Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September

Intimidation and Retaliation: The Challenge to get Resident Physicians to Report Medical Errors

Jeff House, M.D.
Associate Professor Department of Medicine Division of General Internal
Medicine Program Director, Internal Medicine Residency; Performance Improvement Officer
10-4-2 Resident physicians, being the first responders for patient care, have several daily patient interactions, and work closely with nurses, physicians, and other allied health disciplines. They have a unique vantage point from which to report adverse events, errors, and near misses. Despite this opportunity, residents do not routinely report medical errors. Residents contribute only a few percent of all events reported. Reported barriers for this deficiency include not knowing the process of reporting, lack of time, being unsure who is responsible for making a report, believing it is not a key part of training, and assuming that nothing will come from reporting the event.  Perhaps the most disturbing barrier to reporting medical errors is the fear of retribution or “shaming”. Reluctance for trainees to report problems for fear of retaliation is not unique to medical errors. The accreditation Council for Graduate Medical Education (ACGME) recognizes this problem and re‐ quires that programs “provide an environment in which residents may raise and resolve issues with‐ out fear of intimidation or retaliation”.  On an annual basis, the ACGME anonymously surveys all residents and are specifically asked if they can raise problems or concerns without fear of intimidation or retaliation.  Despite the addition of safe‐ guards such as confidential reporting mechanisms and grievance policies, this is an area of the AC‐ GME survey that commonly gets lower marks. In our Internal Medicine Residency Program at UF Health‐Jacksonville, we have used the Thomas‐ Kilmann Conflict Mode Instrument to assess how residents cope with conflict.  This assessment tool has also been used by contributors of the Alliance for Academic Internal Medicine (AAIM). It characterizes five different management styles: accommodating, avoiding, collaborating, competing, and compromising. Our results thus far have shown that although trainees have the ability to use all five types, the avoidant style was common amongst trainees. This is a common result of many learners who serve in a more subordinate role. Similar results can be seen with medical students. Although avoiding difficult issues may seem like an easy way to handle a potential problem, many issues may remain unresolved. In the area of medical errors, systems issues may not be addressed or individual personnel may be left making the same mistake in future instances. How are programs working to allay learners’ fears of retaliation and intimidation when it comes to reporting of medical errors? Promoting an environment of patient safety, the ACGME has begun focusing on resident and fellow education to go beyond the traditional medical knowledge and patient care teaching.  One of the focuses of what is a major overhaul to resident education is enhancing patient safety and practice based learning improvement.  Residents are now required to participate in identifying system errors and implementing potential systems solutions. Residents are also expected to work on multi-disciplinary patient safety teams to improve quality of care.  Working on inter‐professional teams allows residents to see the results of medical error reporting, and understand that reporting errors is not a blaming or finger pointing exercise but a means in which to improve quality of care. The ACGME initiatives in patient safety and quality improvement put the accountability for encouraging patient safety on the program directors and teaching faculty. In fact the ACGME explicitly states that programs must be committed to and responsible for promoting patient safety and resident well‐being in a supportive educational environment.  The ACGME’s emphasis on being supportive and encouraging residents to speak up when they encounter quality concerns has potential to shift much of the feelings of reprisal that have plagued teaching programs in the past. In summary, residency training programs should emphasize to learners the importance of reporting patient safety concerns. Residents should be made aware that reporting medical errors is an integral part of their medical education. Reporting errors can be the nidus for quality improvement initiatives, scholarly opportunities, and most importantly safer health care delivery systems. Programs can facilitate the process by creating a nurturing work environment to help trainees feel empowered to bring problems and solutions to their supervisors.  Lastly, participating in multidisciplinary teams help residents understand how other services impact the quality of health care and how reporting errors can potentially lead to system solutions.  The ACGME has recognized the significance of changing the culture of patient safety; therefore residency training programs will not be far behind.   Bibliography: Fiscella K, Roman‐Diaz M, Lue BH, Botelho R, Frankel R. ʹBeing a foreigner, I may be punished if I make a small mistakeʹ: assessing transcultural experiences in caring for patients. Fam Pract. 1997 Apr;14(2):112‐6. Crutcher RA, Szafran O, Woloschuk W, Chatur F, Hansen C. Family medicine graduatesʹ perceptions of intimidation, harassment, and discrimination during residency training. BMC Med Educ. 2011 Oct 24;11:88. doi: 10.1186/1472‐6920‐11‐88. Barbara G. Jericho, Rosalie F. Tassone, Nikki M. Centomani, Jennifer Clary, Crescent Turner, Michael Sikora, David Mayer, and Timothy McDonald (2010) An Assessment of an Education‐ al Intervention on Resident Physician Attitudes, Knowledge, and Skills Related to Adverse Event Reporting. Journal of Graduate Medical Education: June 2010, Vol. 2, No. 2, pp. 188‐194. Wallace EA, Duffy FD.  Embracing conflict: Engaging in difficult and productive conversations to enhance a positive conversations to enhance a positive institutional culture. Academic Internal Medicine Insight. 2011;9(2):12‐14 ACGME.org