ORLANDO—2000 saw the release of To Err Is Human: Building a Safer Health System, the first in a series of publications from the Quality of Health Care in America, which was a project initiated by the Institute of Medicine. This landmark report noted that approximately 98,000 deaths occur each year in the U.S. due to medical errors in hospitals.1 Despite this sobering statistic, many barriers prevent healthcare professionals from feeling comfortable reporting medical errors or other sensitive healthcare work-related concerns.
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At the 2022 ACR Education Exchange, Karina Torralba, MD, MACM, RhMSUS, professor of medicine and head of the Division of Medicine, Rheumatology and Immunology, Loma Linda University School of Medicine, Loma Linda, Calif., spoke on this subject, offering potential solutions to the problem.
Dr. Torralba began by defining the term psychological safety, which refers to the perception that there are no negative consequences to oneself, status or career when taking interpersonal risks, such as reporting mistakes or problems. Some of the reasons medical trainees refrain from reporting problems and errors include the perceived harm such reporting may have on the reputation of their program, the concern that such reporting will reflect poorly on the individual resident or fellow (i.e., they may appear incompetent) or the legal liability issues that may be involved in reporting a mistake. Dr. Torralba noted that after a trainee commits a medical error, they may experience increased anxiety about future errors, have decreased job confidence and satisfaction, suffer from insomnia and have thoughts of leaving medicine altogether.
Why is it important for trainees and others at medical institutions to feel comfortable discussing problems they have encountered? Creating a safe space for open discussion about such issues can improve a trainee’s sense of wellness and enable growth, making them better learners, scholars and future faculty members.
In this vein, allowing faculty to feel comfortable expressing concerns may improve their sense of wellness and productivity, and enhance a program’s ability to retain talented faculty members in the school or division.
Finally, with regard to patients, who are the most important stakeholders in the healthcare system, promoting psychological safety can lead to improvements in patient safety and quality of care.
Dr. Torralba described how each rheumatology fellowship training program has two main curricula: the explicit curriculum and the hidden curriculum. The explicit curriculum refers to teaching that allows trainees to acquire specific medical knowledge and skills, which are usually imparted via formal didactics, conferences and workshops.
The hidden curriculum involves learning that comes through observation of faculty attitudes and behaviors, including those directed toward trainees, colleagues and patients. The hidden curriculum is not explicitly laid out for faculty, but depends on a program’s culture and the individual sense of responsibility each faculty member feels for role modeling good habits and behaviors.
As trainees progress from novice to more expert clinician status, they ultimately can achieve autonomy and possess the knowledge, skills and attitudes that result in outstanding clinical care by observing good behaviors on the part of their mentors and teachers. Faculty members must make it clear they welcome discussion of problems and mistakes so that problematic situations can be adequately addressed and corrected, said Dr. Torralba.
Clinical training in medicine—and particularly in rheumatology—can often involve ambiguity and uncertainty. Whereas the pre-clinical years of medical school are spent in the controlled learning environment of the classroom, clinical training takes place in the less controlled context of the clinic and hospital, where interpersonal interactions abound, the answers are not always clear and the learner must be willing and able to take interpersonal risk to grow.
The COVID-19 pandemic has added to the sense of uncertainty and unpredictability in medical training. Many trainees have had to learn how to evaluate and care for patients via telemedicine, a means of clinical care in which most residents and fellows have received little or no formal training. Indeed, even the faculty members overseeing the use of telemedicine may not have significant experience with this method of care.
The pandemic has also reduced participation in patient safety investigations and made it more challenging to identify systematic problems affecting patient care.
Finally, many trainees and faculty members have reported increased stress, increased challenges regarding workload and a decreased sense of professional development throughout the past two years.
Psychological safety is the perception that there are no negative consequences to oneself, status or career when taking interpersonal risks, such as reporting mistakes or problems.
Fostering Psychological Safety
With these obstacles in place, how can a program foster a sense of psychological safety and allow trainees and faculty members alike to express concerns? To create a workplace group culture that supports psychological safety, Dr. Torralba discussed the CENTRE acronym:
- C stands for confidentiality, meaning individuals speak only about their own experiences, share only what the group agrees can be discussed and can trust that these conversations are private and not subject to gossip;
- E stands for equal airtime, meaning each member of the workforce group is given equal opportunity to participate in discussions and allowing participants to take turns providing productive feedback;
- N stands for nonjudgmental—or respectful—listening, which entails trusting that what someone says is a genuine experience;
- T stands for timeliness, which refers to enabling the discussion of issues close to when they first arise and ensuring group discussions start and end on time;
- R stands for to right to pass, meaning a participant in a group discussion should be allowed to skip their turn in the conversation if more time is needed for reflection; and
- E stands for engaged, meaning everyone is encouraged to be an active participant in the discussion and to take it seriously.
Dr. Torralba’s talk was outstanding and indicated why it’s so important to support psychological safety in rheumatology training programs. Although it may be human to err, it’s certainly not always second nature to be able to construct a safe space for reporting errors, and the need for progress in this area remains clearer than ever.
Jason Liebowitz, MD, completed his fellowship in rheumatology at Johns Hopkins University, Baltimore, where he also earned his medical degree. He is currently in practice with Skylands Medical Group, N.J.
- U.S. Institute of Medicine Committee on Quality of Health Care in America, Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, D.C. National Academies Press. 2000.