways companies let employees participate in the social web [monograph on the Internet]. San Francisco, CA: Web Strategy; 2009 Jul 15 [cited 2010 Aug 3]. Available from: www.web-strategist.com/blog/2009/07/15/three-ways-companies-let-employees-participate-in-the-social-web.
More from this Journal section
First Responders: The DMAT Team
Monday, 30 August 2010
Judy O’Young, MD Fall 2010 - Volume 14 Number 3 Twilight on Tuesday, January 12, 2010 in Port-au-Prince, Haiti: about 40 seconds of chaos. 7.0 magnitude. Buildings begin to crack and the sound makes people think of the gunfire that is all too frequent in the downtown area. For safety, people run inside. Buildings, shoddily constructed, crumple, trapping those inside. One of the best hotels, the Montana, on a verdant hillside overlooking the steaming plain of lowland Port-au-Prince, pancakes entombing more than 300 people. The air is thick with heat and the dust of concrete. Afternoon on Tuesday, January 12, 2010 in Oakland, CA: news on the car radio tells me I will make my fourth trip to Haiti sooner than planned. During 2009, I had worked in and around Port-au-Prince as a volunteer anesthesiologist on three separate Smile Train-funded surgical mission trips. I had stayed at the Montana. I had walked through the Cité de Soleil. My friends and colleagues lived in Delmas, now largely destroyed. We had operated on nearly 200 children and adults with congenital cleft lips and palates, tumors, and burns, after seeing and screening several hundreds more. Because of the poverty, neglect and lack of long-needed medical services, many more adults needed our teams’ attention. Despite the dire living circumstances and lack of resources, locals were unfailingly polite, helpful, and grateful for our efforts. I loved this Pearl of the Antilles with its vibrant culture and people, rara music, voodoo, and native art. Despite Haiti’s turbulent history, the indigenous spirituality and resourcefulness were unparalleled by any country that I have traveled to. I check my ready bag that evening and prepare to depart. My Disaster Medical Assistance Team (DMAT) is on call in January and all members are on standby for deployment. DMATs and International Medical Surgical Response Teams (IMSuRT) are groups available for national disasters and emergencies such as 9/11 and Hurricane Katrina. Recently the National Disaster Medical Service (NDMS) had been preparing DMAT and IMSuRT groups for work on a global scale. Months of team meetings involving disaster response and planning, equipment training and orientation, and numerous deployments have prepared team members to provide triage, evaluation, and first-response treatment of populations in times of disaster. Wednesday, January 13, 14:53 pm: simultaneous cell phone text, e-mail, and voice mail set us in motion. By the grace of our Kaiser Permanente departmental scheduler and the generosity of my departmental chief and colleagues, I commit as a rostered team member, and leave the following day for Atlanta. After an overnight briefing, including DMAT teams from Massachusetts, Florida, and New Jersey, we board a government charter aircraft and fly directly into Touissant L’Overture airport in Port-au-Prince, landing Friday, January 15. Long distance disaster relief is seldom smooth. Teams arrive before the equipment caches. Security cannot be guaranteed in the logical hospital sites where patients are. Infrastructure and transportation are nonexistent. Running water, electricity, cell phone, and Internet service are absent. An alphabet soup of international and federal agencies (PAHO, UN, USAID, and CDC) as well as the pre-existing nongovernmental organizations are in disarray. Air traffic control and the airport terminal are destroyed. The one runway, unlit, is not built for receiving overloaded flights. All these issues become secondary once the teams find their sites and equipment and supply lines are established. The Petionville Country Club becomes a triage and day treatment center for the tent city that forms on the nearby golf course. The Quisquiya School in Port-au-Prince adjacent to the Ministry of Public Heath’s Gheskio HIV clinic becomes a mobile field hospital with surgical and obstetric capability for the tented camp built on the neighboring soccer field. Federally deployed US teams of medical volunteers from different states are working cooperatively in a single encampment. The teams quickly adapt to the heat and insects, the lack of running water, the MREs (“meals refused by enemy”), and to each other. Day and night shifts alternate sleeping on cots in tents and battling mosquitoes and heat rash. The US Army’s 82nd Airborne establishes a helicopter landing zone across from the soccer field and ensures a steady flow of the most critical patients evacuated from the University Hospital and the surrounding neighborhood. The cases shift from week-old orthopedic crush injuries and long bone fractures to gunshot wounds and day-old babies with sepsis and respiratory failure. We deliver 11 babies and operate on 30 patients. We can run 2 simultaneous operations, but are limited by the lack of oxygen and supplies for spinal or nerve block anesthesia. There seem to be babies and children everywhere. A respiratory therapist hand-ventilates a tiny premature infant overnight before she can be helicoptered out to the USNS Comfort. A pharmacist cradles a child while dispensing medication. A warehouse supply logistician comforts a boy who has lost his leg. The work is constant, grueling because of the heat and uncertainties, and often hopeless. Bright spots appear in the camaraderie of shared adversity and in the unexpected resilience of a particular patient. Guillame, not expected to live, gets hope in the form of an oxygen tank delivered by his brother’s motorcycle. Micheline, upon being told she is paraplegic and will never walk again, finally consents to a much needed amputation of her gangrenous lower leg. Robert, a lost child, is re-united with an uncle. Patient #361 gets the next available spot for air evacuation out to Florida. At night and on Sunday morning, the hymns of prayer and gratitude from the people in the adjacent tent city rise above the generator’s drone and float back to us through the warm heavy air. Arms are raised in supplication, and thanks are given for the “it could be worse” scenarios. Small groups of team members pray together. The scent of garlic and peppers being cooked mingles with the acrid smoke of burning trash and decay. After two weeks, word arrives that a plane is to take the first teams back to the US. Landing and equipment resupply schedules remain highly variable and uncertain. However, replacement teams are en route to relieve us. The transition is rapid but thorough, with shifts overlapping and orientations completed. We had been cocooned inside the surgical field hospital where we had arrived in darkness, isolated within and guarded by the 82nd Airborne, so it was a shock to transit through the main streets of the still-ruined city. Daily activity, as I had seen in my previous travels to Haiti, is returning. Strangers were helping each other and it is good.
Monday, 30 August 2010
Lee Jacobs, MD Fall 2010 - Volume 14 Number 3 When Haiti suffered one of the worst natural disasters ever to occur in the Western hemisphere, people from all over the world responded with donations of time and money. The first response was excellent—although at times overwhelming the fragile infrastructure—it was substantial and well intended. In the past The Permanente Journal (TPJ) has chronicled the experiences of health professionals responding to disasters, including the Katrina flooding1 and the Bande Aceh tsunami.2 Here, TPJ shares the stories of those who responded to the earthquake in Haiti and of those who support them; more stories will appear in the Winter 2011 issue. As important as these stories are, they are only the first chapter in the story yet to be told of Haiti’s recovery: The story of a country almost completely destroyed and the story of a people caring for each other and coping with their present difficult situation. The story yet to be written will be of the massive rebuilding and relocation that must be supported by people and finances from around the world. During my recent trip to Haiti with a health care team, I had several community leaders describe how immediately after the earthquake, groups from several countries and agencies provided food, living supplies and health needs. After the initial response, care from outside Haiti has markedly decreased and now there are only a precious few volunteer short-term teams, most faith-based, assisting the Haitians. Haitian leaders wonder: Have Americans forgotten their plight already? There is excellent ongoing support by several large agencies, but the challenge is just too great to meet the basic living needs of the Haitians. The destruction in Haiti is more widespread and devastating than imaginable. Having been part of a medical relief team in Bande Aceh, I have seen destruction and the plight of displaced people. Although the challenges in Haiti are quite different, it is my opinion that the long-term relief needs in Haiti will actually be greater than Bande Aceh. Living conditions for most Haitians were bad before the earthquake, now the conditions are unspeakable. Thousands of Haitians are living in tents creating clusters that look like refugee camps. Fortunately, large-scale disease outbreaks have been avoided because international agencies have provided clean water and scores of port-a-potties. Tent life is awful. Several Haitians I know who are living in tents tell me of the difficulties of their present living conditions, especially during the heavy rains of May when water would flow through the floors of their tents. One friend of mine lives in a tent with 15 family members. People are hungry. Initially, rice and beans were delivered, now only rice is being made available. Without jobs, many walk aimlessly around these camps. Finally, there are no regular communications from the Haitian government. Nobody knows what to expect. I’m certain talented people at the United Nations, World Health Organization and US Agency for International Development are making plans to help the Haitian people. InterAction, a coalition of aid organizations, planned to divide their available funds for immediate relief and for long-term rebuilding.3 It can only be assumed that holding funds in reserve must reflect the belief that no further major inflow of relief funds is expected. If that is in fact the case, then the overall funds available will be tremendously inadequate. The funds donated for Haiti relief in the first 4 months was $1.3 billion, which is significantly less than the donations in the first 4 months to either 9/11 ($2.3 billion) or Katrina ($3.4 billion).4 Several major needs over the next decade will include: orphan care, medical and dental care, optical support, microenterprise development, and, of course, light and heavy construction. People and money will be badly needed for years to come. So What Can Be Done? First, the extent of this ongoing disaster and the immediate needs of the Haitian people must return to the awareness of the world, especially those of us in North America. Champions are needed to advocate for the Haitian people, beginning with President Obama and then others who can influence Americans, such as celebrities. Second, major funding far in excess to what has already been donated is needed. Giving must be considered an ongoing need and not an isolated fundraising event. I remember the time when the tragedy of the African AIDS epidemic eventually made such an impact on the world that we started to see regular fundraisers, documentaries, and other ongoing reminders of the needs of the African continent. The living conditions of the Haitian people need to be raised to a similar level of awareness. Finally, we must make certain that some of our erroneous assumptions do not blunt relief responses. The history of corruption in the Haitian government doesn’t change the need. Past living conditions do not make current conditions any more tolerable: the majority of Haitians are living in great uncertainty and in much poorer living conditions. The Haitians are a wonderful people, a highly literate people, a caring people. Now they are a people in need. How would you answer the question asked by the Haitian leaders? Have we already forgotten them? References 1. Assisting hurricane evacuees in Houston and Louisiana. Perm J 2006 Fall;10(3):59-61. 2. Beekley S, editor. Permanente and the tsunami relief efforts—one year later—the volunteers’ stories: a journal. Perm J 2005;9(4):72-82. 3. Moore MT. Haiti relief less than Katrina, 9/11 [monograph on the Internet]. McLean, VA: USA Today; 2010 May 13 [cited 2010 Jul 28]. Available from: www.usatoday.com/news/sharing/2010-05-13-haiti-donations_N.htm. 4. Parker S. Comparing contributions [graph on the Internet]. McLean, VA: USA Today; 2010 May 13 [cited 2010 Jul 28]. Available from: www.usatoday.com/news/sharing/2010-05-13-haiti-donations_N.htm.
Physician-Assisted Suicide and Euthanasia: Can You Even Imagine Teaching Medical Students How to End Their Patients’ Lives?
Wednesday, 21 December 2011
J Donald Boudreau, MD Fall 2011 - Volume 15 Number 4 http://dx.doi.org/10.7812/TPP/11-099 Abstract The author has provided a full-text PDF translation in French. Suicide assisté et euthanasie: Pouvez-vous même imaginer qu’on enseigne aux futurs médecins comment mettre fin à la vie de leurs patients? The peer-reviewed literature includes numerous well-informed opinions on the topics of euthanasia and physician-assisted suicide. However, there is a paucity of commentary on the interface of these issues with medical education. This is surprising, given the universal assumption that in the event of the legalization of euthanasia, the individuals on whom society expects to confer the primary responsibility for carrying out these acts are members of the medical profession. Medical students and residents would inevitably and necessarily be implicated. It is my perspective that everyone in the profession, including those charged with educating future generations of physicians, has a critical interest in participating in this ongoing debate. I explore potential implications for medical education of a widespread sanctioning of physician-inflicted and physician-assisted death. My analysis, which uses a consequential-basis approach, leads me to conclude that euthanasia, when understood to include physician aid in hastening death, is incommensurate with humanism and the practice of medicine that considers healing as its overriding mandate. I ask readers to imagine the consequences of being required to teach students how to end their patients’ lives and urge medical educators to remain cognizant of their responsibility in upholding long-entrenched and foundational professional values. Humanism If one accepts the definition of humanism as “a deep-seated personal conviction about one’s obligation to others, especially others in need,”1 its importance to medicine becomes incontestable. The literature is increasingly attentive to the roles of humanism in clinical practice.2 In spite of the airtime devoted to the topic, little heed seems to have been paid to an issue, waiting in the wings, with the potential to reverberate at the very core of humanism in medicine. The issue is euthanasia. When I use the term euthanasia in this commentary, I am referring to “physician-inflicted death.” In other words, I am asking the reader to consider a situation in which the physician is prepared to administer a lethal injection to a legally and factually competent patient who has given informed consent to the act. In many respects physician-assisted suicide raises many of the same ethical and professional issues as euthanasia because in both cases the physician is complicit in the patient’s death. There is extensive literature on the physician-assisted suicide debate. Proponents argue that physician-assisted suicide acknowledges the primacy of personal autonomy, promotes human dignity, and may represent a deeply humanizing act. Opponents raise the specter of the slippery slope, appeal to the notion that physicians must maintain an absolute repugnance to killing, and point out that autonomy and self-determination are rarely pressing concerns once people actually find themselves at the end of life.3 This essay does not offer new empirical findings or a reconfigured conceptual framework for the debate. Rather, it anchors the dialogue explicitly in the educational context—a context in which there is a paucity of commentary on the interface of euthanasia with pedagogy. This contentious issue is not exclusively one of axiology. Pedagogic considerations are important. Regardless of which side of the argument one stands, an analysis of possible consequences on the professionalization of medical students and residents must not be neglected. It is widely recognized that clinical educators contribute more to students’ development than the acquisition of new knowledge and skills; they transmit values and participate in the forging of professional identities. They are “professionalizers.” Collectively, they instill, insinuate, and instantiate a way of seeing, thinking, acting, and being in the clinical world. The socialization and formative process is powerful and pervasive; it leads inevitably to clashes for influence over the hearts and minds of learners. It is thus not surprising that a 2008 review on the teaching of humanism emphasized the importance of role-modeling of reflection and focused mentorships.4 Students are required to delve into many issues that are permeated with personal values and situated within belief systems. Controversies such as abortions, reproductive technologies, alternative and complementary medicine—all of these and many more—can readily challenge entrenched explanatory models and worldviews. To that list has now been added the “right to a dignified death.” Right to a Dignified Death Discussion of this topic has become prominent in the public squares of many communities. Two recent examples are the Death with Dignity Act in Washington State in the US and bill C-384 that was before the Canadian federal government in 2010. The latter, if enacted, would have legalized euthanasia, stating, “A medical practitioner does not commit homicide if he or she aids a person to die with dignity … .”5 It was debated in the parliament—and defeated. Whether or not it is considered part of the formal curriculum, the topic of dying with dignity—its definition(s), clinical correlates, scope, access, moral dimensions, and political overtones—has become a salient feature of the ecology of medical schools. Euthanasia In Western societies—often described as secular, pluralistic, liberal, and tolerant—there is a predilection to equating assisted suicide with ensuring a “good” death. In contrast, for some members of the medical profession, a more apt synonym might be assisted self-murder. A source of conflict may be the word euthanasia. Some clinicians, frustrated with lack of semantic clarity, have recommended that it be abandoned.6 Its meaning in English has evolved. The Oxford English Dictionary defines the noun as “a gentle and easy death.”7 The concept of euthanasia has fluctuated since it was used in writing by Suetonius, the Roman historian. In the 19th century, it came to be understood as “the care of the dying.” An 1826 Latin manuscript referred to medical euthanasia as the “skillful alleviation of suffering.”8 The physician was expected to provide for conditions that would facilitate a gentle death and was admonished: “… and least of all should he be permitted, prompted either by other people’s request or his own sense of mercy, to end the patient’s pitiful condition by purposefully and deliberately hastening death.”8 Euthanasia made reference to a state—a condition—at the time of death. Recently, it has acquired the notion of performance—the act of inducing a gentle and easy death. Mirroring this evolution, the words euthanize and euthanatize have been coined and are newcomers in our lexicon. The first sample sentence given by the Oxford English Dictionary to illustrate the use of the transitive verb euthanize dates to 1975.7 The notion of physician aid in dying has accreted to the word euthanasia through time; it stands at a considerable distance from the word’s original meaning and intention. Given the plasticity and adaptability of language, one can foresee the eventual appearance of a new noun, one that will represent the individual who performs acts of euthanasia. I refer here to that person as a “euthanatrician.” The term euthanizer has been used.9 Other neologisms such as euthanologist or euthanasist may eventually prevail. Few would argue against a death characterized by gentleness. The comments that follow thus revolve around euthanasia cloaked in its contemporary connotation, that of hastening death—death where, when, and in the manner the patient chooses, within the customarily accepted bounds of unremitting suffering, terminal illness, and informed and voluntary consent. It has been referred to as “requested death.”10 To advance the discussion, I am prompted to consider medicine’s relation with the other end of the life cycle—birth. The paper by Cane refers to “euthanasia” as “obstetrics of the soul.”8 Although there are obvious limitations to the analogy of euthanasia as delivery of the soul, it may be useful in illustrating a critical distinction. It is self-evident that an obstetrician may facilitate and be a witness to birth; however, an obstetrician can now also induce labor and delivery. Similarly, the euthanatrician could, on one hand, limit the range of action to facilitating care of the dying patient or, on the other hand, extend the scope of interventions by applying strategies to induce death. The obstetrician has a relationship to life, just as our imagined euthanatrician might have to death. Education of a Medical Act What might the adoption of euthanasia as a medical act bring into medical education, and how might it influence the nurturing of humanism? The literature is sparse concerning this issue. One can ferret out empirical studies conducted to understand the perspectives of physicians.11,12 The attitude of medical students toward euthanasia has been aptly described.13,14 Investigators in locations where physician-assisted suicide has been legalized have chronicled the experiences of professionals and institutions.15,16 Not surprisingly, there are articles on the teaching of euthanasia in veterinary medicine.17,18 However, consideration of consequences for medical education is largely absent from the literature. With the goal of consciousness-raising, I will suggest what these may consist. Medical schools, which are expected to be socially responsive, would have to respond with targeted initiatives. Although one might anticipate residency education to be more directly affected, impacts throughout the education continuum can be anticipated. Modules in euthanasia would be proposed, and notwithstanding traditional arguments that curricula are overburdened with content, an academic home would be found. The process would necessitate the identification of specific objectives in knowledge, skills, and attitudinal domains. The call for integration of basic sciences (eg, physiology of dying) with clinical concerns (eg, advanced communication-skills training in end-of-life talk) would be inevitable. There would be negotiations between academic units for leadership, and bioethicists would be commandeered into service roles. Ethicists would surely be in demand to help uncover moral boundaries and, as is evident in veterinary medicine, be called on to negotiate ethical tensions.19 Conceivably, internecine battles would erupt in certain institutions. Sources of conflicts and distress have already been outlined by a palliative-care team in a Swiss hospital.20 Diametrically opposed viewpoints, even between colleagues within the same medical specialty, have been recorded in the peer-reviewed literature.21,22 For competency-based programs, there would be an impetus to clarify “competency” in euthanasia. Because this approach rests on a foundation of unambiguous, measurable, and enabling outcomes,23 the idea of proficiency in expediting death would have to be explored. Leaders in undergraduate education would have to decide whether to accept it as a core competency and resolve whether medical students’ responsibility should be confined to the communicative and decision-making process with patients and families or whether it should include procedural skills. If it were considered most appropriate to limit medical students’ involvement to ethical discussions, clinical supervisors could in theory deploy emergent clinical practice guidelines. An eight-step approach of potential use to physicians facing requests for physician-assisted suicide has already been published.24 One can foresee a need for addressing issues such as assessment of performance, level of competency in euthanasia based on levels of training, graded responsibility for resident teaching in the skill of “euthanizing,” and requirements (eg, numbers of procedures observed and/or performed) for maintenance of competence. As unimaginable as these notions may appear, euthanasia could not—indeed should not—be exempt from standard discussions attendant to any new curricular objective. Parallel to the deployment of modified educational programs, the clinical discipline would become increasingly complex. It is hardly far-fetched to envision the emergence of evidence of best practices. Accreditation bodies would likely be subject to efforts by various stakeholder groups to formulate additional standards relating to physician aid in hastening death. Developments would inevitably mirror the experiences of academic institutions with respect to the issue of . For example, the Accreditation Council for Graduate Medical Education has set forth guidelines mandating that residencies in obstetrics and gynecology must include learner experiences in induced abortions.25 The Association of Professors of Gynecologists and Obstetricians has listed abortions as a core objective for medical students.26 A long-established volunteer group, Medical Students for Choice, has successfully lobbied academic centers to expand abortions training.27 A New Corpus? Finally, as preposterous as it may appear at first glance, credentialing bodies might be pressured to confer recognition on a new corpus. Given the unceasing pressure for specialization, the profession might witness the birth of a new discipline. I refer to it here as “euthanatrics.” The notion of a new specialty for assisting in death is not an original concept; in an argument in favor of conferring the responsibility for euthanizing on the legal profession, it was called “legistrothanatry.”28 Laws legalizing euthanasia and/or physician assistance in dying have been enacted in the US in Oregon, Washington, and Montana and in the Netherlands and Belgium. Early reports of the impacts of evolving jurisprudence have identified areas of concern. One account examining the transcript of a conversation between a patient requesting assisted suicide and her physician identifies lacunae in the consent-seeking process.29 A formal assessment by the Dutch Ministries of Health and Justice of their 2002 law recommended that “[p]hysicians should be further educated on the effects and side effects of morphine and benzodiazepines so that they can select the correct medicines if life termination is the envisaged objective”15 (emphasis added). In the report’s “Quality Improvement” section, the regional euthanasia review committees are described as having the option of inviting physicians whose adherence to standards of due care are deemed lacking for an “instructive talk.”15 Although this is a somewhat overbearing reformulation of formative feedback, it does presage quality-assurance issues that the profession will be required to address if obliged to prepare itself for delivery of services related to physician-assisted suicide. Is this trajectory toward euthanatrics desirable? Do we wish to embrace a discipline that has the induction of death as one of its defining clinical acts? How would undergraduate programs, such as the one I am affiliated with, currently renewing itself on the assumption that the primary mandate of medicine is healing,30 reconcile its foundational premise with the goal of physician-assisted suicide? As much as the original conception of euthanasia—the skillful relief of suffering—is harmonious with an emphasis on healing, its evolving meaning is (arguably) in conflict. I would predict that many physicians would recoil at the prospect of being called on to become authentic role models for euthanatricians. Attempts at integrating “intentional hastening of death” into the clinical methods taught in many schools might call their cohesive force into question. For example, at our school two of the desired behavioral characteristics of the healer include “presence” and “accompaniment.”31 In the context of physician-assisted suicide, would these attributes then come to be seen as facultative or of secondary importance? To accept euthanatrics and much of what it entails (eg, the obligation to select the correct medication for life termination) as core content risks undermining the curriculum’s conceptual framework. This development has the potential to erode commitments to whole-person care, which many believe includes the potential for a transformational, perhaps transcendental, movement toward personal integrity—even in the face of death. Healing and Euthanizing—Miscible? My personal belief is that healing and euthanizing are simply not miscible. I believe it to be expressly true in medical schools, which are crucibles of professional identity formation. However, it must be acknowledged that divergent viewpoints exist. For example, it is intriguing that the institutional motto for the medical school of the Oregon Health & Science University is “Where healing, teaching and discovery come together.”32 Though it is located in a US state with legislation that permits physician-assisted suicide, and presumably the school’s programs have addressed issues related to Oregon’s Death with Dignity Act, it continues to fly the banner of healing. This situation points either to the existence of alternative perspectives or to conflicting values (the latter perhaps unrecognized or ignored). The presence of ethical tensions within hospices in Oregon, as they face the challenge of respecting the Death with Dignity Act while simultaneously striving to adhere to their institutional values, has already been documented.33 It is therefore not a flight of fancy to speculate that similar tensions may be experienced by members of the academic community in that jurisdiction. Regardless of one’s personal beliefs, it is incumbent on medical educators to consider the consequences of teaching euthanasia—that is, as the word is understood today—of teaching an act intended to hasten death. Surely, all readers would agree that we need to teach eu-thanasia, euthanasia as described in 1826: compassionate, competent, and consummate care of the dying. A more debatable point is: To what extent should we, as a profession inextricable from humanism, travel down the road toward euthanatrics? Responses to this question must take into account both professional and personal values. Undeniably, physicians endorsing pro-euthanasia legislation have honorable intentions, motivated by humane considerations grounded in prima facie ethical principles such as respect for dignity (even though there are deeply conflicting views on what such respect requires). Whatever the views in this regard, it is nonetheless plausible that proponents of euthanasia may be blind to unintended harmful consequences, especially at institutional and societal levels. What would legalizing physician-assisted suicide do to the institutions of medicine and law, to the medical profession, and to fundamental societal values, in particular respect for each individual human life and human life in general? Ethicist Margaret Somerville has argued that in secular societies, medicine and law are the principal carriers of these values. She describes the medical profession and its related institutions as “value-creating, value-carrying and consensus-forming for society as a whole”34 As a consequence, it should be obvious that we share a profound obligation to consider the implications of our actions on this value-laden system. In the case of legalized physician-mediated suicide, harm may be done to the profession and to those charged with replenishing its membership. A physician’s assistance in suicide can indeed be construed as helping the patient: helping in the sense of being an ally in the patient’s quest to fulfill personal goals, or helping by buttressing individual autonomy. However, there are also features of such action that can be qualified as harmful: harmful by sowing confusion in trainees about the conceptual core of traditional clinical methods, or harmful by eroding respect for absolute moral values such as “do not kill.”35 The phrase primum non nocere is greatly cherished by the profession. It is the first “golden rule” that we transmit to our junior colleagues. Another related but less well known phrase, used by medical luminaries such as Thomas Syndenham36 and James Makittrick Adair37 is juvantia et laedenti. It is derived from the Latin verbs iuvo (“help”) and laedo (“hurt”). I propose that in our deliberations about euthanasia, we keep in our collective imagination the notion of juvantia et laedentia: “things that [can] help and things that [can] harm.” Disclosure Statement The author(s) have no conflicts of interest to disclose. Acknowledgments I thank my colleagues at the McGill Centre for Medical Education and Abraham Fuks, MD, and Gordon Crelinsten, MD, for their advice and enthusiastic support. I am grateful to Professor David Williams for his review of Latin translations. I am especially beholden to Professor Margaret Somerville for her scholarly criticism of the manuscript, from its inception, and for her assistance in crafting an appropriate title for the paper. I also acknowledge the reviewers of The Permanente Journal for their insightful commentary. Very importantly, I am grateful for the generous financial support of the Arnold P Gold Foundation and request that readers note that the opinions expressed herein are my personal views and not necessarily reflective of the perspectives of the foundation, its staff members, affiliates, or benefactors. Katharine O’Moore-Klopf, ELS, of KOK Edit provided editorial assistance. References 1. Cohen JJ. Viewpoint: linking professionalism to humanism: what it means, why it matters. Acad Med 2007 Nov;82(11):1029–32.2. Miller SZ, Schmidt HJ. The habit of humanism: a framework for making humanistic care a reflexive clinical skill. Acad Med 1999 Jul;74(7):800–3.3. Cook M. From a doctor who changed her mind [Web log on the Internet]. Sydney, Australia: MercatorNet—New Media Foundation, Ltd: Careful!; 2011 Apr 9 [cited 2011 Sep 28]. Available from: www.mercatornet.com/careful/view/8965.4. Stern DT, Cohen JJ, Bruder A, Packer B, Sole A. Teaching humanism. Perspect Biol Med 2008 Autumn;51(4):495–507.5. Bill C-384. Parliament of Canada, Bill C-384, No: 40-2, Hansard-57 (May 13, 2009).6. Kuiper M, Whetstine LM, Holmes JL, et al. Euthanasia: a word no longer to be used or abused. Intensive Care Med 2007 Mar;33(3):549–50.7. Oxford English Dictionary [dictionary on the Internet]. Oxford, UK: Oxford University Press. © 2011 [cited 2009 Dec 10]. Available from: www.oed.com.8. Cane W. “Medical euthanasia”; a paper, published in Latin in 1826, translated and reintroduced to the medical profession. J Hist Med Allied Sci 1952;7(4):401–16.9. Veatch RM. The impossibility of a morality internal to medicine. J Med Philos 2001 Dec;26(6):621–42.10. McInerney F. “Requested death”: a new social movement. Soc Sci Med 2000 Jan;50(1):137–54.11. Curlin FA, Lawrence RE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med 2007 Feb 8;356(6):593–600.12. Peretti-Watel P, Bendiane MK, Galinier A, et al. French physicians’ attitudes toward legislation of euthanasia and the ambiguous relationship between euthanasia and palliative care. J Palliat Care 2003 Winter;19(4):271–7.13. Clemens KE, Klein E, Jaspers B, Klaschik E. Attitudes toward active euthanasia among medical students at two German universities. Support Care Can 2008 Jun;16(6):539–45.14. Karlsson M, Strang P, Milberg A. Attitudes toward euthanasia among Swedish medical students. Palliat Med 2007 Oct;21(7):615–22.15. Gevers S. Evaluation of the Dutch legislation on euthanasia and assisted suicide. Eur J Health Law 2007 Dec;14(4):369–79.16. Ganzini L, Harvath TA, Jackson A, Goy ER, Miller LL, Delorit MA. Experiences of Oregon nurses and social workers with hospice patients who requested assistance with suicide. N Engl J Med 2002 Aug 22;347(8):582–8.17. Cohen-Salter C, Folmer-Brown S, Hogrefe KM, Brosnahan M. A model euthanasia workshop: one class’s experience at Tufts University. J Vet Med Ed 2004 Spring;31(1):72–5.18. Martin F, Ruby KL, Deking TM, Tauton AE. Factors associated with client, staff, and student satisfaction regarding small animal euthanasia procedures at a veterinary teaching hospital. J Am Vet Med Assoc 2004 Jun 1;224(11):1774–9.19. Morgan CA, McDonald M. Ethical dilemmas in veterinary medicine. Vet Clin North Am Small Anim Pract 2007 Jan;37(1):165–79; abstract x.20. Pereira J, Anwar D, Pralong G, Pralong J, Mazzocato C, Bigler JM. Assisted suicide and euthanasia should not be practiced in palliative care units. J Palliat Med 2008 Oct;11(8):1074–6.21. Hamilton NG, Hamilton CA. Competing paradigms of response to assisted suicide requests in Oregon. Am J Psychiatry 2005 Jun;162(6):1060–5.22. Ganzini L. Physician-assisted suicide. Am J Psychiatry 2006 Jun;163(6):1109–10; author reply 1110.23. Albanese MA, Mejicano G, Mullan P, Kokotailo P, Gruppen L. Defining characteristics of educational competencies. Med Educ 2008 Mar;42(3):248–55.24. Emanuel LL. Facing requests for physician-assisted suicide: toward a practical and principled clinical skill set. JAMA 1998 Aug 19;280(7):643–7.25. ACGME Program Requirements for Graduate Medical Education in Obstetrics and Gynecology [monograph on the Internet]. Chicago: Accreditation Council for Graduate Medical Education; effective 2008 [updated 2011 Jul 1] [cited 2011 Sep 28]. Available from: www.acgme.org/acWebsite/downloads/RRC_progReq/220obstetricsandgynecology01012008.pdf.26. Epsey E, Ogburn T, Leeman L, Nguyen T, Gill G. Abortion education in the medical curriculum: a survey of student attitudes. Contraception 2008 Mar;77(3):205–8.27. Steinauer J, LaRochelle F, Rowh M, Backus L, Sandahl Y, Foster A. First impressions: what are preclinical medical students in the US and Canada learning about sexual and reproductive health? Contraception 2009 Jul;80(1):74–80.28. Sade RM, Marshall MF. Legistrothanatry: a new specialty for assisting in death. Perspect Biol Med 1996 Summer;39(4):547–9.29. Foley K, Hendin H. The Oregon report. Don’t ask, don’t tell. Hastings Cent Rep 1999 May–Jun;29(3):37–42.30. Boudreau JD, Cassell EJ, Fuks A. A healing curriculum. Med Educ 2007 Dec;41(12):1193–201.31. Boudreau JD, Cruess SR, Cruess RL. Physicianship: Educating for professionalism in the post-Flexnerian era. Perspect Biol Med 2011 Winter;54(1):89–105.32. Oregon Health & Science University School of Medicine [homepage on the Internet]. Portland (OR): Oregon Health & Science University; © 2001–2011 [cited 2010 Oct 1]. Available from: www.ohsu.edu/xd/education/schools/school-of-medicine/.33. Campbell CS, Cox JC. Hospice and physician-assisted death: collaboration, compliance, and complicity. Hastings Center Rep 2010 Sep–Oct;40(5):26–35.34. Somerville M. When doctors swear to do no harm, it is implied that they should take no lives [monograph on the Internet]. Toronto, Ontario, Cananda: The Mark; 2009 Nov 10 (updated 2010) [cited 2011 Oct 1]. Available from: www.themarknews.com/articles/655-why-euthanasia-is-bad-for-doctors.35. Pellegrino ED. Some things ought never to be done: moral absolutes in clinical ethics. Theor Med Bioeth 2005;26(6):469–86.36. Sydneham T. The works of Thomas Sydenham, MD.  Translated from the Latin edition of Dr Greenhill with a life of the author by R.G Latham. Birmingham (AL): Classics of Medicine Library; 1979. p 362.37. Adair JM. Commentaries on the principles and practice of physic. London: J Balfour, at Edinburgh . Farmington Hills (MI): Gale Eighteenth Century Collections Online; 2010.
From Tragedy, Opportunity—A New Beginning for Haiti and the Dominican Republic
Monday, 30 August 2010
John Freedman, MD Fall 2010 - Volume 14 Number 3 I went to Haiti in late January as a member of an Operation Rainbow (www.operationrainbow.org) surgical team which comprised both Kaiser Permanente (KP) and non-KP team members. As background, my own medical charity, Medical Exchange International (www.medicalexchangeintl.org), had partnered with Operation Rainbow in the past to provide anesthesia equipment for several surgical missions in the developing world. In Haiti, we had an opportunity not only to provide pulse oximeters and anesthesia supplies, but also to help out on the clinical front line. As an anesthesiologist with a background in medicine and critical care, I split my time about half and half between the operating rooms and the intensive care unit (ICU), both of which were intense and busy. Whereas I could write at length about what we did and how we coped with severely constrained resources, I want to focus this article on an important “epiphenomenon”: the catalytic action of the earthquake tragedy to create a new inflection point in the long history of Haiti-Dominican Republic relations. Although we experienced the startling devastation in Port-au-Prince when we went into the city to deliver a pulse oximeter, our clinical work took place entirely at the Buen Samaritano (or Bon Samaritain in French) makeshift hospital in the town of Jimani, one mile east of the Haitian-Dominican border in the Dominican Republic. Before the earthquake, the facility was a yet-to-open complex comprising a chapel, an orphanage, and a dental clinic. After the earthquake, the chapel and the orphanage were rapidly converted to hospital wards, and the dental clinic became our acute care venue including a 4-room operating suite. We estimated we had about 250 patients on site, almost all of whom were injured Haitian refugees. We did between 20 and 50 surgical cases a day in 4 converted dental consultation rooms. The vast majority of our surgical cases were orthopedic and plastics procedures, as expected. In our makeshift ICU, I cared for 5 to 10 patients on any given day, and we also opened up a perinatal ward when we suddenly found ourselves doing C-sections (if you build it, they will come …). The facility was staffed by volunteers from all over the world. We worked closely with our own superb Operation Rainbow orthopedic surgeons, including our mission lead Dave Atkin, MD, from San Francisco and pediatric specialist Chris Comstock, MD, from Corpus Christi, Texas, and with surgeons from around the US and around the globe. In the ICU, I worked closely with an excellent emergency/critical care team from Barcelona (and by closely I mean cross-covering to maintain 24/7 on-site care—the real thing). Nurses and pharmacists from all over the world worked together, and I remember being particularly touched when I saw a group of Israelis help an Arab team unload several tons of food that was brought in by the United Arab Emirates. All this is to say that there was a tremendous and truly inspiring internationalism—a deep humanism was in full bloom here. This leads me to my main point: I witnessed first-hand an extraordinary stepping-up-to-the-plate by the Dominican government and the Dominican people. From the moment we arrived, we saw that the Dominicans had dedicated their major international airport in Santo Domingo to international relief efforts. Because Haiti’s airports were marginally functional at best, this was crucial to the immediate relief efforts. The short aid corridor between the Dominican Republic border and Port-au-Prince was active 24/7 with an endless stream of trucks laden with food, water, tents, coal, firewood, blankets, medical supplies, and more from dozens of countries and with a very notable contribution from the Dominican Republic itself. For example, the Dominican Republic sent 15 mobile cafeterias serving 100,000 meals a day into Haiti. Santo Domingo Water Corporation sent dozens of tank trucks, each containing 2000 gallons of water. Estimates of total Dominican Republic aid for Haiti to date have exceeded $17 million, no small sum for a small island republic that is itself a developing nation. We witnessed the Dominican army conspicuously keeping the Dominican side of the relief corridor safe and functional until the United Nations (UN) Peacekeeping Force (which fortuitously had been in Haiti prior to the earthquake) took over on the Haitian side to assure the relief lifeline kept flowing. Thankfully, the Dominican authorities allowed thousands of Haitian refugees to cross the border eastward into the Dominican Republic to seek care in our emergency relief hospital and in other Dominican hospitals. At Buen Samaritano, I noted that many of the drugs we used, and a hefty component of the supplies we used such as oxygen masks, epidural kits, and IV catheters, came from the Dominican Republic. The Dominican personnel presence was huge, literally hundreds of Dominicans representing the Dominican Public Health Department (known by its Spanish acronym of SESPAS), the Dominican Food Aid Program, the Dominican Republic’s major emergency relief organization (known as URN for Unidad de Rescate Nacional), as well as Dominican representatives from countless humanitarian programs such as the Pan-American Health Organization (PAHO), US Agency for International Development, the UN World Food Program, and Ninos de las Naciones. The Dominican-based ARS Humano provided the trailers we used for our tuberculosis isolation ward and our spinal cord injury care unit. Dominican interpreters navigated the tricky Creole-French-Spanish language challenges for us. The Dominican government allowed US military transport choppers as well as those of several private US entities into their airspace to help us evacuate some of our most critically ill patients to the USNS Comfort hospital ship. The Dominican army was on-site day and night in Jimani, keeping us safe and keeping the peace amidst the influx of refugees. The Dominican charity Esperanza provided transportation and meals for our team. Last but certainly not least (from an anesthesiologist’s standpoint), the Dominican Red Cross filled our rapidly depleting oxygen tanks every few days—life-giving assistance, literally and figuratively. This Dominican largesse would be worthy of praise and worth relating in and of itself. But what makes it all the more heartening and extraordinary, in fact truly “game-changing” if one can apply that adjective to international relations, is that it opens a new era in the long history of tense and violent relations between these two neighboring nations. Columbus landed on the island of Hispaniola on his first voyage to the New World in 1492 and promptly claimed it for Spain. But it did not take long for the French to wrest half of the island from the Spanish, thus establishing two separate but equal colonies with political, cultural, and economic disparities that persist to this day. The Dominicans still resent a period of Haitian occupation from 1822 through 1844, though some Haitian scholars insist that the Haitians were “invited” in to ensure abolition of slavery in post-Spanish Dominica. Little known to most outsiders, the Dominicans ultimately had to win their independence not from Spain but from their Haitian overseers. The Dominicans repaid the favor in kind with a brutal retaliatory massacre of over 20,000 Haitians by the despotic Trujillo regime in 1937. To make matters worse, the persistent sharp contrast in prosperity, and some say an inherent racism in the Dominican Republic—have continued to fuel the fires of hatred, fear, and mistrust. The Dominican Republic ranks a respectable 90 out of 182 countries on the UN’s Human Development Index, a composite measure of wealth, health, and educational indices. Haiti comes in at a miserable 149, just a hair above Sudan. The Dominican economy has long profited from cheap Haitian labor: more than 90% of the country’s sugar workers are of Haitian origin. The average Dominican can expect to live into his or her 70s, whereas 61 is the average life expectancy for Haitians and this is now surely reduced as a result of the earthquake. All of this makes it understandable that Haiti rejected an offer of over 3000 Dominican troops which was tendered the week after the quake with the intent of assisting the UN battalion in securing the aid corridor in eastern Haiti. To many Haitians that offer was similar to the idea of having Russian “peacekeepers” come into the Ukraine. But that long and mostly ugly relationship which has prevailed for centuries may now be coming to an end. The opening was there after January 12, 2010, and the Dominicans took it. Some say it is in their interest to prevent a “failed Haiti” (if that is not already the case) and that the Dominicans are just pragmatists working to stem the tide of refugees. No doubt there is, as always, an element of public relations at work here and in fact the Dominicans have received some good press for their efforts. But having seen it in action, on the front lines, the Dominican effort by my observation is more than pragmatic and more than PR. It is huge and robust, carefully thought out, and thoroughly genuine. Time will tell if this represents a true turning point and ushers in a new era for these two countries that uneasily share an island in our own backyard. Haiti’s tragedy is the costliest natural disaster in recorded history according to the Inter-American Development Bank. But as with any great tragedy, there is great opportunity inherent in the rebuilding phase, and the Dominicans seem to have grasped that. The Dominican effort and the healing of Haiti-Dominican Republic relations may turn out to be a very major ingredient in the formula for Haiti’s long-term (and I use the word advisedly) reconstruction.
Disaster Readiness Tips Steeped in My Time in Haiti
Monday, 30 August 2010
Vivian Reyes, MD Fall 2010 - Volume 14 Number 3 March 10, 2010 After leaving Haiti and returning to my life in the Bay Area, I felt as if I returned to another world. The orderly rows of lights as I descended into Miami airport were a stark contrast to the haphazard state of Port-au-Prince. There are few similarities between the scene I left and that to which I returned. But, what if the same tragedy happened in our own country? I learned many lessons during my five-week mission to Haiti, and will share a few of them here so that we can be better prepared to respond to future events on our own soil. We have all heard the statement, “Communication is always the biggest problem during a disaster.” In retrospect, I realize I never truly understood the implications of this statement until now. When I arrived in Haiti, local phone coverage was intermittent, at best. Even when calls went through, the reception was often so bad that it was more frustrating than helpful. Satellite phones were unreliable and generally unusable. Surprisingly, my iPhone seemed to send and receive text messages and e-mail without much problem. Although this was good for simple communications, texting proved too time-consuming, and time was a luxury I did not have. Coordinating relief operations via any electronic means proved to be difficult, and face-to-face communication became invaluable. As a lesson learned, I would urge everyone to become adept at text messaging so that you are better prepared for times when communication is limited. I heard many stories of trapped victims texting their friends and family. Through this communication alone victims were rescued. Although helpful, the time delay and content limits of text messages made me realize how important it is to be self-sufficient and decisive during the aftermath of a disaster. “Be prepared,” is another commonly heard statement in disaster readiness. Before I left for Haiti, I read The Unthinkable, Who Survives When Disaster Strikes—and Why by Amanda Ripley.1 She describes human response to disasters and discusses ways in which we can react better to such situations. Ms Ripley writes that the people around you during a disaster are the critical component to whether you survive it. In Haiti, several days passed before international aid arrived. Before then, the Haitians could rely only on those around them. Preparation makes a difference not only in how effective the response is, but ultimately in how many lives are saved. As a lesson learned, each and every one of us should think of how we will help our neighbors during a disaster. The more times you run through scenarios in your mind or in a drill, the better you will react in a real event. Now when you hear “Be prepared,” don’t just consider the supplies you might need, but also think of what role you will play in the hours or days after a disaster without communication. The next lesson is one that became a hot topic after Hurricane Katrina: “Crisis care guidelines,” previously: “crisis standards of care” or “alternate standards of care.” During the management of disasters, resources are limited, and patients will not be able to get the same quality of care that they would get during an average, non-disaster-stricken time. Crisis care guidelines were developed to help medical professionals navigate through these difficult times. For instance, if there are too few ventilators for patients who require one, which patients get the ventilators? Similarly, mass casualty triage is another form of crisis care management. In Haiti, the baseline country standard of care was generally not to intubate critically ill patients. As disaster responders it is imperative that we have a grasp of the current standards of care. What also became apparent is that these standards change rapidly depending on the resources available. For instance, when the German Red Cross set up a tent hospital 15 minutes away from our clinic with ventilator and intensive care unit capability, our clinic’s standards of care changed. Similarly, when the hospitals around us filled up and stopped taking critically ill patients, our standards changed. This occurred day by day, and sometimes hour by hour. This accentuated the fluid nature of disaster work, and is something that should be considered when we consider crisis care guidelines in our own hospitals and within our own communities. Finally, the last lesson is organization. In a blog, I mentioned the chaos in Haiti during the emergency response. This is not unique to Haiti, and is expected after any catastrophic event. Whereas I seem to thrive in chaotic environments, I also recognize the importance of trying to minimize chaos to improve efficiency and productivity. During visits to several different hospitals in Port-au-Prince, I witnessed American physicians, nurses, and medical support volunteers arriving unannounced and offering their expertise. Similarly, many donors sent large quantities of supplies to various hospitals in Haiti. Although these gestures are very much appreciated, the proper coordination of these activities would allow for better productivity of volunteer medical staff and better management and use of supplies. Similarly, better coordination would allow for better safety, security, and planning. The lesson learned from this is that if anyone is interested in participating in future disaster efforts, signing up now to be a health care volunteer is the best approach. You may do this through your hospital, www.kpcares.org (available to any Kaiser Permanente employee nationally), your county or state professional associations, or various nongovernmental organizations. If you wish to donate money or supplies to future relief efforts, donate to organizations that you trust now so that they can appropriately coordinate their efforts and be prepared and ready for the next disaster. If everyone followed these simple steps, I am convinced that the level of chaos would be more manageable and the efficiency of response efforts would improve. The people of Haiti may seem like they live in a different world, but as Amanda Ripley describes in her book, “Fear is a primitive response.” Humans, no matter where they are, will have the same fear response. If we stand ready for disaster, we will fear it less, and we will come together and manage it. Let us learn from this tragedy and prepare ourselves, so that this historic tragedy will not repeat itself. Thank you for your tremendous support. Reference 1. Ripley A. The unthinkable, who survives when disaster strikes—and why. New York: Crown; 2008.
Disaster Medical Relief— Haiti Earthquake January 12, 2010
Monday, 30 August 2010
Disaster Relief Organization Hernando Garzon, MD Fall 2010 - Volume 14 Number 3 Our collective organizational response and my personal experience in Haiti were different from any prior disaster response in which I have been involved. I have had the fortune to be involved with Kaiser Permanente (KP) volunteers and disaster relief efforts during large-scale disasters since we sent the first teams to Southeast Asia after the 2004 tsunami. In addition to the more than 40 people we sent in relief efforts to Sri Lanka and Indonesia for the tsunami, multiple KP physicians volunteers traveled to Kashmir after the earthquake in Pakistan in late 2005 to work as part of Relief International’s program. KP physicians collaborated with the Department of Health and Human Services to provide medical care in the Gulf Coast after Hurricane Katrina in 2005. Another KP physician and I volunteered with Doctors Without Borders after postelection violence broke out in early 2008. In the years since we first sent volunteer disaster medical relief workers to provide aid after the tsunami, many changes have occurred within KP’s Global Health and volunteer programs that have resulted in better support for this distinctly important and rewarding work. Under the sponsorship of The Permanente Medical Group leadership, we have: Created a framework to support physician volunteerism by coordinating the efforts of the Assistant Physician-in-Chief of Health Promotion, Community Benefit, Public Affairs and dedicated physicians at each facility via the KPCares program. Developed relationships with multiple medical relief organizations including Doctors Without Borders, Relief International, International Medical Corps, Medshare, and others. Created a KP National Volunteerism Web site (www.KPCares.org) for all employees of the Northern California, Mid-Atlantic and Georgia Regions. This enables all KP staff to both post and search volunteer opportunities. In addition, it allows staff to register in a comprehensive disaster response database that was used, with the invaluable support of Program Office’s Community Benefit, to identify skilled clinicians immediately after the Haitian earthquake. This database continues to serve as a resource should a disaster occur in our own local communities. Developed and delivered several Continuing Medical Education courses on the topics of disaster medical relief and humanitarian medical work in austere environments. In total, these efforts created a KP response to the Haiti earthquake unlike any response we have mounted in the past. A small number of KP staff traveled to Haiti with organizations they had identified on their own immediately following the earthquake, or reconnected with relief organizations with which they had worked in the past. The greatest impact however, was via KP’s contribution as the main contributor of medical personnel and logistical support to Relief International’s disaster response (see www.RI.org). We used the KPCares.org Web site to gather information on interested volunteers, and in the first month alone sent over 30 physicians and nurses to Haiti with Relief International. In the first few weeks we staffed a team of emergency physicians, nurses, and medics who largely delivered trauma care. Our subsequent waves of volunteers ran the spectrum of Family Medicine, Pediatrics, Ob/Gyn, Internal Medicine, and Mental Health. They represented the Regions of Northern California, Southern California, and the Mid-Atlantic. All donated at least two weeks of their time with the support of their departments and colleagues. We are now also involved with the Relief International long-term capacity building project in Haiti, and contribute about two medical volunteers at a time for their efforts to run five community clinics, staffed primarily by Haitian medical personnel. Our volunteers provide teaching and educational support for the Haitian national staff. On a personal level, as intense and chaotic as the first few weeks of the relief effort were, I was deeply inspired by the successful development of our new capability to respond. KP now has the ability to mobilize our volunteers and their expertise to assist in future humanitarian disasters. I could not be more proud to work for an organization that supports volunteer and community service efforts in such a comprehensive and systematic way. There is no greater reward than to be of service in a time of need in a way that honors the principles of our professional commitment to medicine.
Bridging Physician-Patient Perspectives Following an Adverse Medical Outcome
Monday, 19 September 2011
Mark Montijo, PhD; Kathleen Nelson, RN, MPA; Mark Scafidi, JD; Dave St Pierre, MHROD; Dorothy Tarrant, LCSW, MPA; Jocelyne Vistan, MA; Maureen Whitmore, MA Fall 2011 - Volume 15 Number 4 “Human error and systems conditions periodically align and combine to contribute to unanticipated adverse outcomes for patients. What is most important is the manner in which we handle these adverse outcomes. Patient safety and clinician welfare will be best served if we are honest about unanticipated adverse outcomes with our patients, open with our colleagues and ourselves, and able to handle such occurrences with sympathy and empathy for our patients and our colleagues.” —Kaiser Permanente’s Statement of Principle, from the Implementation Guidelines for Communicating Unanticipated Adverse Outcomes, October 20021 During the course of physician-patient interactions in today’s increasingly complex health care environment, conflict inevitably arises. Advances brought on by modern medical technology–effective drugs, accurate tests and diagnoses, physiological processes mapped and documented in electronic medical records–have raised the bar for consumer expectations of health care professionals. Physicians are held to very high standards, sometimes leaving them and their patients ill-equipped to cope with medical complications and unexpected outcomes. In the aftermath of an unanticipated adverse outcome, how health care professionals deal with errors has gained greater importance and attention, and has led to the creation of Kaiser Permanente’s (KP) HealthCare Ombudsman/Mediator (HCOM) program in 2003.2,3 (See sidebar: HealthCare Ombudsman/Mediator Program: Overview.) HealthCare Ombudsman/Mediator Program: Overview The HealthCare Ombudsman/Mediator (HCOM) Program was established within Kaiser Permanente (KP) in 2003. There are 28 HCOMs serving KP in both Northern and Southern California. While the primary HCOM focus is to resolve patient disputes regarding the quality of care, for which there is over a 90% satisfaction rate among clinicians and staff, a significant time (hundreds of hours) is spent educating physicians and clinicians how to: communicate unanticipated adverse outcomes or medical error better listen and appreciate a patient’s perspective of an adverse event facilitate a sincere apology when warranted re-establish clinician-patient trust through transparent communication regarding medical care. The HCOM program is but one aspect of a fully integrated approach in handling unanticipated adverse outcomes. This approach also includes the Situation Management Team (SMT), Medical Legal and Early Resolution Payments (ERP), Communicating Unanticipated Adverse Outcomes (CUAO) training programs and formal processes contained within Quality, Risk Management and Member Services. The HCOM is involved in a variety of cases, ranging from unanticipated adverse outcomes and medical errors to physician-patient communication breakdown and patient dissatisfaction with treatment outcome or quality of care. Anyone who has an interest in the medical care of a patient may make a referral to the HCOM. To support better physician-patient communication, the HCOM actively listens to patient concerns, makes informal inquiries within the health organization, seeks answers to those concerns, and facilitates frank and transparent discussions between patients and physicians. In preparation for these conversations, the HCOM will help physicians deal with their own reactions to these events and help frame thoughtful responses, particularly when an apology is warranted. The following case is based upon a true story and presented to illustrate how divergent physician and patient perspectives can be bridged following an adverse outcome. The patient’s daughter provides insight into her mother’s experience and how it affected their family. The physician offers his point of view and thought process before initiating a disclosure conversation. The HCOM’s role is to understand the parties’ competing perspectives, find commonality in their objectives, unite them in overcoming earlier mistrusts and fears, and ensure that both parties emerge with a better understanding of the other’s intentions. The Patient’s Story Until my mother went through this experience, it never occurred to me how much medical professionals ask of us. Our family was asked to entrust the care of our loved one to strangers, her life and health to a system that sometimes creates barriers for the sake of efficiency. Then in the face of an error we are expected to stay quiet and accept this devastating impact on our loved one. My 75-year old mother was plagued with multiple medical problems and consequently, I was very involved in her care. My mother was not a complainer and tolerated more pain than necessary. So, when she began complaining of pain in her left knee, we knew surgery might be imminent. However, as other medical problems needed resolution, she waited a long time for her total knee replacement. Finally, the surgery occurred, leaving us with the hope my mother’s knee pain would resolve. Two weeks into her recuperation, however, her surgeon informed us that something had gone wrong. They inserted the wrong part in my mother’s knee during surgery. I couldn’t believe it. I was afraid once my mother was admitted for surgery she would become a number, no longer a person but a body part awaiting repair. My worst fears were realized. Worse yet, I was the one who talked my mother into getting this surgery. Although I appreciated his honesty, this was not the outcome my mother expected. And why did he wait two weeks to admit his error? I felt somehow responsible. I had advocated for my mother to have this surgery. How could I have let this happen on my watch? Now she needed a second surgery and I worried that she may not be comforted by my advice. How was she ever going to trust her doctor again after all that had happened? This experience left us reeling and we didn’t know who to turn to. Working with the HCOM was initially not a consideration; however, the HCOM explained her role as a neutral mediator who could facilitate our meeting with the doctor to address our many unanswered questions. Although I was still angry and frustrated and unsure the HCOM’s involvement would lead to a productive conversation, it seemed the only way we were to get some answers and get mom the care she needed. When my mother and I finally met with the physician, I sensed he was nervous and tentative, worried about how we were going to react to what he would share with us. He talked us through the surgery in detail, even showing us models of parts he used during surgery and explaining the function of each. He did so with patience and kindness, reminding me why we trusted him in the first place. He was a well-intended doctor having my mother’s best interests at heart; a human being who simply had made a mistake. He thoughtfully offered to assist us in choosing another surgeon if we preferred not to have him perform my mother’s repeat surgery. Although I anticipated my mother’s anxiety, I knew there would be no other physician she would trust. It felt as though we had been on a long and difficult journey with him and it made sense for us to continue to travel this road together. My mother and I really valued meeting with her physician who gave us a better understanding of the events surrounding her surgery. I recall how hesitant we were to bring forward our initial concerns, fearing we could compromise my mother’s future care. I feel fortunate to have found a resource in the HCOM; she was honest, genuine and treated our entire family with respect and dignity, particularly during those times when we felt isolated and alone. Ultimately, it was the HCOM who reached out and supported us, helping to restore our faith in the physician’s integrity and KP’s efforts to prevent this error from happening to others. From the beginning we have said we believe things happen for a reason. My mom was chosen as she was strong enough to survive and because of what happened to her, care will be safer for other patients. The Physician’s Story As a trained, experienced orthopedic surgeon having performed hundreds of knee arthroplasties in my career, I know surgical misadventures are an inherent risk of invasive surgery. But inserting a wrong femoral component into a patient is not something I’d ever done before. How could I have made such an obvious mistake? I recounted all the events of that day, retraced every step and wondered, and perhaps hoped it was someone else’s misstep that caused the error. Even if that were true, I knew as primary surgeon I had to assume responsibility for what had happened and others would hold me accountable as well. Then I worried how this would affect my reputation, if I had put my medical license and livelihood at risk? How would I explain myself to a peer review? Then I had a rescuing thought; inserting the wrong prosthesis can be an incidental episode that happens during surgery without necessarily affecting the overall outcome. I decided to wait and see how the patient responded to the procedure. If she responded well, I saw no reason to worry her needlessly. As days passed, then a week, I struggled with my decision to withhold this information from the patient and her family. I sought reassurance in medical literature and discussed the event with colleagues, still hoping the wrong prosthesis wouldn’t cause a problem. Yet, the more information I discovered, the more I became aware that my patient may endure unexpected complications and require a second operation. One colleague suggested I speak confidentially with the HCOM. I was reticent to share my story with a nonphysician but did so anyway not knowing what to expect. I approached the HCOM and asked if she thought I needed to disclose the error to the patient. She advised exactly that which I feared most—disclosure. Observing my hesitancy, she advised I consult with the Assistant Physician-in-Chief of Risk who also counseled disclosure. The decision was now clear; the way to go about it was not. Fearing the disappointment and anger my patient and family would likely show me, the HCOM prepared me for this conversation, suggesting I use my anatomy model and sample surgical parts to help explain the wrong prosthesis inserted and its possible consequences. She also advised me to let the patient and family know this error is being taken very seriously and we are looking into how this happened so we can make sure it doesn’t happen to someone else. Two weeks had passed since the surgery and I anxiously waited to meet with the patient and family to discuss my surgical mishap. As I did so, I awkwardly felt a sense of relief in telling the truth and apologizing for any harm I may have caused, even as I feared the backlash of anger that was sure to follow. However, the patient became only tearful and disheartened as I explained the need for a revision surgery. The family consoled her and appreciated my honesty, although clearly disappointed with the news. I offered, for the patient’s consideration, the option of choosing another surgeon for her second operation. Days later, the family informed me of their wish that I perform the corrective surgery. My patient expressed her trust in me, noting the importance of our long-standing relationship to her successful knee repair and recovery. I had graciously been given a second chance and looked forward to performing her surgical repair. As the surgery day arrived, the patient’s daughter told me how difficult it was to persuade her mother to undergo a second surgery; I again experienced a pang of conscience simultaneously with a resolve to set things right. The surgery, in fact, did go well. I remained vigilant if not anxious to see if my patient would recover without complication, which she did. Thereafter, I followed-up with my patient and her family, explaining the systemic changes made to prevent a wrong part from ever being introduced during a surgical procedure. This process of explaining myself, opening me up to colleague scrutiny and patient disappointment, was by no means easy. Nevertheless, I know the price paid was infinitely less than living with the thought I had caused harm to a patient and did nothing to remedy it with a truthful disclosure and a heartfelt apology. The orthopedic surgeon in our story, not unlike the patient’s daughter, experiences mental anguish and soul-searching. As commonly occurs, this physician questions his competence, relentlessly revisiting details of his patient’s surgery in his awakened mind and sleepless nights. Nothing prepares physicians for how to appropriately respond to errors, as an atmosphere of mastery, precision, and competency pervades their rigorous medical education and training. The competitive nature underlying one’s medical training does not encourage physicians to easily share guilt, fear, and uncertainty with colleagues.4 Moreover, a medical error of this import may thrust the physician into the unfamiliar and intimidating medical legal world, further isolating him and threatening his medical reputation. Physicians are healers who have taken a sacred oath to “do no harm.” To the physician, it can be demoralizing when years of rigorous education and training, all designed to help the patient, result in harm. The initial impulse may be to turn away from the patient who was harmed, even though this is the time they need their physician the most.4 Obviously, a medical error is devastating, but in its aftermath, miscalculating what is important to the patient and the family can make things worse. Going back and picking up communication that has been dropped can bring healing to a difficult situation. Stepping closer to the flame is counterintuitive, but it is exactly what is needed. This physician and patient were courageous enough to take that step. It is an HCOM’s responsibility to connect these two very different stories in a way that creates a new story of collaboration and relatedness. Stories such as these take on a life of their own and become the road map for everything that befalls the patient and the physician. The more the stories are retold, the more divergent the different perspectives become. Yet, the common theme between these two stories is humanness. The physician and the family both feel guilt for their role in what occurred, each feeling accountable and invested in the patient’s well-being. An HCOM’s intervention is instrumental in assisting physicians and patients to restore a trusting relationship. Re-established communication following an unanticipated adverse outcome often yields a deeper, more meaningful relationship than existed before: a relationship built on collaboration, understanding, and respect.5 Highly skilled and expertly trained HCOMs draw upon their diverse backgrounds and disciplines to identify participants’ differing perspectives, share individual feelings and draw parallels between their common experiences and intentions. Participants are moved beyond their respective roles as physician and family to embrace their shared humanity and concern for a better outcome, not just for this patient but for others who follow. Ultimately, the HCOM’s goal is to help the patient, family, and care team inhabit their best version of themselves by being honest and transparent in their communications. Donald Berwick, MD, Administrator for the Centers for Medicare and Medicaid Services and former President and CEO of the Institute for Healthcare Improvement writes, “… extend transparency to all aspects of care, including science, costs, outcomes, processes, and errors. Apologize when things go wrong.”6 Through skillful shuttle diplomacy and face-to-face mediation, the HCOM process allows both physicians and patients to gain insight into the other’s inner narrative, moving ever closer to resolution. References 1. Regional support capabilities: Quality, service, and performance improvement—risk management and patient safety: Communicating unanticipated adverse outcomes and situation management teams (CUAO/SMT) [Web page on the Internet]. Oakland, CA: The Permanente Federation; 2011 [cited 2011 Jul 24]. Available from: http://kpnet.kp.org/permfed/support/improvement/risk/cuoa.html. 2. When things go wrong: responding to adverse events. A consensus statement of the Harvard hospitals [monograph on the Internet]. Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; March 2006 [cited 2011 Jul 20]. Available from: www.macoalition.org/documents/respondingToAdverseEvents.pdf. 3. Department of Care and Service Quality: Healthcare Ombudsman/Mediator [homepage on the Internet]. Oakland, CA: Kaiser Permanente; updated 2011 [cited 2011 Jul 20]. Available from: http://kpnet.kp.org/qrrm/risk/HCOM3/hcom_index.htm. 4. Delbanco T, Bell SK. Guilty, afraid, and alone—struggling with medical error. N Engl J Med 2007 Oct 25;357(17):1682-3. 5. Winslade J, Monk G. Narrative mediation: a new approach to conflict resolution. San Francisco, CA: Jossey-Bass: 2000. 6. Berwick D. What ‘patient-centered’ should mean: confessions of an extremist. Health Aff (Millwood) 2009 Jul-Aug;28(4):w555-65. Suggested Reading 1. Clark K. Advocacy in health care: a sample of state and private systems. Dispute Resolution Magazine 2010 Spring;16(3):10-12. Available from: www.servantlawyership.com/my_slideshow/Advocacy%20in%20Health%20Care.ABA%20DR%20magazine.4.2010.pdf 2. Liebman C, Hyman CS. A mediation skills model to manage disclosure of errors and adverse events to patients. Health Aff (Millwood) 2004 Jul-Aug;23(4):22-32. 3. Disclosing errors and examining mistakes: Kaiser Permanente keeps patients informed and involved. Joint Commission Perspectives on Patient Safety 2006 Sep;6(9):9-10. 4. Hardee J. An overview of empathy. Perm J 2003 Fall;7(4):51-4. 5. Leape LL. Full disclosure and apology—an idea whose time has come. The Physician Exec 2006 Mar-Apr;32(2):16-8. 6. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider ‘‘second victim’’ after adverse patient events. Qual Saf Health Care 2009 Oct;18(5):325–30. 7. Leape L. Understanding the power of apology: How saying “I’m sorry” helps heal patients and caregivers. Focus on Patient Safety 2005;8(4):1-3. 8. Weber D. Who’s sorry now. Physician Exec 2006 Mar-Apr;32(2):11-4. 9. Healing the Healer [video on the Internet]. Oakland, CA: Kaiser Permanente; 2011 [cited 2011 Jul 20]. Available from: http://kpnet.kp.org/qrrm/risk/HCOM3/hcom_index.htm#healing. 10. Formanek R, Bonacum D. “The other side of the fence”: A geriatric surgical case study of error disclosure. Perm J 2008 Winter;12(1):39-45.