Creating a Culture of Disclosure

Last night I attended an #HCLDR tweet chat on medical error where Dr. Brian Goldman was the guest facilitator. The first topic was “What stops health professionals from talking more openly,at work,about their mistakes?” Not surprisingly, most people talked about a culture of denial that covers up or redirects blame for medical errors because of fear, fear of litigation or of shaming from peers. Since I started working in medicine 10 years ago, I have heard many stories about shaming and punishment being used as “Medical Education Techniques”. I think the cultural issues begins earlier and if we are going to change cultural artifacts, we need to understand their roots.

Many years ago John Holt wrote:

...the anxiety children feel at constantly being tested, their fear of failure, punishment, and disgrace, severely reduces their ability both to perceive and to remember, and drives them away from the material being studied into strategies for fooling teachers into thinking they know what they really don’t 

Medical students arrive on our doorsteps knowing how to memorize the right answer for THE TEST, so they can continue to play their lifelong role as “the best and the brightest”. They have spent at least 12 years watching what happens to people who don’t excel on THE TEST and have created a whole cycle of behaviors that guarantee not being one of them. The more intellectually gifted they are, the higher the personal expectation of “knowing the answer.”

So here is the Catch 22, medical students in a multiple choice heavy school are wonderfully prepared for a medical world that doesn’t exist. Medicine is a messy, multifaceted, and complex system that requires the ability to analyze, communicate, read, problem solve, create etc. Clinical life challenges everything med students previously knew about their intellectual abilities and if incompetence is viewed as failure by preceptors and peers, the student will becomes masterful at hiding/denying that incompetence.

I believe that recognizing one’s incompetence is the first step in the learning cycle and that acceptance and recognition of one’s incompetence should be celebrated as the gateway to further learning instead of as an obstacle that forebodes failure.

So yes, I hear you saying “What! How do you expect us to do that, Deirdre? Party with sparklers in the coffee room?”

I talked to numerous residents today who said that is already starting to happen with M & M rounds in many of their departments. Questions like “How could WE have handled this better? What can WE learn from this incidence?” are being asked by department heads, preceptors and residents. These conversations are covering CanMed Roles that go beyond “What dose of X was the patient given?” Students say they look forward to these sessions particularly when they lose a patient they have gotten to know. In some cases, the deptartment will chose a variety of problematic cases under a theme to address systemic errors. These students are learning the value of a culture of disclosure.

Let’s start by building formative assessment into all our courses, so students expect to identify errors in their thinking early on. Response technology such as clickers are a great tool for allowing students to anonymously identify errors in memorization. If between 30% and 70% of the students get an answer incorrect, pair them up to debate the correct answer, then retest.

At the University of Saskatchewan College of Medicine, we teach all our residents to frame self correction/feedback around questions like “What helped this patient improve?, What might I do differently next time?, What do I need to look up tonight?” thereby forming a habit of livelong deliberate practice. We teach the language of cognitive error in the same class to help students become familiar with how the brain of even the smartest can be tricked.

A culture of disclosure is built around foundations of acknowledgement of mistakes, goals of self improvement, and patient centeredness becoming normalized in medical school.