In 1987, the chief of staff of the Lexington VAMC and the staff attorney for the VA Regional Counsel Office in Lexington, Kentucky, discovered that a recent patient death was due to a mistake made in the medical care provided at their facility. They decided to disclose what happened to the family who had no knowledge of this mistake in care because “it was the right thing to do.”
The Lexington Model for disclosure, as it became known worldwide, continued to flourish under the leadership of Kraman and Hamm.1,2 The VA National Center for Ethics in Health Care adopted these principles of disclosure in drafting a national VHA policy directive in 2008, which was updated in 2012.3 However, despite the ethical and professional imperatives, disclosing adverse events (AEs) to patients and family members has continued to be one of the most difficult challenges in the practice of medicine.
VHA policy has made a distinction between clinical disclosure, conducted by a clinician with a patient as a routine professional practice, and institutional disclosure, conducted by institutional leadership for an AE rising above a threshold of serious patient harm. According to VHA Director of Risk Management Yuri Walker in a 2013 personal communication, the frequency of institutional disclosure reports from VAMCs since 2011 have reflected significant variation in disclosure practice among facilities of similar size and complexity.
In this report, the authors share their experience developing and delivering a simulation-based disclosure training program in the VHA intended to close the gap between policy expectations and practical challenges for providers and institutions when facing the task of disclosing an AE to patients and families.
It is not difficult to understand why health care providers (HCPs) are uncomfortable about disclosing AEs to patients. The study by Delbanco and Bell describes physicians experiencing guilt, shame, and fear of retribution after a patient experiences an AE. The resulting silence and avoidance of the patient only compounds patient harm.4 Many HCPs believe disclosure will lead to tort claims, provide evidence against their defense, encourage reporting to the National Practitioners’ Databank, and damage their reputations with a potentially negative impact on their careers.5-7
In a 2009 survey of 1,891 practicing physicians in the U.S., one-third did not agree with disclosing serious medical errors to patients.8 Another survey of physicians reported wide variations in responses about whether they would offer an apology after making a medical mistake.9 Therefore, a gap between patient expectations and HCP communication when a medical mistake occurs should be expected.10
Few HCPs receive training in empathic communication skills for effective disclosure of AEs to patients and families.11 In a survey of 3,171 physicians in the U.S. and Canada, Waterman and colleagues found that only 10% of physicians believed they had adequate support from their health care organizations (HCOs) after an AE occurred, even though 86% expressed significant interest in receiving training on the disclosure of AEs.12 Despite this gap, some medical educators, such as Katie Watson at Northwestern University, are successfully demonstrating the power of teaching medical students improvisational acting skills to enhance professionalism and communication in future physician–patient interaction.13
In 2010, the Lexington VAMC was awarded a 3-year VA Systems Improvement Capability Grant, which funded the development of a Disclosure Training Program (DTP). A team of investigators designed a 2-day workshop based on principles of experiential learning. Each workshop incorporated interactive teaching techniques using filmed clinical vignettes to provide a context for facilitated small-group disclosure simulations with professional actors.14 A total of 14 workshops were conducted for 346 participants from December 2011 to September 2012.
The DTP workshop integrates focused didactic sessions with interactive audience-workshop facilitator discussion, debriefing of teaching films, and disclosure simulations, with the majority of time spent the conducting and debriefing of simulations. Core content addressed during workshop activities included the following:
1. Historical origins of disclosure policy at the VHA
2. Ethical obligation, professional duty, and legal mandates for disclosure
3. Empathic communication–cognitive and emotive
4. VHA Handbook 1004.08, Disclosure of Adverse Events to Patient
5. Institutional and Clinical Disclosure of AEs
6. Psychological and physical needs of patients after an AE
7. Disclosure linking risk management to patient safety in a health care system
8. Legal implications for disclosure
9. State apology laws
10. Implementing disclosure programs in health care facilities
11. Facility support for providers after a patient AE
The principles of empathic communication and the core elements of AE disclosure to patients are reinforced during small-group simulations with actors portraying patients or family members. Each small-group simulation typically involves 3 to 4 workshop participants and 1 to 2 actors. Participants are given the task of conducting a clinical or institutional disclosure.
