Anthony Orsini, D.O 0:00
But Todd, if I told you that I just, you know, gave your wife an overdose, or that you have cancer, I can say the nicest things in the world. If I'm sitting back like that, your brain's gonna say he says he's sorry, but he looks like somebody who wants to talk about the NFL draft coming up.

Austin Littrell 0:26
Welcome to Off the Chart, a business of medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders, and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Latralla. I'm the associate editor of Medical Economics, and I'd like to thank you for joining us today. In today's episode, Medical Economics Managing Editor Todd Shryock sat down with Dr. Anthony Orsini, a practicing neonatologist, founder of the Orsini Way, and member of the Medical Economics Editorial Advisory Board, to talk about medical error disclosure. Dr. Orsini points to a recent survey finding that fewer than half of physicians say they know the exact steps to take when an error occurs, and he argues that the distance between knowing an error happened and knowing how to talk about it is where most malpractice claims actually begin. Todd and Dr. Orsini walk through the mistakes that turn a disclosable error into a lawsuit, things like staying silent, speculating about a cause before the review is finished, retreating into medical jargon, and letting body language contradict every empathetic word in the room. They also get into the data behind transparency programs, the apology laws Dr. Orsini says are now in the books in 39 states. Whether a harmless error still has to be disclosed, and who on the care team should be the one to actually deliver the news. And one more note before we start: Dr. Orsini's new medical economics video series, Conversations That Matter, debuted last week, September 2nd. The first episode looks at why breaking bad news is one of the hardest tasks in medicine, where physicians tend to go wrong, and how a more structured and empathetic approach keeps the devastating moment from getting worse. A link to that first episode is in the show notes below. With that said, Dr. Orsini, thank you for joining us. So now let's get into the episode.

Todd Shryock 2:00
I'm here with Dr. Anthony Orsini. He's a practicing physician and founder of the Orsini Way, a program and digital platform that shows healthcare professionals a way to communicate and enhances patient satisfaction and improves outcomes. Doc, thanks for joining me.

Anthony Orsini, D.O 2:16
Thanks for having me, Todd. It's been I've been looking forward to this for quite some time. This is great.

Todd Shryock 2:21
Today we're going to talk about medical error disclosures. That is a very touchy topic with physicians, and I understand there are some common mistakes that physicians often make. Tell me about some of them.

Anthony Orsini, D.O 2:35
Well, medical error disclosures is probably one of the hottest topics right now in medicine, and CMS now and JCO are now requiring you know training for both for residents and for physicians to be trained on how to do this because we understand just how important it is for both the patients, the families, and the and the physicians and providers to disclose these medical errors quickly and transparently, and how you do it can make the difference between a major lawsuit or even in some cases rebuilding trust with that patient who disclosed the medical errors. So it's very important that you know we have we do it right. So you know, first the first important thing about medical error disclosures is first you have to disclose them, and often when a medical error occurs, physicians don't know what to do. And in fact, in a recent study, less than 50% of physicians stated that they knew the exact steps that they should take when a medical error occurs, and this is even more important when you're a primary care physician and you don't have the hospital that to back you up. And so, the first important thing is to is to have the disclosure. You know, before the University of Michigan study came out years ago, the the culture of medicine was just deny and deflect, and so even recently, you know, I've had some some recent exposure to a medical error in in one of the hospitals that I work at recently, where not only didn't the physician know the proper steps, but neither did anyone else in the hospital, and so the biggest mistake you can make is to not disclose it. And if you do disclose that error, make sure you do it properly because sometimes thinking you're you're maybe a very person who really thinks you're doing the right thing as a physician, and you go and disclose that medical error, but do it improperly, and you're not prepared for it. You could often make things worse. So that's one of the more important things to know about medical error disclosures. Secondly, the real goal here is to be transparent and honest, and it's very easy for a physician or a provider. To get defensive, to get nervous, and you know when we are asked to do something that makes us uncomfortable, we're asked to do something that we're not trained to do. We don't know whether we're doing it correctly. Of course, it's going to create anxiety. So it's very important that you know how to disclose it. That you disclose it transparently, and that you do it correctly using the proper body language. You showing the goal here is to show empathy and understanding, and to not get defensive. And you can imagine if you put yourself in the shoes of a physician who was just involved in a medical era, that you know it would create anxiety, and you would probably get defensive automatically, especially if the family and patients are appropriately upset, and they should. So it's really important to make sure that you are transparent and that you use the proper body language, and then third, I would say the third most important thing is to not use medical jargon, and to you know, when we are as human beings are uncomfortable in a situation, we revert to an area that we are comfortable in, and this is the same as you know when we've been teaching doctors how to deliver tragic news. It's natural for us when we're in an uncomfortable situation to go to where we are most comfortable, and where physicians and nurses are are most comfortable are back to medical school or when they're doing rounds, and so it's natural for us to just start speaking in medical jargon and to not explain things, or to assume that the patient or family that we're disclosing the medical error already knows what to do, what you've done, and how you've thought about. So you really want to make sure that you avoid that medical terminology. And then fourth is you know most language and communication 80% of it is nonverbal, and we as human beings are making millions of assessments per second on someone's body language, and so if we are uncomfortable, if we're feeling defensive, and we're not aware of our body language, our nonverbals and our verbal cues will be totally mismatched.

Anthony Orsini, D.O 7:27
And as human beings, the human brain will always look at the nonverbal to see what the message is. And so we have to make sure that our verbals and nonverbals are consistent. Here's an example: I can tell you that I'm so sorry, and that this is something that should never happen. And really, use all empathetic words that I can. But if I'm standing up and I'm telling the patient and family about the error, my nonverbals are saying that I really don't want to be here, that I want to be out. Or if I'm sitting too casually, or if I'm tapping my foot, or I'm being very nervous, the message is not going to come clear. It's certainly not going to be empathetic, even if we say everything that we want to. And then, in a disclosure conversation, the family needs for you to know that you understand their fear. So empathy, true empathy. You have to put yourselves in their shoes. You know, I've had physicians say to me, "Well, I disclosed a medical error, and the family got really nervous, really mad, and they started yelling. Well, I probably would too. And so, if you understand that this is a natural response, you're not going to react to that, and that's the best thing that you can do. And then the final thing I would say: the biggest mistake that people make is that in our efforts to be transparent, we speculate and we try to tell a family, especially if they want some answers about what happened, you know, this was my fault, or this was an error of the surgeon, or etc. But the reality is that these things are rarely a single person error. That there's processes in place, and that usually this is a breakdown in process. So it's important to be transparent, but never speculate. That doesn't mean that we're going to hide anything from the family, because what's really important is going to be that follow-up conversation after the review takes place. When you sit with the family and you tell them exactly what happened, but you may think that you know what happened, only to find out later on that it was not exactly so. That's one of the bigger mistakes that we see when we're training physicians on disclosure is that we try to do the right thing and automatically speculate on what went wrong, and that's the worst thing that we can do.

Todd Shryock 9:59
How hard. Is it for physicians to admit an error that may have impacted somebody's life in a negative way? I mean, human nature is very difficult to admit an error in anything, let alone something as serious as medical practice.

Anthony Orsini, D.O 10:15
It is extremely hard, but what the you know studies have shown over and over again what the families really want to hear is they want to hear "I'm sorry. They want to hear an apology, and this apology is so important not only for the disclosure of medical errors, but it's important for closure from the family. The family needs to hear that, and you see time and time again in case studies where it comes out in the court documents that really all they wanted was someone to say they were sorry, it's so important that at last count there were 39 states in the country that have what is so-called an apology law, apology law, and there's either full apology laws or there's partial apology laws. Apology laws basically mean that if I say I'm sorry as a physician, that can't be brought up in the court. Extremely important because everyone knows they want to they want they want to hear that, and and having the apology law encourages physicians to say that. Now, some states you can't say I'm. I apologize. This was my fault, but you can say I apologize that this happened. I'm so sorry. This is not at the standard of care that we practice at this hospital. This is not acceptable, and we're going to get down to the bottom of this and figure out where the process broke down, but it's important to say you're sorry. In contrast, Todd, you'd be surprised. You said it's really hard for someone to admit it's their fault. In my experience, when we do the role playing with the doctors and the nurse, sometimes they say it's their fault too much. They try to do the same thing. Now, here's here for instance, right? A physician writes a dosage of morphine, for instance, and the dosage was too high, and the patient stops breathing, needs to be resuscitated, does okay, doesn't do okay. It doesn't really matter. The physician wrote the wrong order. It is a natural thing. Most physicians would come right out and say, you know, because the family is going to say, "Well, who did this? I did that. I wrote the wrong order. But if you know anything about medicine, especially in a hospital setting, or even in an outpatient setting, if you write a prescription as a primary care doctor, and you write for triple the dose. We have checks and balances in place. That pharma is going to get that prescription, and the pharmacist is going to call me, and they're going to say, "Doctor, we're saying you didn't read me point 1.2 milligrams. You meant point one milligrams. And so, in a hospital setting, there's even more checks and balances where I would write the order. The electronic medical record a lot of times will flag that order if it's wrong. If the electronic medical record doesn't flag the order, then the pharmacist checks the order, and then the nurse has to check it again before she gives it. So for someone to get an overdose, you have to it has to fail in multiple spots, and so that's why we always talk about the process breaks down, and so physicians sometimes jump to conclusions. I mean, yes, I was the one who wrote the order, but somewhere this process broke down.

Todd Shryock 13:33
Being sued for malpractice is is one of the biggest fears of of physicians. Do you find that that being more transparent and being more open when a mistake happens does that reduce the likelihood of of being sued?

Anthony Orsini, D.O 13:49
Oh, and and not only does it, but there's a lot of data that shows that right. So back to in 2010, University of Michigan was the first paper that was published, showing that going from a deny and deflect kind of procedure, which was standard of care before then, to a transparent procedure process where you're transparent, the physicians disclose the medical errors in a timely manner. It showed a significant reduction in lawsuits. It showed a significant reduction in in time of of of closure. In fact, new claims went down from the University of Michigan study by 36% by disclosing medical errors in a transparent manner. So lawsuits went down by two thirds. New claims went down by one 1/3, and their total liability costs went down by 60% And perhaps the most important statistic is that their time of resolution of the claims went from over one and a half years to below a year. And why is that so important? It's important because it's. Time for both the physician and the patient to start healing. We need closure, and we don't want this to go on. So it actually, we have a lot of data. There's stuff at a University of Illinois. There's Massachusetts. So the evidence is really clear that this that having a communication resolution program and being transparent decreases costs and decreases anxiety, and it is your best chance to rebuild trust with that family.

Todd Shryock 15:28
When you were talking about body language earlier, I'm wondering: is that something that you can train people to do, or do they have to actually believe in the apology they're issuing and have it come naturally.

Anthony Orsini, D.O 15:42
That's a great question. You know, I've been training doctors on having difficult conversations since 2010, and we a lot of programs that we use use videotaped role playing with with the physician, so that we could comment on their body language. So yes, body language is something that can be learned. So our nonverbal cues come from one involuntary, right? If we're feeling nervous, you see it. You are looking at me right now. Our brains are processing someone's nonverbal language millions of times per second. That's incredible, right? I mean, millions of times per second, you're looking at me saying, and your mind is automatically calculating: Is he a nice guy? Is he full of you know what? Is he nervous? And so, you know, it's very important that we understand that. So, body language can be either involuntary when we're not paying attention, but also can be voluntary. We have to understand that by putting my hands above the table, it's showing more confidence. Being down like this makes me more nervous. By standing up, I'm sending one message. I really don't want to be here. By sitting down, another message. How I sit, you know, I have a natural tendency when I sit to sit back in my chair, cross my legs, they call that in body language a long sitter, you know. And so that's my go-to position when I sit. Well, that's a very appropriate posture when I'm speaking with a patient, trying to build rapport, being friends with them, etc. it's great for my patient experience. But Todd, if I told you that I just, you know, gave your wife an overdose, or that you have cancer, I can say the nicest things in the world. If I'm sitting back like that, your brain's going to say he says he's sorry, but he looks like somebody wants to talk about the NFL draft coming up, and so we can teach that nonverbals, and it's a powerful tool in any conversation, whether it's just to make friends with someone, or it's something during like such a serious conversation like medical errors.

Keith A. Reynolds 18:02
Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60 seconds, we deliver proven, real-world tactics you can plug into your practice today. Whether that means speeding up check-in, lifting staff morale, or nudging patient satisfaction north, no theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before lunch, but the best ideas don't all come from our newsroom. They come from you. Got a clever workflow hack, an employee engagement win, or a lesson learned the hard way? I want to feature it. Shoot me an email at kreynolds@mjhlifesciences.com with your topic, a quick outline, or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching, and I'll see you in the next B2 Management Minute. One

Todd Shryock 18:55
thing that we haven't talked about regarding medical errors is what actually should be considered an error that needs to be shared with a patient? For instance, there's a big difference between I operated on the wrong leg and I wrote a fairly harmless prescription for an antifungal instead of an antibiotic or something like that. Like, do you disclose every error? Like, is there a line there, or how does that work?

Anthony Orsini, D.O 19:23
That's a fantastic question, and the short answer to that is yes. You disclose every error, and the reason for that, number one, it's the right thing to do. But the other reason is that no matter how small the error was, when the patient finds out that it happened, they're going to be angry. Why didn't you tell me? And so I recently worked with a hospital where there was it was a baby with an overdose of morphine, and it was such a minor error. This this was a hospital. Out of state, and we were doing some some consulting with them. It was a very minor error. Baby really had no adverse effects to it at all. Maybe was a little sleepy, but certainly not stopping breathing. And it turned out to be the pharmacist's mistake after we did the process analysis. It was just mixed incorrectly, But everyone did decided that they weren't going to say anything. Nothing happened. Why make a big deal? Well, guess what? The mother found out, and now we had something-a major event. Mothers was angry, who now doesn't trust the hospital staff whatsoever anymore. If it's a primary care doctor, rest assured that they're changing their doctor. Whereas it was such a minor event that if the physician or someone at the hospital had just said, "Hey, listen, we just want to let you know this happened. We're looking into the process, disclose that error in correctly. That mother would be much different in her response to that, because in the end, Todd, what's really important to know is that remarkably, most patients understand that we are human beings, and as much as we should all point to try our goal as perfection, people understand that not everybody's perfect and no system's perfect. And so, by saying, "Listen, if that physician had said, "This is what happened. We got down to the bottom of it. I just want to let you know your baby's fine. I'm I'm gonna do everything I can to rebuild your trust, and I'll let you know what we've done to make sure it doesn't happen again. That would have been a non-event.

Todd Shryock 21:56
What about when someone on the care team, let's say a nurse, for instance, is the one who makes the mistake? Who makes that call? Like, does is should it be the nurse apologizing, or should it be the physician who's leading the care team making that apology?

Anthony Orsini, D.O 22:12
Fantastic question, and I think in in every event, each one is different and unique. What we do know is that when the physician is involved, especially if it's a primary care doctor or a physician that you already have a relationship with, so in a hospital setting, maybe the hospitalist or the the physician who's the attending, that when the physician is involved with the actual disclosure, it goes much better. The old days, when I was younger, and I'm older than I look, I hope, or maybe I'm I look older than I am. I don't know. You tell me. But in the when I was training, when a medical error was occurred, the first thing the patient or family would see would be the hospital attorney, the risk manager walking, maybe another legal counsel, and the patient sitting in their bed, going, "What's going on here? This must be a big deal. And then the first question they would ask is, "Well, where's the doctor? Why isn't she here? Why isn't he here? And so the physician should be leading that. Whether the nurse is there or not is really depends on the individual case. But in general, what should happen is when that error occurs, the physician should contact their risk manager. There should be a pre-interview meeting with the nurse when it's the nurse's fault. Even if it's not the nurse's fault, she should be there. They discuss what they know and what they don't know, and they come up with a plan on what they're how they're going to do this, and they then the doctor will then run that. If the nurse, if it's appropriate for that to be the nurse there, yes. If it's not, maybe it's not. You know, because again, you might think it was the nurse's fault, but you might find out that it really wasn't. So that's the the long answer, but a great question about who should be there. Certainly, three guys with suitcases and somebody else in a suit should not be the ones to disclose the medical error when the physician's right there.

Todd Shryock 24:22
Is there anything else that you would like to mention that we haven't talked about?

Anthony Orsini, D.O 24:27
Well, I really want to talk about this whole idea of knowing what to do. You know, in a recent survey, less than 50% of physicians actually knew what to do when a medical error occurs. I know that it's a little bit easier for people that are working in hospitals because most major hospitals have a risk management department. If you are not in a hospital setting, if you're a primary care physician, you probably have a risk management person who's part of your malpractice. Insurance company, they usually have someone that you can contact 24/7 when this happens, but they don't always answer the phone, and you may not have to do that. It doesn't take a lot of time to get prepared to learn. I mean, as physicians, we are constantly being asked to do CMEs. We're constantly being asked to learn about this, to learn about that. Medical errors is something. Why would we ever want to think about it? It's never going to happen to me. You know, it's bad mojo. If I if I think about it, it might happen. Let's just pretend it's kind of like people don't want to get life insurance, right? If I get life insurance, you know I'm going to die. I would say that there, you know, there are are learning modules to take, and we certainly do that ourselves. But there are programs out there that you really do want to be prepared, and I hope that you'll never have to use it. But if you're in a big practice or a small practice, maybe it's not you that needs it. Maybe one of your partners will need it. You know, so you could be the managing partner. It it doesn't take a lot of time, and it's certainly through the learning modules, etc. Very inexpensive to do that. Many of them, like us, give out CMEs, etc. But my biggest message would be like, they happen. You know, at a conservative level, there's 50,000 deaths a year due to medical errors. But small errors, like you mentioned, are so important. Why not be prepared? Know how to know how to disclose that error. Understand not just you know don't read a book about what to say. We don't want to know what to say. We want to know how to say it, and that's what we've been doing. You know, my organization's been doing that for 15 years now about teaching people how to say things. So my big message is: it. I hope it never happens to you, but be prepared when it does happen, and maybe some of the tips that I gave you might help you at least if it happens before you have time to get trained.

Todd Shryock 27:11
Very good, Doc. Thanks for joining me. It's a fascinating topic. It

Anthony Orsini, D.O 27:14
was a pleasure, Todd. Thank you so much.

Austin Littrell 27:28
Once again, that was a conversation between Medical Economics Managing Editor Todd Shryock and Dr. Anthony Orsini, a practicing neonatologist, founder of the Orsini Way, and member of the Medical Economics Editorial Advisory Board. You can find a link to the first episode of his new series, Conversations That Matter, in the show notes below. My name is Austin Latrell, and on behalf of the Whole Medical Economics and Physicians Practice Teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. As always, be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice. You can find us by searching Off the chart wherever you get your podcasts. Also, if you'd like the best stories that Medical Economics and Physicians Practice published, delivered straight to your email six days of the week, subscribe to our newsletters at medicaleconomics.com and physicianspractice.com. Off the chart, a business of medicine podcast, is executive produced by Chris Masolini and Keith Reynolds, and produced by Austin Latrell. Medical Economics and Physicians Practice are both members of the MJH Life Sciences family. Thank you.

Transcribed by https://otter.ai