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Join Scott Ellner, a general surgeon. We delve into a compelling story from a decade ago, where a medical error had profound consequences for both a patient and the surgeon involved. Discover the emotional toll on health care professionals, the importance of creating a just culture in health care institutions, and the significance of forgiveness and growth in the face of adversity.

Scott Ellner has been a general surgeon for over 20 years, and can be reached at PEAK Health.

He discusses the KevinMD article, “Humanism in health care: How to address patient harm.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today, we welcome back Scott Ellner. He is a general surgeon and a physician executive at Peak Health Technologies. Today’s KevinMD article is “Humanism in health care: how to address patient harm.” Scott, welcome back to the show.

Scott Ellner: Great to be here, Kevin. Good to see you again.

Kevin Pho: Scott has been on recently. Go to KevinMD.com/podcast and search for his name to hear his story. But today, let’s jump right into your most recent article about humanism in health care and how to address patient harm. For those who didn’t get a chance to read your article, just tell us about it.

Scott Ellner: Sure, well, a little bit of background. Kevin, imagine a day when you just realized that you have harmed one of your patients. For many of us, it is a real-life situation. We chose medicine to heal and comfort the most vulnerable. When a situation like that arises, many of us are just not prepared for the circumstances.

In 2005, I had an experience, and fortunately, it was my first sentinel event. I was a fellow in the operating room. Unfortunately, the nurses who were trading out places during shift change were angry at each other, took their eyes off the patient, and actually got into a fight in the sterile area. What happened as a result is that one of the Kocher clamps that we were using in that operation was miscounted, even though the counts were correct at the end of the case, and that clamp was left in the patient’s abdomen.

Afterward, instead of a just culture, which you would expect in a highly reliable organization today, there was a lot of shame. There was a lot of blame and guilt. We were offered into a room afterward where the attorneys swooped down on us, and we were told not to say anything and not to disclose anything. You could tell there was a lot of pain amongst the people in that room, including the nurses, the techs, and the anesthesiologist.

The background from that story really led me to pursue safety and quality in health care and to really understand the impact it has on our physician workforce. That is a little bit of background on why the story came together and why I wrote about the situation and the second victim phenomenon.

Kevin Pho: Let’s go back to that story that you told when you were a fellow. What were some of the emotions and thoughts that were going through your mind in the immediate aftermath?

Scott Ellner: Great question. You know, we go through medical school and we are really confident in our abilities. We just went through it and are the top one percent academically. Then you make a mistake and you feel shame and guilt. In some instances, there is humiliation. You are afraid, asking what this means for your practice. Will you be sued? That is an obvious question. Where do you turn?

There is a lot of confusion. First and foremost, you are worried about the patient. You are worried about what you need to do to help this patient, particularly if it is a situation that could result in death. It is a very scary situation for a health care professional.

Kevin Pho: At that time, and I am going to assume that this was years ago, did you have any support or any guidance to help you emotionally through that difficult time?

Scott Ellner: Really, aside from my family, I felt alone. I felt vulnerable. I really didn’t know who to turn to. In fact, when I was told to go talk to our chief risk officer, I felt like I was going to the principal’s office. I wondered what this meant for me and if I was going to be let go from the fellowship. A lot of these occurrences, these adverse events, are not something we intentionally wake up in the morning and think we are going to do. However, the support just wasn’t there. The just culture that we strive for was just not present at the time. It was early, shortly after the “To Err Is Human” article came out.

Kevin Pho: You mentioned a couple of terms that I want to go more granular into. One is “second victim syndrome.” Tell us what that is.

Scott Ellner: Right, it is a term that was coined by Albert Wu in the early 2000s. The first victim when there is harm that occurs is the patient and their family. The second victim is the health care professional who is involved in unintentionally causing that error or that harm. As a result of the feelings of guilt from causing that type of harm, the practitioner can become despondent. They can turn to substance abuse, or they may even consider leaving the profession.

Frankly, when 70,000 physicians left the physician workforce between 2021 and 2022, we can’t afford to lose these great academicians and great people practicing medicine. So the second victim phenomenon is real. It also leads to sometimes suicide, which is very painful to talk about.

Kevin Pho: In terms of addressing these issues after adverse events, you mentioned the “just culture.” Tell us more about that.

Scott Ellner: Right. Just culture is a term where we really look at a culture of safety in which people feel that they can speak up on behalf of the patient, on behalf of themselves, and be able to do what is right to prevent errors. It is not a culture where we blame people or point fingers. It is a culture where we all take accountability. We take accountability for actions and work together to learn from a mistake and to be better, so that we don’t cause the same mistake to happen again in the future. Many organizations are doing a great job focusing on a just culture.

Kevin Pho: To see that concept in action, can you paint us a picture, whether real or hypothetical, about that just culture in action at a medical institution?

Scott Ellner: Well, in the article I wrote, I presented a real-life story of a colleague who was very despondent because he had caused a small bowel injury in a patient. Unknowingly, the patient was dying of septic shock in the ICU. He was advised and informed by our legal counsel, our compliance officer, and the chief risk officer that it is OK to show sympathy. It is OK to disclose what happened in the right context and to say you are sorry because most states have statutes or laws that protect against saying “I’m sorry” or showing sympathy, meaning that information cannot be admissible as evidence in court for malpractice claims.

In this situation, the gentleman felt supported and comforted that he could go to the patient’s husband, because the patient was in a medically induced coma, and share what happened. It was amazing. The husband put his arm on the shoulder of that surgeon, who was very hurt and despondent, and said: “Doc, I can see this is really troubling you, and I want you to know that I understand and I will support you, and I know you are going to do your best to support my wife.”

Kevin Pho: Tell us the importance of that apology and saying “I’m sorry” from the physician standpoint. How important is it for doctors?

Scott Ellner: Well, I tell you, I wish I would have known this when I was going through medical school and my training. I didn’t realize the importance of it until I actually did a fellowship with the National Patient Safety Foundation as I started my training. I interacted with Richard Boothman, who is kind of a luminary in the safety culture. He is an attorney, and he talked about the context of apologizing and saying “I’m sorry.” He had found that medical malpractice claims are actually reduced when, in the right context, you can actually apologize to the patient, show sympathy, show that you really care, and inform the patient based on the discussions you have had. This is where informed consent is really important, ensuring they understand what they had signed in a document where you explained the risks prior.

Kevin Pho: You mentioned that apologies in most states aren’t admissible or can’t be used against the medical institution or physician. So are we in a situation where physicians and medical professionals have to check their state laws before issuing apologies?

Scott Ellner: Well, it is a good question, and I want to be careful that I am certainly not providing legal advice. What I will say is that it is always best to check with your legal counsel, whether it is through your practice or your employment arrangement with your health system, to say that you would like to express your sympathy to the patient and ask if it is OK. I would do this because a majority of us feel that when an error happens, it is important to just check and make sure you don’t want it scripted. You don’t want this to feel like it is something that you are being told to do and have it come across as inauthentic or disingenuous. You want to make sure that you have the freedom to say “I apologize.” You don’t have to go into a lot of detail; just show some compassion and sympathy.

Kevin Pho: In order to create that just culture, how much of that onus is on the medical leadership, the administrators, and the legal team of the hospital? How much of the onus is on them?

Scott Ellner: It starts with the top of any organization. When I say the top, I mean the board of directors. The board of any health system or institution needs to understand that a just culture is the most important aspect of creating a safe environment for your patients and your employees. The board should hold the CEO of the organization accountable for creating that just culture so people feel comfortable speaking up and sharing concerns in a thoughtful way. You know, there is complaining, and then there is empathy and active listening. I always say behind every complaint, there is a request. So when somebody is bringing up a complaint, really understand and listen to what it is that they are requesting. That helps to create the just culture where people will speak up to do the right thing on behalf of the patient and for their colleagues.

Kevin Pho: Now, where are we in terms of the prevalence of a just culture? Do the majority of hospitals practice that? How far are we away from your ideal?

Scott Ellner: We have a lot of work to do. There are organizations that have absolutely embraced a just culture, and you can see it and feel it when you go into those organizations. There is an understanding that the administrative teams are supporting the physicians in the work they do. But then I would be remiss if I didn’t bring up the story of RaDonda Vaught in Tennessee, who was convicted. I believe she was convicted of manslaughter for an unintentional medication error. It is hard to understand. I don’t know all the details, but it is hard to understand how in a just culture, when a situation like that occurred, a health care professional could actually be convicted of a crime because of an error. So that is an example of why more work needs to be done.

Kevin Pho: Talk more about that. When medical professionals are convicted on criminal charges for adverse events, tell us the effect and the impact it has not only on that professional themselves, but on the institution and their coworkers as a whole.

Scott Ellner: When a conviction for doing your job and causing an error happens, it is troubling. Sometimes there are egregious errors, but a conviction where there is criminal involvement means it was proven beyond a reasonable doubt, and that is going to create distrust within the health care industry. We already have a shortage of great nurses. When a young professional who is looking to get into health care sees something like this happen, it is going to be a deterrent. So we really have to understand the consequences of why this happened. I truly believe, and again, I don’t know all the reasons, but I truly believe it is a systems issue. We have to explore why there was a breakdown in that type of adverse event because we are going to lose great people. They are not going to go into the noble profession of health care.

Kevin Pho: Tell us the next steps. How can we promote a just culture and have it spread to more hospitals and medical institutions?

Scott Ellner: The first thing is that all administrators and boards need to go through training to really understand what high reliability and just culture are. There are groups out there that do a great job and will help to promote and bring this information to any organization. But it is more than just bringing it to the organization. It is walking the walk and talking the talk, and actually living it day by day. One thing that I would promote is that we should be kind to each other. That would create a safe space for psychological safety so that we have the courage to speak up. Even if you are a medical student, a nursing student, or a tech in the room and you see something wrong, speak up and ask a question. Ask if this is right. We need to decrease that fear and that authority gradient in health care because it is the right thing to do for our patients and ultimately for the health care providers that may be harmed themselves as a second victim.

Kevin Pho: We are talking to Scott Ellner. He is a general surgeon and a physician executive at Peak Health Technologies. Today’s KevinMD article is “Humanism in health care: how to address patient harm.” Scott, as always, we will end with your take-home messages to the KevinMD audience.

Scott Ellner: The take-home message for all my colleagues is that we must remember we went into health care to support the most vulnerable. When you are feeling like you have nowhere to turn because something went wrong, there are opportunities to reach out to helplines. The American Medical Association has a helpline to discuss if something isn’t right, and there are mental health opportunities. I would say the one thing I wanted to mention, Kevin, is the Dr. Lorna Breen Act, which was passed in 2022. There are grants out there to help with mental health and substance abuse that every institution should look into to support our health care professionals.

Kevin Pho: Scott, once again, thank you so much for coming on the show and sharing your story, time, and insight.

Scott Ellner: Thanks for having me, Kevin.