Perspective
Physician Assistants and the Disclosure of Medical Error Douglas M. Brock, PhD, Alicia Quella, PhD, MPAS, PA-C, Lauren Lipira, MSW, Dave W. Lu, MD, MBE, and Thomas H. Gallagher, MD
Abstract Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure
M
edical errors are difficult and challenging experiences for patients, their families, and the health care professionals who care for them. Defined in the 2000 Institute of Medicine report To Err Is Human as “a failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim,” medical errors were first estimated to account for as many as 98,000 preventable deaths1 and 1,000,000 excess injuries per year.2 These estimates may be conservative if considering the underreporting of errors and other adverse events.3 Despite over a decade of interventions to better identify errors and reduce their incidence, they remain a common cause of patient mortality and morbidity.4,5 So, while many investigators continue their efforts to reduce the incidence of errors, others have focused on understanding how
Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Brock, Department of Family Medicine and MEDEX Northwest, University of Washington, 4311 11th Ave. NE, Suite 200, Seattle, WA 98015; telephone: (206) 616-1736; e-mail: [email protected]. Acad Med. 2014;89:858–862. First published online April 18, 2014 doi: 10.1097/ACM.0000000000000261
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is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear.
With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.
best to communicate with patients and their families after errors occur.6,7 General agreement exists that effective disclosure of medical errors requires careful delivery of all relevant information, an honest apology, a sincere willingness to help the patient understand the error’s implications, a description of how similar errors will be prevented in the future, and effective management of complex emotional responses.6 Research shows that patients want and expect transparent disclosure of errors,8,9 and evidence suggests that disclosure, if it has any effect at all on patients’ responses to a medical error, has a positive one.9 Correspondingly, surveyed patients have reported being more forgiving and less litigious if they believe their provider is committed to disclosure.10 In List 1, we provide a general framework for effective disclosure based on previous recommendations.6,7,11
and have drafted policies to improve communications between providers and their patients after a serious error.14–16
In parallel with the patient safety movement’s increased emphasis on transparency in communications, especially those disclosing adverse events,11 professional organizations such as the American Medical Association12 and the Joint Commission13 have adopted policies recommending full disclosure. State legislatures, regulators, hospitals, and health care systems also support transparent communication
Still, disclosing errors remains a challenge for individual providers and health care teams.17 Providers may fear malpractice claims, damaged reputations, or disciplinary actions. To address malpractice concerns, 35 states and the District of Columbia have enacted laws making apology for adverse events inadmissible as a statement of fault,16 significantly reducing the size of claims filed and judgments awarded.18,19 Providers may also worry that patients will react with anger or sadness, reject further treatment, or lose trust in their caregivers. These concerns are associated with providers’ depression and anxiety, substance abuse, and other negative responses.20,21 In this article, we focus on how the physician assistant (PA) profession will benefit from inclusion in the investigations and discussions of how to best communicate error to patients. We further propose next steps for researchers and educators seeking to establish a role for PAs in disclosure. PAs and Error Disclosure
Although the literature has explored the roles of risk managers, physicians,
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The Role of Professional Associations
List 1 Elements of Effective Disclosure of Medical Errors to Patients Context • Present information in a timely fashion. • Present, if appropriate, information in multiple discussions. • Present information in language the patient and family can understand. • Focus goals and outcomes around the needs of the patient and family. Content • Explain that an error occurred. • Apologize and express regret for the error. • Convey the underlying elements resulting in the error. • Address medical ramifications for how the error will be managed. • Describe steps that will be taken to prevent the recurrence of the error. • Arrange, if needed, to speak again at a time that is convenient to patient and family. Additional considerations • Expect and be able to manage patient’s complex emotions.
nurses, and emergency medical service workers in disclosing medical errors,13,22–29 it has little discussed the role that PAs might play. In 2012, the 100,000th PA was certified; over 85% of all PAs ever certified are still in practice.30 The number of clinically practicing PAs is projected to increase between 2010 and 2025 by 72%.31 PAs (originally conceived of as general practitioners, although most now practice in surgical and medical subspecialties32 and in urgent care settings)33 are licensed to practice medicine under the supervision of a physician, but also exhibit widely varying levels of autonomy.34 They play active roles in medical decision making and are broadly integrated into the modern health care system, providing direct patient care; conducting physical exams; diagnosing, treating, and managing disease; and prescribing medications. A PA’s specific scope of practice is defined by experience, education, state law, facility policy, and the supervising physician’s delegation of responsibilities. This balance between supervision and independent practice creates unique—and potentially challenging—dynamics for PAs in sensitive disclosure conversations with patients, yet no commonly accepted guidelines for PAs’ role in these conver sations exist. This gap leaves PAs with out a way to determine whether the responsibilities delegated them by their supervising physicians serve their patients’ best interests or to navigate ethical issues that may arise if supervising physicians request PAs to disclose errors on their
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behalf or, conversely, fail to include PAs in disclosure conversations. Just as the roles of other health care providers in the planning and implementation of disclosure conversations have been explored, PAs will also benefit from inclusion in efforts to better understand how to better disclose errors. One might argue that PA disclosure actions can be subsumed under existing physician guidelines. There are legal requirements indicating when physicians should assume primary responsibility for medical error.35–37 Physicians’ liability for PAs’ errors can result in two ways. First, agency law can hold physicians directly liable for the acts of PAs under their supervision.38 This includes cases where PAs are not adequately supervised, breach their responsibilities to patients, or are hired with known dangerous propensities (e.g., alcohol addiction). Second, vicarious liability occurs when supervising physicians are held liable for negligent acts of PAs.38 This includes cases where supervisors have the right, obligation, or duty to control the actions of the violators but fail to do so. However, PAs are held to the same standard of care as physicians, and supervision does not shield PAs from malpractice suits. Some evidence suggests that the incidence of suits against PAs is increasing at a faster rate than for physicians, perhaps reflecting the increasing independence and accountability of PAs.39 Established disclosure guidelines defining the PA role in cases that do not involve supervising physician liability or negligence are lacking.
PA credentialing bodies have not fully addressed the importance of disclosure skills. The exam blueprint used by the National Commission on Certification of Physician Assistants (NCCPA) focuses on medical conditions and clinical skills but does not assess error disclosure or other complex communication skills.40 The NCCPA could promote training in error disclosure skills through continuing medical education. The American Academy of Physician Assistants (AAPA)41 advocates acknowledgment and apology for error in a policy that states: A physician assistant should disclose to his or her supervising physician information about errors made in the course of caring for a patient. The supervising physician and PA should disclose the error to the patient if such information is significant to the patient’s interests and well being. Errors do not always constitute improper, negligent, or unethical behavior, but failure to disclose them may.
This instruction may confuse clinicians in three ways. First, the threshold for disclosure (“if such information is significant to the patient’s interests and well being”) is open to broad interpretation. Second, the policy statement does not describe or acknowledge the essential elements of an effective disclosure. Finally, it does not define a specific disclosure role and designated responsibilities for the PA. In the absence of more objective definitions, variability can be expected in whether an error is disclosed, and if disclosed, how it is delivered. Opportunities for Research and Education in Error Disclosure
Early work describing the importance of fully disclosing medical error called for individual physicians, hospitals and health care organizations, certifying and accrediting bodies, educators, and researchers to each take action.23 However, scholarly examinations of PAs’ role in disclosing error have not been published; a similar call regarding PAs is now warranted. Adopting a proposal from Gallagher and Levinson,23 we have summarized recommendations (Table 1) for key stakeholders to guide research and educational opportunities around PAs and error disclosure.
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Table 1 Next Steps for Providers, Educators, Researchers, and Policy Makers to Define the Role of PAs in Disclosing Medical Errors to Patients Group
Next steps: Training and research opportunities
Individual PAs
• Speak to colleagues about error disclosure • Discuss disclosure policy/plans with supervising physician • Complete error disclosure and communication training • Seek opportunities to practice disclosure skills • Speak to colleagues about error disclosure • Discuss disclosure policy/plans with PA • Complete error disclosure continuing education • Seek opportunities to practice disclosure skills with PA • Model disclosure skills for PA
Physicians supervising PAs
Educators of PAs
• Develop and require education of PAs and PA trainees in the incidence of error and in appropriate evidence-based disclosure practices
Researchers of PA profession
• Explore epidemiology of medical error associated with PA practice • Explore current practice for PA role in disclosure of error • Explore dependent practice role with regard to error and error disclosure • Explore patients’ disclosure preferences • Prospectively explore training interventions for PA role in reestablishing patient trust following error • Prospectively explore training intervention for PA role in error disclose
Professional societiesa
• Create and disseminate disclosure training specific to PA role and practice within interprofessional teams • Educate PAs and PA trainees about error disclosure • Establish evidence-based guidelines for PA disclosure
Accrediting bodiesb
• Establish requirements that licensed PAs understand the nature of medical error and the importance of disclosure
Abbreviation: PA, physician assistant. American Academy of Physician Assistants; Physician Assistant Education Association. b National Commission on Certification of Physician Assistants. a
Research
From a research perspective, it would be beneficial to determine the nature and prevalence of medical errors and the frequency of disclosures specifically associated with PAs. Researchers should also explore the role that the relationship between the PA and supervising physician plays in the occurrence and disclosure of medical errors involving PAs. They should seek to understand how PAs and their supervising physicians identify medical errors requiring disclosure and how they believe disclosures should be discussed, planned, and executed. Pinpointing where the beliefs of PAs and supervising physicians differ will help identify areas of synergy and conflict. A logical next step would be to survey PAs and supervising physicians about their beliefs and experiences around the disclosure of medical errors.
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The importance of systems errors resulting from a cascade of mistakes across health care teams warrants continuing attention. PAs frequently function in teams, making this especially germane. Some investigators have looked at teams consisting of nurses and physicians, where disclosure of error may be hindered by traditional roles and power differentials.24 PAs may be similarly limited in their capacity to fully participate in error disclosure conversations. Conversely, physicians may delegate the task of disclosure to PAs. As investigations continue to explore the role of teams in the reduction and disclosure of error, it would be beneficial to clarify the PA’s role, providing an increased understanding of how best to leverage the skills of the PA as part of the health care team. Education
Teaching PAs the skills of error disclosure is hampered by a dearth of
policy statements directing educational programs and hospitals to attend to the unique PA practice model. Professional standards for error disclosure do exist for hospital and clinical settings,11 and error disclosure skills are increasingly taught as part of undergraduate medical and nursing education. However, the extent to which individual PA programs have implemented curricula specific to error disclosure is not well understood. PA training should include and reinforce the components of effective disclosure, discussion of the unique role PAs might play in team disclosure, and the appropriate steps to resolving conflicting views between team members. These efforts will benefit from examination of the growing body of literature that explores the training of resident physicians and medical students.42 Interprofessional training experiences also offer especially fruitful means to train PA students in the complexities of effective error disclosure.43 Training can be achieved through didactic instruction, but complex communication skills will benefit from simulation or the use of standardized patients. Standardized patients provide a common simulation modality with a high degree of flexibility and fidelity necessary to train complex disclosure communication skills in interprofessional contexts.44 Simulation is also a relatively economical and practical means to teach complex communication skills,45 including error disclosure.46 Physician modeling of effective commu nication skills, whether in training or in practice, may better prepare PAs for challenging conversations, including disagreements with physicians and health care team members. In each case, opportunities exist for the creation and dissemination of novel trainings to ensure awareness and support effective disclosure. However, although training opportunities exist, it is not clear what error disclosure instruction PA programs may already provide or to what extent existing curricula can be modified to include teaching these skills. Training solutions are likely to be highly program specific. Discussion and Recommendations
Medical errors remain a significant cause of injury and death. When errors occur, patients and their providers struggle to understand what has happened and how to ensure continuing care. PAs work with
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Perspective
physician–supervisors and as members of interprofessional teams. They practice in a wide variety of medical domains with varying degrees of independence. However, unlike their physician and nursing colleagues, the PA profession and its training institutions have yet to focus significant attention on the critical task of communicating medical error to patients. PAs need to recognize the scope and nature of error, acknowledge their role in the prevention of error, and understand the legal, professional, and emotional impacts of error disclosure. In this article, we call for inclusion of PAs in research and educational explorations around error and for the establishment of practice guidelines supporting PA inclusion in discussions around the disclosure of a medical error. PAs bring strong clinical training and broad experiences in the delivery of patient care. They establish trust, and patients look to them to ensure their safety. Policy statements and disclosure guidelines, informed by research, directing training programs to acknowledge PA individual and interprofessional team roles would further support efforts to reduce error and improve the quality of patient care. We recommend that the AAPA define and adopt initial policy describing the PA role in discussions, planning, and transparent disclosure of error that aligns with the standards already described by the American Medical Association12 and the Joint Commission.13 Specific to the PA role, the AAPA should develop policy statements recommending that supervising physicians and PAs discuss error when it occurs and jointly develop a plan for the disclosure of that error. We recommend that, whenever possible, both the supervising physician and PA participate in the actual disclosure and that the PA adhere to the same standards (e.g., apology) expected of physicians in these conversations. Furthermore, guidelines must support PAs in consistently advocating for the transparent disclosure of all errors. When disagreement occurs between a supervising physician and PA, guidelines should emphasize the value of requesting that a third party mediate. PAs should not be delegated sole responsibility for disclosure, nor be placed in the position of holding principal responsibility for disclosing another’s error. Guidelines
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should reinforce the necessity of reporting all errors, minor or serious, to supervising physicians. These recommendations better align the PA role with their physician and nursing colleagues while also encouraging PAs to accept personal responsibility when having made a medical error. We encourage the Physician Assistant Education Association (PAEA) to broadly endorse evidence-based training in the specific communication skills necessary for effective disclosure of error. The PAEA can promote the work of programs already teaching disclosure skills and provide training recommendations. These recommendations would initially be based on best-practice models for physicians and nurses but would later evolve to speak specifically to the PA role. The Accreditation Review Commission on Education for the Physician Assistant defines educational standards for the PA profession. We encourage the commission to review emerging standards around error disclosure and integrate appropriate PA educational program standards to parallel these efforts. Research remains to be done before final policy statements and PA role-specific guidelines training can likely be adopted. The nature, severity, and incidence of errors associated with PA practice are poorly understood, and how supervising physicians and PAs respond to error has not been closely examined. However, the PA profession, in collaboration with their fellow health care professions, can establish initial standards that can then be subject to empirical examination. Ultimately, this research can address many critical questions of PA practice. For example, should PAs and their physician supervisors always disclose together? What characteristics of the error and of the patient need to be addressed in making disclosure decisions? What contextual factors play a role? Should guidelines vary across medical specialty and degree of PA autonomy? These and many other questions warrant continuing investigation. Most, if not all, PAs will experience errors in their careers. PA and other medical and interprofessional researchers and educators should focus attention on establishing the most beneficial role for PAs in disclosure. This will require research to establish what constitutes existing practice and that examines evidence-based approaches to
defining best-practice models for PAs. Building on this body of work, PA training programs should then increase their focus on training students in the skills necessary to reduce error, but also how to openly and transparently communicate error when it does occur. Guidelines specific to the PA role will fill an existing gap in discussions around medical error and provide opportunities to improve the quality of care. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Dr. Brock is associate professor, University of Washington Department of Family Medicine and MEDEX Northwest, Seattle, Washington. Dr. Quella is lecturer, University of Washington Department of Family Medicine and MEDEX Northwest, Spokane, Washington. Ms. Lipira is research scientist, University of Washington Department of Medicine, Seattle, Washington. Dr. Lu is assistant professor, Northwestern University, Department of Emergency Medicine, Chicago, Illinois. Dr. Gallagher is professor, University of Washington Department of Medicine, Seattle, Washington.
References 1 Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 2 Weingart SN, McL Wilson R, Gibberd RW, Harrison B. Epidemiology of medical error. West J Med. 2000;172:390–393. 3 Classen DC, Resar R, Griffin F, et al. “Global trigger tool” shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30:581–589. 4 Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363:2124–2134. 5 Shekelle PG, Pronovost PJ, Wachter RM, et al. Advancing the science of patient safety. Ann Intern Med. 2011;154:693–696. 6 Gallagher TH, Studdert D, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356:2713–2719. 7 Mazor KM, Greene SM, Roblin D, et al. More than words: Patients’ views on apology and disclosure when things go wrong in cancer care. Patient Educ Couns. 2013;90:341–346. 8 Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001–1007. 9 Mazor KM, Reed GW, Yood RA, Fischer MA, Baril J, Gurwitz JH. Disclosure of medical errors: What factors influence how patients respond? J Gen Intern Med. 2006;21:704–710.
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Perspective 10 Helmchen LA, Richards MR, McDonald TB. How does routine disclosure of medical error affect patients’ propensity to sue and their assessment of provider quality? Evidence from survey data. Med Care. 2010;48:955– 961. 11 Safe Practices for Better Healthcare—2010 Update: A Consensus Report. Washington, DC: National Quality Forum; 2010. 12 Council on Ethical and Judicial Affairs. Code of Medical Ethics of the American Medical Association: Current Opinions With Annotations. Chicago, Ill: American Medical Association; 2009. 13 Loren DJ, Garbutt J, Dunagan WC, et al. Risk managers, physicians, and disclosure of harmful medical errors. Jt Comm J Qual Patient Saf. 2010;36:101–108. 14 Wei M. Doctors, apologies, and the law: An analysis and critique of apology laws. J Health Law. 2007;40:107–159. 15 McDonnell WM, Guenther E. Narrative review: Do state laws make it easier to say “I’m sorry?” Ann Intern Med. 2008;149:811–816. 16 Mastroianni AC, Mello MM, Sommer S, Hardy M, Gallagher TH. The flaws in state “apology” and “disclosure” laws dilute their intended impact on malpractice suits. Health Aff (Millwood). 2010;29:1611–1619. 17 Iedema R, Allen S, Britton K, et al. Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: The “100 patient stories” qualitative study. BMJ. 2011;343:d4423. 18 Ho B, Liu E. What’s an apology worth? Decomposing the effect of apologies on medical malpractice payments using state apology laws. J Empir Leg Stud. 2011;8(suppl 1):179–199. 19 Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153:213–221. 20 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;18:325–330. 21 White AA, Waterman AD, McCotter P, Boyle D, Gallagher TH. Supporting health care workers after medical error: Considerations for health care leaders. J Clin Outcomes Manag. 2008;15:240–247.
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22 Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: How physicians would disclose harmful medical errors to patients. Arch Intern Med. 2006;166:1585–1593. 23 Gallagher TH, Levinson W. Disclosing harmful medical errors to patients: A time for professional action. Arch Intern Med. 2005;165:1819–1824. 24 Jeffs L, Espin S, Rorabeck L, et al. Not overstepping professional boundaries: The challenging role of nurses in simulated error disclosures. J Nurs Care Qual. 2011;26:320– 327. 25 Gallagher TH, Cook AJ, Brenner RJ, et al. Disclosing harmful mammography errors to patients. Radiology. 2009;253:443–452. 26 Gallagher TH, Waterman AD, Garbutt JM, et al. US and Canadian physicians’ attitudes and experiences regarding disclosing errors to patients. Arch Intern Med. 2006;166:1605– 1611. 27 Garbutt J, Waterman AD, Kapp JM, et al. Lost opportunities: How physicians communicate about medical errors. Health Aff (Millwood). 2008;27:246–255. 28 Shannon SE, Foglia MB, Hardy M, Gallagher TH. Disclosing errors to patients: Perspectives of registered nurses. Jt Comm J Qual Patient Saf. 2009;35:5–12. 29 Lu DW, Guenther E, Wesley AK, Gallagher TH. Disclosure of harmful medical errors in out-of-hospital care. Ann Emerg Med. 2013;61:215–221. 30 Delaney J. Celebrate your profession during National PA Week. PA Pro Now. 2012. http://www.aapa.org/news_ and_publications/pa_pro_now/item. aspx?id=5188&terms=celebrate%20your%20 profession. Accessed February 14, 2014. 31 Hooker RS, Cawley JF, Everett CM. Predictive modeling the physician assistant supply: 2010–2025. Public Health Rep. 2011;126: 708–716. 32 Morgan PA, Hooker RS. Choice of specialties among physician assistants in the United States. Health Aff (Millwood). 2010;29:887–892. 33 Hooker RS, Klocko DJ, Larkin GL. Physician assistants in emergency medicine: The impact of their role. Acad Emerg Med. 2011;18:72–77.
34 Hooker RS, Cawley JF, Asprey DP. Physician Assistants: Policy and Practice. 3rd ed. Philadelphia, Pa: F.A. Davis Co.; 2010. 35 Moses RE, Feld AD. Physician liability for medical errors of nonphysician clinicians: Nurse practitioners and physician assistants. Am J Gastroenterol. 2007;102:6–9. 36 Gore CL. A physician’s liability for mistakes of a physician assistant. J Leg Med. 2000;21:125–142. 37 DeMott DA. Restatement of the Law Third, Agency. Philadelphia, Pa: American Law Institute; 2006. 38 Ledges M, Victoroff M, Ginde AA. Physician assistants and your risk of malpractice. Med Econ. 2011. http://medicaleconomics. modernmedicine.com/medical-economics/ news/modernmedicine/modern-medicinefeature-articles/physician-assistants-andyour. Accessed February 14, 2014. 39 Hooker RS, Nicholson JG, Le T. Does the employment of physician assistants and nurse practitioners increase liability? J Med Licensure Discipline. 2009;95(2):6–16. 40 National Commission on Certification of Physician Assistants Content Blueprint. 2013. http://www.nccpa.net/ExamsContentBlueprint. Accessed February 28, 2014. 41 Guidelines for Ethical Conduct for the Physician Assistant Profession. 2008. http://www.aapa.org/your_pa_career/ becoming_a_pa/resources/item. aspx?id=1518&terms=ethical%20conduct. Accessed February 14, 2014. 42 Stroud L, Wong BM, Hollenberg E, Levinson W. Teaching medical error disclosure to physicians-in-training: A scoping review. Acad Med. 2013;88:884–892. 43 Odegard PS, Robins L, Murphy N, et al. Interprofessional initiatives at the University of Washington. Am J Pharm Educ. 2009;73:63. 44 Chan DK, Gallagher TH, Reznick R, Levinson W. How surgeons disclose medical errors to patients: A study using standardized patients. Surgery. 2005;138:851–858. 45 Eppich W, Howard V, Vozenilek J, Curran I. Simulation-based team training in healthcare. Simul Healthc. 2011;6(suppl):S14–S19. 46 Hamman WR, Beaudin-Seiler BM, Beaubien JM, et al. Using simulation to identify and resolve threats to patient safety. Am J Manag Care. 2010;16:e145–e150.
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Physician Assistants and the Disclosure of Medical Error Douglas M. Brock, PhD, Alicia Quella, PhD, MPAS, PA-C, Lauren Lipira, MSW, Dave W. Lu, MD, MBE, and Thomas H. Gallagher, MD
Abstract Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Recommendations for error disclosure typically consist of an explanation that an error has occurred, delivery of an explicit apology, an explanation of the facts around the event, its medical ramifications and how care will be managed, and a description of how similar errors will be prevented in the future. Although error disclosure
M
edical errors are difficult and challenging experiences for patients, their families, and the health care professionals who care for them. Defined in the 2000 Institute of Medicine report To Err Is Human as “a failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim,” medical errors were first estimated to account for as many as 98,000 preventable deaths1 and 1,000,000 excess injuries per year.2 These estimates may be conservative if considering the underreporting of errors and other adverse events.3 Despite over a decade of interventions to better identify errors and reduce their incidence, they remain a common cause of patient mortality and morbidity.4,5 So, while many investigators continue their efforts to reduce the incidence of errors, others have focused on understanding how
Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Brock, Department of Family Medicine and MEDEX Northwest, University of Washington, 4311 11th Ave. NE, Suite 200, Seattle, WA 98015; telephone: (206) 616-1736; e-mail: [email protected]. Acad Med. 2014;89:858–862. First published online April 18, 2014 doi: 10.1097/ACM.0000000000000261
858
is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. PAs are trained in the medical model and technically practice under the supervision of a physician. They are also commonly integrated into interprofessional health care teams in surgical and urgent care settings. PA practice is characterized by widely varying degrees of provider autonomy. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear.
With the number of practicing PAs growing rapidly in nearly all domains of medicine, their role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.
best to communicate with patients and their families after errors occur.6,7 General agreement exists that effective disclosure of medical errors requires careful delivery of all relevant information, an honest apology, a sincere willingness to help the patient understand the error’s implications, a description of how similar errors will be prevented in the future, and effective management of complex emotional responses.6 Research shows that patients want and expect transparent disclosure of errors,8,9 and evidence suggests that disclosure, if it has any effect at all on patients’ responses to a medical error, has a positive one.9 Correspondingly, surveyed patients have reported being more forgiving and less litigious if they believe their provider is committed to disclosure.10 In List 1, we provide a general framework for effective disclosure based on previous recommendations.6,7,11
and have drafted policies to improve communications between providers and their patients after a serious error.14–16
In parallel with the patient safety movement’s increased emphasis on transparency in communications, especially those disclosing adverse events,11 professional organizations such as the American Medical Association12 and the Joint Commission13 have adopted policies recommending full disclosure. State legislatures, regulators, hospitals, and health care systems also support transparent communication
Still, disclosing errors remains a challenge for individual providers and health care teams.17 Providers may fear malpractice claims, damaged reputations, or disciplinary actions. To address malpractice concerns, 35 states and the District of Columbia have enacted laws making apology for adverse events inadmissible as a statement of fault,16 significantly reducing the size of claims filed and judgments awarded.18,19 Providers may also worry that patients will react with anger or sadness, reject further treatment, or lose trust in their caregivers. These concerns are associated with providers’ depression and anxiety, substance abuse, and other negative responses.20,21 In this article, we focus on how the physician assistant (PA) profession will benefit from inclusion in the investigations and discussions of how to best communicate error to patients. We further propose next steps for researchers and educators seeking to establish a role for PAs in disclosure. PAs and Error Disclosure
Although the literature has explored the roles of risk managers, physicians,
Academic Medicine, Vol. 89, No. 6 / June 2014
Perspective
The Role of Professional Associations
List 1 Elements of Effective Disclosure of Medical Errors to Patients Context • Present information in a timely fashion. • Present, if appropriate, information in multiple discussions. • Present information in language the patient and family can understand. • Focus goals and outcomes around the needs of the patient and family. Content • Explain that an error occurred. • Apologize and express regret for the error. • Convey the underlying elements resulting in the error. • Address medical ramifications for how the error will be managed. • Describe steps that will be taken to prevent the recurrence of the error. • Arrange, if needed, to speak again at a time that is convenient to patient and family. Additional considerations • Expect and be able to manage patient’s complex emotions.
nurses, and emergency medical service workers in disclosing medical errors,13,22–29 it has little discussed the role that PAs might play. In 2012, the 100,000th PA was certified; over 85% of all PAs ever certified are still in practice.30 The number of clinically practicing PAs is projected to increase between 2010 and 2025 by 72%.31 PAs (originally conceived of as general practitioners, although most now practice in surgical and medical subspecialties32 and in urgent care settings)33 are licensed to practice medicine under the supervision of a physician, but also exhibit widely varying levels of autonomy.34 They play active roles in medical decision making and are broadly integrated into the modern health care system, providing direct patient care; conducting physical exams; diagnosing, treating, and managing disease; and prescribing medications. A PA’s specific scope of practice is defined by experience, education, state law, facility policy, and the supervising physician’s delegation of responsibilities. This balance between supervision and independent practice creates unique—and potentially challenging—dynamics for PAs in sensitive disclosure conversations with patients, yet no commonly accepted guidelines for PAs’ role in these conver sations exist. This gap leaves PAs with out a way to determine whether the responsibilities delegated them by their supervising physicians serve their patients’ best interests or to navigate ethical issues that may arise if supervising physicians request PAs to disclose errors on their
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behalf or, conversely, fail to include PAs in disclosure conversations. Just as the roles of other health care providers in the planning and implementation of disclosure conversations have been explored, PAs will also benefit from inclusion in efforts to better understand how to better disclose errors. One might argue that PA disclosure actions can be subsumed under existing physician guidelines. There are legal requirements indicating when physicians should assume primary responsibility for medical error.35–37 Physicians’ liability for PAs’ errors can result in two ways. First, agency law can hold physicians directly liable for the acts of PAs under their supervision.38 This includes cases where PAs are not adequately supervised, breach their responsibilities to patients, or are hired with known dangerous propensities (e.g., alcohol addiction). Second, vicarious liability occurs when supervising physicians are held liable for negligent acts of PAs.38 This includes cases where supervisors have the right, obligation, or duty to control the actions of the violators but fail to do so. However, PAs are held to the same standard of care as physicians, and supervision does not shield PAs from malpractice suits. Some evidence suggests that the incidence of suits against PAs is increasing at a faster rate than for physicians, perhaps reflecting the increasing independence and accountability of PAs.39 Established disclosure guidelines defining the PA role in cases that do not involve supervising physician liability or negligence are lacking.
PA credentialing bodies have not fully addressed the importance of disclosure skills. The exam blueprint used by the National Commission on Certification of Physician Assistants (NCCPA) focuses on medical conditions and clinical skills but does not assess error disclosure or other complex communication skills.40 The NCCPA could promote training in error disclosure skills through continuing medical education. The American Academy of Physician Assistants (AAPA)41 advocates acknowledgment and apology for error in a policy that states: A physician assistant should disclose to his or her supervising physician information about errors made in the course of caring for a patient. The supervising physician and PA should disclose the error to the patient if such information is significant to the patient’s interests and well being. Errors do not always constitute improper, negligent, or unethical behavior, but failure to disclose them may.
This instruction may confuse clinicians in three ways. First, the threshold for disclosure (“if such information is significant to the patient’s interests and well being”) is open to broad interpretation. Second, the policy statement does not describe or acknowledge the essential elements of an effective disclosure. Finally, it does not define a specific disclosure role and designated responsibilities for the PA. In the absence of more objective definitions, variability can be expected in whether an error is disclosed, and if disclosed, how it is delivered. Opportunities for Research and Education in Error Disclosure
Early work describing the importance of fully disclosing medical error called for individual physicians, hospitals and health care organizations, certifying and accrediting bodies, educators, and researchers to each take action.23 However, scholarly examinations of PAs’ role in disclosing error have not been published; a similar call regarding PAs is now warranted. Adopting a proposal from Gallagher and Levinson,23 we have summarized recommendations (Table 1) for key stakeholders to guide research and educational opportunities around PAs and error disclosure.
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Table 1 Next Steps for Providers, Educators, Researchers, and Policy Makers to Define the Role of PAs in Disclosing Medical Errors to Patients Group
Next steps: Training and research opportunities
Individual PAs
• Speak to colleagues about error disclosure • Discuss disclosure policy/plans with supervising physician • Complete error disclosure and communication training • Seek opportunities to practice disclosure skills • Speak to colleagues about error disclosure • Discuss disclosure policy/plans with PA • Complete error disclosure continuing education • Seek opportunities to practice disclosure skills with PA • Model disclosure skills for PA
Physicians supervising PAs
Educators of PAs
• Develop and require education of PAs and PA trainees in the incidence of error and in appropriate evidence-based disclosure practices
Researchers of PA profession
• Explore epidemiology of medical error associated with PA practice • Explore current practice for PA role in disclosure of error • Explore dependent practice role with regard to error and error disclosure • Explore patients’ disclosure preferences • Prospectively explore training interventions for PA role in reestablishing patient trust following error • Prospectively explore training intervention for PA role in error disclose
Professional societiesa
• Create and disseminate disclosure training specific to PA role and practice within interprofessional teams • Educate PAs and PA trainees about error disclosure • Establish evidence-based guidelines for PA disclosure
Accrediting bodiesb
• Establish requirements that licensed PAs understand the nature of medical error and the importance of disclosure
Abbreviation: PA, physician assistant. American Academy of Physician Assistants; Physician Assistant Education Association. b National Commission on Certification of Physician Assistants. a
Research
From a research perspective, it would be beneficial to determine the nature and prevalence of medical errors and the frequency of disclosures specifically associated with PAs. Researchers should also explore the role that the relationship between the PA and supervising physician plays in the occurrence and disclosure of medical errors involving PAs. They should seek to understand how PAs and their supervising physicians identify medical errors requiring disclosure and how they believe disclosures should be discussed, planned, and executed. Pinpointing where the beliefs of PAs and supervising physicians differ will help identify areas of synergy and conflict. A logical next step would be to survey PAs and supervising physicians about their beliefs and experiences around the disclosure of medical errors.
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The importance of systems errors resulting from a cascade of mistakes across health care teams warrants continuing attention. PAs frequently function in teams, making this especially germane. Some investigators have looked at teams consisting of nurses and physicians, where disclosure of error may be hindered by traditional roles and power differentials.24 PAs may be similarly limited in their capacity to fully participate in error disclosure conversations. Conversely, physicians may delegate the task of disclosure to PAs. As investigations continue to explore the role of teams in the reduction and disclosure of error, it would be beneficial to clarify the PA’s role, providing an increased understanding of how best to leverage the skills of the PA as part of the health care team. Education
Teaching PAs the skills of error disclosure is hampered by a dearth of
policy statements directing educational programs and hospitals to attend to the unique PA practice model. Professional standards for error disclosure do exist for hospital and clinical settings,11 and error disclosure skills are increasingly taught as part of undergraduate medical and nursing education. However, the extent to which individual PA programs have implemented curricula specific to error disclosure is not well understood. PA training should include and reinforce the components of effective disclosure, discussion of the unique role PAs might play in team disclosure, and the appropriate steps to resolving conflicting views between team members. These efforts will benefit from examination of the growing body of literature that explores the training of resident physicians and medical students.42 Interprofessional training experiences also offer especially fruitful means to train PA students in the complexities of effective error disclosure.43 Training can be achieved through didactic instruction, but complex communication skills will benefit from simulation or the use of standardized patients. Standardized patients provide a common simulation modality with a high degree of flexibility and fidelity necessary to train complex disclosure communication skills in interprofessional contexts.44 Simulation is also a relatively economical and practical means to teach complex communication skills,45 including error disclosure.46 Physician modeling of effective commu nication skills, whether in training or in practice, may better prepare PAs for challenging conversations, including disagreements with physicians and health care team members. In each case, opportunities exist for the creation and dissemination of novel trainings to ensure awareness and support effective disclosure. However, although training opportunities exist, it is not clear what error disclosure instruction PA programs may already provide or to what extent existing curricula can be modified to include teaching these skills. Training solutions are likely to be highly program specific. Discussion and Recommendations
Medical errors remain a significant cause of injury and death. When errors occur, patients and their providers struggle to understand what has happened and how to ensure continuing care. PAs work with
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physician–supervisors and as members of interprofessional teams. They practice in a wide variety of medical domains with varying degrees of independence. However, unlike their physician and nursing colleagues, the PA profession and its training institutions have yet to focus significant attention on the critical task of communicating medical error to patients. PAs need to recognize the scope and nature of error, acknowledge their role in the prevention of error, and understand the legal, professional, and emotional impacts of error disclosure. In this article, we call for inclusion of PAs in research and educational explorations around error and for the establishment of practice guidelines supporting PA inclusion in discussions around the disclosure of a medical error. PAs bring strong clinical training and broad experiences in the delivery of patient care. They establish trust, and patients look to them to ensure their safety. Policy statements and disclosure guidelines, informed by research, directing training programs to acknowledge PA individual and interprofessional team roles would further support efforts to reduce error and improve the quality of patient care. We recommend that the AAPA define and adopt initial policy describing the PA role in discussions, planning, and transparent disclosure of error that aligns with the standards already described by the American Medical Association12 and the Joint Commission.13 Specific to the PA role, the AAPA should develop policy statements recommending that supervising physicians and PAs discuss error when it occurs and jointly develop a plan for the disclosure of that error. We recommend that, whenever possible, both the supervising physician and PA participate in the actual disclosure and that the PA adhere to the same standards (e.g., apology) expected of physicians in these conversations. Furthermore, guidelines must support PAs in consistently advocating for the transparent disclosure of all errors. When disagreement occurs between a supervising physician and PA, guidelines should emphasize the value of requesting that a third party mediate. PAs should not be delegated sole responsibility for disclosure, nor be placed in the position of holding principal responsibility for disclosing another’s error. Guidelines
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should reinforce the necessity of reporting all errors, minor or serious, to supervising physicians. These recommendations better align the PA role with their physician and nursing colleagues while also encouraging PAs to accept personal responsibility when having made a medical error. We encourage the Physician Assistant Education Association (PAEA) to broadly endorse evidence-based training in the specific communication skills necessary for effective disclosure of error. The PAEA can promote the work of programs already teaching disclosure skills and provide training recommendations. These recommendations would initially be based on best-practice models for physicians and nurses but would later evolve to speak specifically to the PA role. The Accreditation Review Commission on Education for the Physician Assistant defines educational standards for the PA profession. We encourage the commission to review emerging standards around error disclosure and integrate appropriate PA educational program standards to parallel these efforts. Research remains to be done before final policy statements and PA role-specific guidelines training can likely be adopted. The nature, severity, and incidence of errors associated with PA practice are poorly understood, and how supervising physicians and PAs respond to error has not been closely examined. However, the PA profession, in collaboration with their fellow health care professions, can establish initial standards that can then be subject to empirical examination. Ultimately, this research can address many critical questions of PA practice. For example, should PAs and their physician supervisors always disclose together? What characteristics of the error and of the patient need to be addressed in making disclosure decisions? What contextual factors play a role? Should guidelines vary across medical specialty and degree of PA autonomy? These and many other questions warrant continuing investigation. Most, if not all, PAs will experience errors in their careers. PA and other medical and interprofessional researchers and educators should focus attention on establishing the most beneficial role for PAs in disclosure. This will require research to establish what constitutes existing practice and that examines evidence-based approaches to
defining best-practice models for PAs. Building on this body of work, PA training programs should then increase their focus on training students in the skills necessary to reduce error, but also how to openly and transparently communicate error when it does occur. Guidelines specific to the PA role will fill an existing gap in discussions around medical error and provide opportunities to improve the quality of care. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Dr. Brock is associate professor, University of Washington Department of Family Medicine and MEDEX Northwest, Seattle, Washington. Dr. Quella is lecturer, University of Washington Department of Family Medicine and MEDEX Northwest, Spokane, Washington. Ms. Lipira is research scientist, University of Washington Department of Medicine, Seattle, Washington. Dr. Lu is assistant professor, Northwestern University, Department of Emergency Medicine, Chicago, Illinois. Dr. Gallagher is professor, University of Washington Department of Medicine, Seattle, Washington.
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