I recently ran into a colleague who asked me whether I was still writing my column. I said yes and that I was currently writing an article on Selma H. Fraiberg. His response, "You don’t hear that name very much anymore," disappointed me. I responded by saying whenever a colleague, friend, or family member is having a baby, I send them a copy of "The Magic Years" with a clear statement that both parents must read it. It is clearly the best book on child rearing ever written in my opinion.

Ms. Fraiberg, creator of "The Magic Years," was a master’s in social work–trained psychoanalyst affiliated with the department of psychiatry at the University of California, San Francisco, who translated numerous concepts about babies, parents, and the first few years of life with wonderful examples of the type of incidents that every parent faces. She was highly regarded 50 years ago and received a great deal of praise for her book. But, at that time, there was a lot of prejudice against nonmedical degree psychoanalysts, and her book was not regarded as highly as I believe it should have been.

©thinkstockphotos.com

When I was a resident, I was required to read "The Magic Years," understand it, and be able to discuss it. Our teachers were concerned that we were busy being residents but also having children, and we really had to understand child rearing so that we could serve as resources for our residents and our analytic trainees.

Ms. Fraiberg translated psychoanalytic theory into child-rearing guidance in the book by looking at three age ranges: the first 18 months, 18 months to 3 years, and 3-6 years. Some of the examples are still fresh today, even though the book was published originally in 1959.

Dr. T. Berry Brazelton, the renowned pediatrician, wrote an introduction to the 50th anniversary of the book (New York: Scribner, 2008) saying that Ms. Fraiberg "makes each stage of emotional and mental development come alive!" I agree wholeheartedly. Furthermore, I would say that the concepts in the book can inform psychiatrists in our efforts to help our patients. After all, raising children (and growing up) is fraught with pitfalls. As Freud said early in his career, there are three impossible professions: governing nations, raising children, and psychoanalysis.

How the magic unfolds

Parents are often confused by things that children do or say, imaginary friends and animals – frustrating the child by pointing out reality when the child needs that imaginary friend or animal to survive. To the child, these imaginary friends and animals are not silly at all. A good example is what a niece of Ms. Fraiberg’s called the "Laughing Tiger."

Her niece, who was 2 years, 8 months old at the time, created the Laughing Tiger and many other imaginary companions at a time when she was afraid of ferocious animals. The niece’s "imaginary tiger gives her a kind of control over a danger which earlier had left her helpless and anxious," Ms. Fraiberg wrote. Instead of viewing this companion as problematic, it makes more sense to see this use of imagination as a healthy sign. Indeed, the child "can maintain his human ties and his good contact with reality while he maintains his imaginary world," she writes. "Moreover, it can be demonstrated that the child’s contact with the real world is strengthened by his periodic excursions into fantasy."

Virtually every chapter of the book is filled with insights that explain how young children interpret their world, which makes it invaluable for new parents. As we all know too well, the pitfalls in raising a child and growing up are many. I have not referred back to it for personal reasons in recent years. After all, my children are 54, 52, and 50 years old. But my wife and I did make very liberal use of the book throughout the years – while all of our friends were using Dr. Spock to help them navigate the waters of child rearing.

Mastering fear

Ms. Fraiberg gently guides the reader in an understanding of the child’s developing mind, why they cry, why they have tantrums, why they use imagination and how to help mom deal with the child’s anxiety. Take the example of a 2-year-old who was afraid of the family vacuum cleaner. Some young children control their fear of what must seem like loud monsters to them by learning to control the switch. But this toddler, who was known for his tendency to carry around a pocket-size screwdriver, was not satisfied with that solution. He had another idea: "Tiny screws and wheels were removed and lost in this frantic search," Ms. Fraiberg wrote. "...Finally, this limping monster issued its dying croak and succumbed without giving up its secret."

After a couple of years, the youngster’s "drive to investigate" was motivated by factors other than anxiety. Instead, he found investigation, discovery, and reconstruction to be pleasures in themselves. Interestingly, this child grew up to be a physicist.

There are many lessons here for psychoanalysts and our patients. One is that children experience things in which adults have no conscious memory. This means that we can help patients become better parents if we can get them to empathize with the child’s fears and frustrations.

Attachment, active handling

Ms. Fraiberg tells the story of an infant who developed an extremely severe sleep disturbance when she was 8 months old. Around 11 p.m. nightly, the infant woke up screaming, despite her parents’ efforts to calm her down. When her parents checked on her, the baby clung to her mother.

The episodes started after the baby woke up one night when the parents were out and had left her in the care of a babysitter. These meltdowns came in contrast to the child’s earlier reactions to her parents’ absence: "She never seemed to mind before if she wakened and saw a babysitter instead of us," Ms. Fraiberg quotes the parents as saying. "We just didn’t expect anything like this." What might explain this sudden new reaction?

"We know that the attachment to the mother is especially strong at this stage of development and a strange face may disturb the child at this age, even when encountered in the daytime," she writes. "The reaction to the strange face, as we have seen, is an indication of the discrimination of the mother as a person and the recognition of her as the person who gives satisfactions and protection. The stranger’s face that appears when mother’s face is expected produces anxiety because it symbolizes the absence or loss of the mother."

As you can see from that scenario, Ms. Fraiberg lets the mother know how essential she is and how early the child is distressed by the mother’s disappearance. In general, some people argue that they have to go on with their lives and that the baby will have to learn to be away from their mothers. We have to help our patients understand that the learning process is a burden for the infant. Some kids take a long time to learn how to separate from mom. Ms. Fraiberg helped the baby under discussion overcome her anxiety through nursery games in which her mother would hide her face one minute and return the next. She said the game allowed the baby to "work out the problem in her waking hours so that gradually the sleep disturbance disappeared."

Ms. Fraiberg also applies psychoanalytic theory to explain why a 9-month-old with a healthy appetite stopped eating and went on what she calls a "food strike" that lasted for 3 days. The child’s mother – who wanted the meals to be neat and orderly events – had been feeding the baby. So what brought the strike to an end?

One day the child’s father took over the feeding, and to the parents’ surprise, the baby started eating again. The mother immediately blamed herself, but the child’s behavior had nothing to do with her, per se. When the baby’s father tried to feed him, he grabbed the spoon and "plastered his face with strained carrots. Papa seemed quite unconcerned." When the baby turned his cup upside down, allowing his milk to spill all over the floor, the father took the messiness in stride.

This scenario was in stark contrast to those that emerged when the baby’s mother was in charge. When the baby tried to snatch the spoon from his mother, she got an extra spoon. When he tried to play with his milk cup, she moved it out of reach. As soon as the baby’s father allowed him to have freedom in feeding himself, the strike ended.

The explanation for the baby’s behavior changes is rooted in child development theory, Ms. Fraiberg writes. "...A certain amount of active handling of objects is absolutely necessary for the child in discovering and learning about the world around him," she says.

The period of 18 months to 3 years is dominated by words. If the child wishes something, he will use whatever words he has learned up until then, not knowing that they might not have any relationship to what he’s wishing for. If he wants something, he demands it or screams. He does not have language that is precise in any way. He uses words that he hopes will satisfy his wishes.

When the child acquires the word "bye-bye," he "begins to take the departures of his parents with more grace." The acquisition of language also makes it possible for the child to show more self-control and plays a role in the formation of his conscience.

I consider myself a developmental psychiatrist, an area in which child development is essential to all therapeutic engagement. Much can be learned about the patient if we know about his childhood and parents. I often see the patient doing to his child what his parents did to him. Patients are always shocked when I point this out to them, and the process of understanding how they got to where they are occurs. I call it therapeutic living. The book is so important because it tries to help parents learn how to handle tough developmental moments and periods. The section on toilet training is classic.

Please read "The Magic Years," and get your colleagues and students to read it as well. Ms. Fraiberg was a true master of the analytic method.

Dr. Fink is a psychiatrist and consultant, and professor of psychiatry at Temple University, Philadelphia.

I recently ran into a colleague who asked me whether I was still writing my column. I said yes and that I was currently writing an article on Selma H. Fraiberg. His response, "You don’t hear that name very much anymore," disappointed me. I responded by saying whenever a colleague, friend, or family member is having a baby, I send them a copy of "The Magic Years" with a clear statement that both parents must read it. It is clearly the best book on child rearing ever written in my opinion.

Ms. Fraiberg, creator of "The Magic Years," was a master’s in social work–trained psychoanalyst affiliated with the department of psychiatry at the University of California, San Francisco, who translated numerous concepts about babies, parents, and the first few years of life with wonderful examples of the type of incidents that every parent faces. She was highly regarded 50 years ago and received a great deal of praise for her book. But, at that time, there was a lot of prejudice against nonmedical degree psychoanalysts, and her book was not regarded as highly as I believe it should have been.

©thinkstockphotos.com

When I was a resident, I was required to read "The Magic Years," understand it, and be able to discuss it. Our teachers were concerned that we were busy being residents but also having children, and we really had to understand child rearing so that we could serve as resources for our residents and our analytic trainees.

Ms. Fraiberg translated psychoanalytic theory into child-rearing guidance in the book by looking at three age ranges: the first 18 months, 18 months to 3 years, and 3-6 years. Some of the examples are still fresh today, even though the book was published originally in 1959.

Dr. T. Berry Brazelton, the renowned pediatrician, wrote an introduction to the 50th anniversary of the book (New York: Scribner, 2008) saying that Ms. Fraiberg "makes each stage of emotional and mental development come alive!" I agree wholeheartedly. Furthermore, I would say that the concepts in the book can inform psychiatrists in our efforts to help our patients. After all, raising children (and growing up) is fraught with pitfalls. As Freud said early in his career, there are three impossible professions: governing nations, raising children, and psychoanalysis.

How the magic unfolds

Parents are often confused by things that children do or say, imaginary friends and animals – frustrating the child by pointing out reality when the child needs that imaginary friend or animal to survive. To the child, these imaginary friends and animals are not silly at all. A good example is what a niece of Ms. Fraiberg’s called the "Laughing Tiger."

Her niece, who was 2 years, 8 months old at the time, created the Laughing Tiger and many other imaginary companions at a time when she was afraid of ferocious animals. The niece’s "imaginary tiger gives her a kind of control over a danger which earlier had left her helpless and anxious," Ms. Fraiberg wrote. Instead of viewing this companion as problematic, it makes more sense to see this use of imagination as a healthy sign. Indeed, the child "can maintain his human ties and his good contact with reality while he maintains his imaginary world," she writes. "Moreover, it can be demonstrated that the child’s contact with the real world is strengthened by his periodic excursions into fantasy."

Virtually every chapter of the book is filled with insights that explain how young children interpret their world, which makes it invaluable for new parents. As we all know too well, the pitfalls in raising a child and growing up are many. I have not referred back to it for personal reasons in recent years. After all, my children are 54, 52, and 50 years old. But my wife and I did make very liberal use of the book throughout the years – while all of our friends were using Dr. Spock to help them navigate the waters of child rearing.

Mastering fear

Ms. Fraiberg gently guides the reader in an understanding of the child’s developing mind, why they cry, why they have tantrums, why they use imagination and how to help mom deal with the child’s anxiety. Take the example of a 2-year-old who was afraid of the family vacuum cleaner. Some young children control their fear of what must seem like loud monsters to them by learning to control the switch. But this toddler, who was known for his tendency to carry around a pocket-size screwdriver, was not satisfied with that solution. He had another idea: "Tiny screws and wheels were removed and lost in this frantic search," Ms. Fraiberg wrote. "...Finally, this limping monster issued its dying croak and succumbed without giving up its secret."

After a couple of years, the youngster’s "drive to investigate" was motivated by factors other than anxiety. Instead, he found investigation, discovery, and reconstruction to be pleasures in themselves. Interestingly, this child grew up to be a physicist.

There are many lessons here for psychoanalysts and our patients. One is that children experience things in which adults have no conscious memory. This means that we can help patients become better parents if we can get them to empathize with the child’s fears and frustrations.

Attachment, active handling

Ms. Fraiberg tells the story of an infant who developed an extremely severe sleep disturbance when she was 8 months old. Around 11 p.m. nightly, the infant woke up screaming, despite her parents’ efforts to calm her down. When her parents checked on her, the baby clung to her mother.

The episodes started after the baby woke up one night when the parents were out and had left her in the care of a babysitter. These meltdowns came in contrast to the child’s earlier reactions to her parents’ absence: "She never seemed to mind before if she wakened and saw a babysitter instead of us," Ms. Fraiberg quotes the parents as saying. "We just didn’t expect anything like this." What might explain this sudden new reaction?

"We know that the attachment to the mother is especially strong at this stage of development and a strange face may disturb the child at this age, even when encountered in the daytime," she writes. "The reaction to the strange face, as we have seen, is an indication of the discrimination of the mother as a person and the recognition of her as the person who gives satisfactions and protection. The stranger’s face that appears when mother’s face is expected produces anxiety because it symbolizes the absence or loss of the mother."

As you can see from that scenario, Ms. Fraiberg lets the mother know how essential she is and how early the child is distressed by the mother’s disappearance. In general, some people argue that they have to go on with their lives and that the baby will have to learn to be away from their mothers. We have to help our patients understand that the learning process is a burden for the infant. Some kids take a long time to learn how to separate from mom. Ms. Fraiberg helped the baby under discussion overcome her anxiety through nursery games in which her mother would hide her face one minute and return the next. She said the game allowed the baby to "work out the problem in her waking hours so that gradually the sleep disturbance disappeared."

Ms. Fraiberg also applies psychoanalytic theory to explain why a 9-month-old with a healthy appetite stopped eating and went on what she calls a "food strike" that lasted for 3 days. The child’s mother – who wanted the meals to be neat and orderly events – had been feeding the baby. So what brought the strike to an end?

One day the child’s father took over the feeding, and to the parents’ surprise, the baby started eating again. The mother immediately blamed herself, but the child’s behavior had nothing to do with her, per se. When the baby’s father tried to feed him, he grabbed the spoon and "plastered his face with strained carrots. Papa seemed quite unconcerned." When the baby turned his cup upside down, allowing his milk to spill all over the floor, the father took the messiness in stride.

This scenario was in stark contrast to those that emerged when the baby’s mother was in charge. When the baby tried to snatch the spoon from his mother, she got an extra spoon. When he tried to play with his milk cup, she moved it out of reach. As soon as the baby’s father allowed him to have freedom in feeding himself, the strike ended.

The explanation for the baby’s behavior changes is rooted in child development theory, Ms. Fraiberg writes. "...A certain amount of active handling of objects is absolutely necessary for the child in discovering and learning about the world around him," she says.

The period of 18 months to 3 years is dominated by words. If the child wishes something, he will use whatever words he has learned up until then, not knowing that they might not have any relationship to what he’s wishing for. If he wants something, he demands it or screams. He does not have language that is precise in any way. He uses words that he hopes will satisfy his wishes.

When the child acquires the word "bye-bye," he "begins to take the departures of his parents with more grace." The acquisition of language also makes it possible for the child to show more self-control and plays a role in the formation of his conscience.

I consider myself a developmental psychiatrist, an area in which child development is essential to all therapeutic engagement. Much can be learned about the patient if we know about his childhood and parents. I often see the patient doing to his child what his parents did to him. Patients are always shocked when I point this out to them, and the process of understanding how they got to where they are occurs. I call it therapeutic living. The book is so important because it tries to help parents learn how to handle tough developmental moments and periods. The section on toilet training is classic.

Please read "The Magic Years," and get your colleagues and students to read it as well. Ms. Fraiberg was a true master of the analytic method.

Dr. Fink is a psychiatrist and consultant, and professor of psychiatry at Temple University, Philadelphia.

I recently ran into a colleague who asked me whether I was still writing my column. I said yes and that I was currently writing an article on Selma H. Fraiberg. His response, "You don’t hear that name very much anymore," disappointed me. I responded by saying whenever a colleague, friend, or family member is having a baby, I send them a copy of "The Magic Years" with a clear statement that both parents must read it. It is clearly the best book on child rearing ever written in my opinion.

Ms. Fraiberg, creator of "The Magic Years," was a master’s in social work–trained psychoanalyst affiliated with the department of psychiatry at the University of California, San Francisco, who translated numerous concepts about babies, parents, and the first few years of life with wonderful examples of the type of incidents that every parent faces. She was highly regarded 50 years ago and received a great deal of praise for her book. But, at that time, there was a lot of prejudice against nonmedical degree psychoanalysts, and her book was not regarded as highly as I believe it should have been.

©thinkstockphotos.com

When I was a resident, I was required to read "The Magic Years," understand it, and be able to discuss it. Our teachers were concerned that we were busy being residents but also having children, and we really had to understand child rearing so that we could serve as resources for our residents and our analytic trainees.

Ms. Fraiberg translated psychoanalytic theory into child-rearing guidance in the book by looking at three age ranges: the first 18 months, 18 months to 3 years, and 3-6 years. Some of the examples are still fresh today, even though the book was published originally in 1959.

Dr. T. Berry Brazelton, the renowned pediatrician, wrote an introduction to the 50th anniversary of the book (New York: Scribner, 2008) saying that Ms. Fraiberg "makes each stage of emotional and mental development come alive!" I agree wholeheartedly. Furthermore, I would say that the concepts in the book can inform psychiatrists in our efforts to help our patients. After all, raising children (and growing up) is fraught with pitfalls. As Freud said early in his career, there are three impossible professions: governing nations, raising children, and psychoanalysis.

How the magic unfolds

Parents are often confused by things that children do or say, imaginary friends and animals – frustrating the child by pointing out reality when the child needs that imaginary friend or animal to survive. To the child, these imaginary friends and animals are not silly at all. A good example is what a niece of Ms. Fraiberg’s called the "Laughing Tiger."

Her niece, who was 2 years, 8 months old at the time, created the Laughing Tiger and many other imaginary companions at a time when she was afraid of ferocious animals. The niece’s "imaginary tiger gives her a kind of control over a danger which earlier had left her helpless and anxious," Ms. Fraiberg wrote. Instead of viewing this companion as problematic, it makes more sense to see this use of imagination as a healthy sign. Indeed, the child "can maintain his human ties and his good contact with reality while he maintains his imaginary world," she writes. "Moreover, it can be demonstrated that the child’s contact with the real world is strengthened by his periodic excursions into fantasy."

Virtually every chapter of the book is filled with insights that explain how young children interpret their world, which makes it invaluable for new parents. As we all know too well, the pitfalls in raising a child and growing up are many. I have not referred back to it for personal reasons in recent years. After all, my children are 54, 52, and 50 years old. But my wife and I did make very liberal use of the book throughout the years – while all of our friends were using Dr. Spock to help them navigate the waters of child rearing.

Mastering fear

Ms. Fraiberg gently guides the reader in an understanding of the child’s developing mind, why they cry, why they have tantrums, why they use imagination and how to help mom deal with the child’s anxiety. Take the example of a 2-year-old who was afraid of the family vacuum cleaner. Some young children control their fear of what must seem like loud monsters to them by learning to control the switch. But this toddler, who was known for his tendency to carry around a pocket-size screwdriver, was not satisfied with that solution. He had another idea: "Tiny screws and wheels were removed and lost in this frantic search," Ms. Fraiberg wrote. "...Finally, this limping monster issued its dying croak and succumbed without giving up its secret."

After a couple of years, the youngster’s "drive to investigate" was motivated by factors other than anxiety. Instead, he found investigation, discovery, and reconstruction to be pleasures in themselves. Interestingly, this child grew up to be a physicist.

There are many lessons here for psychoanalysts and our patients. One is that children experience things in which adults have no conscious memory. This means that we can help patients become better parents if we can get them to empathize with the child’s fears and frustrations.

Attachment, active handling

Ms. Fraiberg tells the story of an infant who developed an extremely severe sleep disturbance when she was 8 months old. Around 11 p.m. nightly, the infant woke up screaming, despite her parents’ efforts to calm her down. When her parents checked on her, the baby clung to her mother.

The episodes started after the baby woke up one night when the parents were out and had left her in the care of a babysitter. These meltdowns came in contrast to the child’s earlier reactions to her parents’ absence: "She never seemed to mind before if she wakened and saw a babysitter instead of us," Ms. Fraiberg quotes the parents as saying. "We just didn’t expect anything like this." What might explain this sudden new reaction?

"We know that the attachment to the mother is especially strong at this stage of development and a strange face may disturb the child at this age, even when encountered in the daytime," she writes. "The reaction to the strange face, as we have seen, is an indication of the discrimination of the mother as a person and the recognition of her as the person who gives satisfactions and protection. The stranger’s face that appears when mother’s face is expected produces anxiety because it symbolizes the absence or loss of the mother."

As you can see from that scenario, Ms. Fraiberg lets the mother know how essential she is and how early the child is distressed by the mother’s disappearance. In general, some people argue that they have to go on with their lives and that the baby will have to learn to be away from their mothers. We have to help our patients understand that the learning process is a burden for the infant. Some kids take a long time to learn how to separate from mom. Ms. Fraiberg helped the baby under discussion overcome her anxiety through nursery games in which her mother would hide her face one minute and return the next. She said the game allowed the baby to "work out the problem in her waking hours so that gradually the sleep disturbance disappeared."

Ms. Fraiberg also applies psychoanalytic theory to explain why a 9-month-old with a healthy appetite stopped eating and went on what she calls a "food strike" that lasted for 3 days. The child’s mother – who wanted the meals to be neat and orderly events – had been feeding the baby. So what brought the strike to an end?

One day the child’s father took over the feeding, and to the parents’ surprise, the baby started eating again. The mother immediately blamed herself, but the child’s behavior had nothing to do with her, per se. When the baby’s father tried to feed him, he grabbed the spoon and "plastered his face with strained carrots. Papa seemed quite unconcerned." When the baby turned his cup upside down, allowing his milk to spill all over the floor, the father took the messiness in stride.

This scenario was in stark contrast to those that emerged when the baby’s mother was in charge. When the baby tried to snatch the spoon from his mother, she got an extra spoon. When he tried to play with his milk cup, she moved it out of reach. As soon as the baby’s father allowed him to have freedom in feeding himself, the strike ended.

The explanation for the baby’s behavior changes is rooted in child development theory, Ms. Fraiberg writes. "...A certain amount of active handling of objects is absolutely necessary for the child in discovering and learning about the world around him," she says.

The period of 18 months to 3 years is dominated by words. If the child wishes something, he will use whatever words he has learned up until then, not knowing that they might not have any relationship to what he’s wishing for. If he wants something, he demands it or screams. He does not have language that is precise in any way. He uses words that he hopes will satisfy his wishes.

When the child acquires the word "bye-bye," he "begins to take the departures of his parents with more grace." The acquisition of language also makes it possible for the child to show more self-control and plays a role in the formation of his conscience.

I consider myself a developmental psychiatrist, an area in which child development is essential to all therapeutic engagement. Much can be learned about the patient if we know about his childhood and parents. I often see the patient doing to his child what his parents did to him. Patients are always shocked when I point this out to them, and the process of understanding how they got to where they are occurs. I call it therapeutic living. The book is so important because it tries to help parents learn how to handle tough developmental moments and periods. The section on toilet training is classic.

Please read "The Magic Years," and get your colleagues and students to read it as well. Ms. Fraiberg was a true master of the analytic method.

Dr. Fink is a psychiatrist and consultant, and professor of psychiatry at Temple University, Philadelphia.

A standardized handoff program can reduce medical errors and can be replicated at hospitals across the country, says the lead researcher of a new study published in JAMA.

Researchers reviewed the medical literature for successful handoff-intervention programs that they could teach to residents and senior interns working within two units at Boston Children’s Hospital. They ultimately settled on a bundle that included standardized communication and handoff training, a verbal mnemonic to help staff members remember what information to pass off to the next team, and a handoff structure that involved junior and senior physicians meeting in a quiet room to discuss the handoff. In addition, on one unit, residents used a computerized tool linked to the electronic medical record that made it easier for them to pass along important information about the patient.

The analysis included 642 handoffs that occurred before the intervention and 613 that happened afterwards. Researchers found that medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3–40.3) prior to the intervention to 18.3 per 100 admissions (95% CI, 14.7–21.9; P?P=0.04).

Amy Starmer, MD, MPH, associate scientific researcher at Boston Children’s Hospital and lecturer in pediatrics at Harvard Medical School in Boston, says that when implementing an intervention program, it’s important to involve staff from all levels of the hospital.

“We thought carefully about who should be able to make transformational change happen,” says Dr. Starmer. “That included resident program directors, educators, attending physicians who help observe the residents, and senior administrative people in the hospital who knew this was going on and were supportive. Even the technology team was able to devote programming support and resources to allow the development of a computerized tool.”

Visit our website for more information on hospital handoff programs.

A standardized handoff program can reduce medical errors and can be replicated at hospitals across the country, says the lead researcher of a new study published in JAMA.

Researchers reviewed the medical literature for successful handoff-intervention programs that they could teach to residents and senior interns working within two units at Boston Children’s Hospital. They ultimately settled on a bundle that included standardized communication and handoff training, a verbal mnemonic to help staff members remember what information to pass off to the next team, and a handoff structure that involved junior and senior physicians meeting in a quiet room to discuss the handoff. In addition, on one unit, residents used a computerized tool linked to the electronic medical record that made it easier for them to pass along important information about the patient.

The analysis included 642 handoffs that occurred before the intervention and 613 that happened afterwards. Researchers found that medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3–40.3) prior to the intervention to 18.3 per 100 admissions (95% CI, 14.7–21.9; P?P=0.04).

Amy Starmer, MD, MPH, associate scientific researcher at Boston Children’s Hospital and lecturer in pediatrics at Harvard Medical School in Boston, says that when implementing an intervention program, it’s important to involve staff from all levels of the hospital.

“We thought carefully about who should be able to make transformational change happen,” says Dr. Starmer. “That included resident program directors, educators, attending physicians who help observe the residents, and senior administrative people in the hospital who knew this was going on and were supportive. Even the technology team was able to devote programming support and resources to allow the development of a computerized tool.”

Visit our website for more information on hospital handoff programs.

A standardized handoff program can reduce medical errors and can be replicated at hospitals across the country, says the lead researcher of a new study published in JAMA.

Researchers reviewed the medical literature for successful handoff-intervention programs that they could teach to residents and senior interns working within two units at Boston Children’s Hospital. They ultimately settled on a bundle that included standardized communication and handoff training, a verbal mnemonic to help staff members remember what information to pass off to the next team, and a handoff structure that involved junior and senior physicians meeting in a quiet room to discuss the handoff. In addition, on one unit, residents used a computerized tool linked to the electronic medical record that made it easier for them to pass along important information about the patient.

The analysis included 642 handoffs that occurred before the intervention and 613 that happened afterwards. Researchers found that medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3–40.3) prior to the intervention to 18.3 per 100 admissions (95% CI, 14.7–21.9; P?P=0.04).

Amy Starmer, MD, MPH, associate scientific researcher at Boston Children’s Hospital and lecturer in pediatrics at Harvard Medical School in Boston, says that when implementing an intervention program, it’s important to involve staff from all levels of the hospital.

“We thought carefully about who should be able to make transformational change happen,” says Dr. Starmer. “That included resident program directors, educators, attending physicians who help observe the residents, and senior administrative people in the hospital who knew this was going on and were supportive. Even the technology team was able to devote programming support and resources to allow the development of a computerized tool.”

Visit our website for more information on hospital handoff programs.

A report outlining the alarming side effects of synthetic marijuana use in young adults acts as a call to attention for hospitalists, as thousands of patients per year are exposed to the chemicals found in the cannabinoid.

The report from the federal Substance Abuse and Mental Health Services Administration shows that synthetic marijuana was responsible for 11,400 ED visits in one year, with brain and kidney damage, hallucinations, and violent behavior among the severe reactions found in users.

Synthetic marijuana is herbs sprayed or soaked in chemicals, making it difficult for drug tests to detect and more dangerous to consume. Some of the chemicals are found in fertilizers, painkillers, and cancer treatments, creating an unsafe and potentially deadly concoction. It is inexpensive, available online or in convenience stores sold under such brand names as “potpourri,” “K2,” and “spice,” and labeled “not for human consumption.”

The multiple reasons why patients may be having psychoactive effects could be a daunting mystery to solve. However, two hospitalists provide insight on possible treatment options. Scott Carney, MD, FAAP, assistant professor and program director at University of South Carolina School of Medicine in Columbia, and Melissa Schafer, MD, assistant professor of pediatrics at SUNY Upstate Medical University in Syracuse, N.Y., advise hospitalists to treat these patients with IV fluids and close monitoring while they metabolize. A toxicology consultation and psychological evaluation should be ordered, and Dr. Schafer suggests poison control can “help with knowing what is on the streets in your area and what to expect.”

Visit our website for more information on treating symptoms of drug overdose.

A report outlining the alarming side effects of synthetic marijuana use in young adults acts as a call to attention for hospitalists, as thousands of patients per year are exposed to the chemicals found in the cannabinoid.

The report from the federal Substance Abuse and Mental Health Services Administration shows that synthetic marijuana was responsible for 11,400 ED visits in one year, with brain and kidney damage, hallucinations, and violent behavior among the severe reactions found in users.

Synthetic marijuana is herbs sprayed or soaked in chemicals, making it difficult for drug tests to detect and more dangerous to consume. Some of the chemicals are found in fertilizers, painkillers, and cancer treatments, creating an unsafe and potentially deadly concoction. It is inexpensive, available online or in convenience stores sold under such brand names as “potpourri,” “K2,” and “spice,” and labeled “not for human consumption.”

The multiple reasons why patients may be having psychoactive effects could be a daunting mystery to solve. However, two hospitalists provide insight on possible treatment options. Scott Carney, MD, FAAP, assistant professor and program director at University of South Carolina School of Medicine in Columbia, and Melissa Schafer, MD, assistant professor of pediatrics at SUNY Upstate Medical University in Syracuse, N.Y., advise hospitalists to treat these patients with IV fluids and close monitoring while they metabolize. A toxicology consultation and psychological evaluation should be ordered, and Dr. Schafer suggests poison control can “help with knowing what is on the streets in your area and what to expect.”

Visit our website for more information on treating symptoms of drug overdose.

A report outlining the alarming side effects of synthetic marijuana use in young adults acts as a call to attention for hospitalists, as thousands of patients per year are exposed to the chemicals found in the cannabinoid.

The report from the federal Substance Abuse and Mental Health Services Administration shows that synthetic marijuana was responsible for 11,400 ED visits in one year, with brain and kidney damage, hallucinations, and violent behavior among the severe reactions found in users.

Synthetic marijuana is herbs sprayed or soaked in chemicals, making it difficult for drug tests to detect and more dangerous to consume. Some of the chemicals are found in fertilizers, painkillers, and cancer treatments, creating an unsafe and potentially deadly concoction. It is inexpensive, available online or in convenience stores sold under such brand names as “potpourri,” “K2,” and “spice,” and labeled “not for human consumption.”

The multiple reasons why patients may be having psychoactive effects could be a daunting mystery to solve. However, two hospitalists provide insight on possible treatment options. Scott Carney, MD, FAAP, assistant professor and program director at University of South Carolina School of Medicine in Columbia, and Melissa Schafer, MD, assistant professor of pediatrics at SUNY Upstate Medical University in Syracuse, N.Y., advise hospitalists to treat these patients with IV fluids and close monitoring while they metabolize. A toxicology consultation and psychological evaluation should be ordered, and Dr. Schafer suggests poison control can “help with knowing what is on the streets in your area and what to expect.”

Visit our website for more information on treating symptoms of drug overdose.

The question of whether health insurance equals healthcare access is complicated in the roughly two dozen states that have chosen not to expand Medicaid—an option granted by the U.S. Supreme Court in its June 2012 decision that upheld the law’s main tenets. Even with the federal government paying the full cost for the first three years (decreasing to 90% by 2020), some states have argued that the economic burden will be too great.

According to a recent analysis by the Kaiser Family Foundation, roughly five million uninsured adults may now fall into a “coverage gap” as a result. In essence, they will earn too much to be covered under the highly variable Medicaid caps established by individual states but too little to receive any federal tax credits to help pay for insurance in the exchanges. With limited options, the report suggests, they are likely to remain uninsured.

Safety net hospitals also may be squeezed between conflicting state and federal Medicaid priorities. During the initial Affordable Care Act (ACA) negotiations, hospitals agreed to $155 billion in cuts over 10 years, including sharp reductions in Disproportionate Share Hospital (DSH) payments, in anticipation of seeing a significant decrease in uninsured patients. Despite lower DSH payments, the hospitals expected to recoup the money through more Medicaid or private insurance reimbursements.

"The Medicaid expansion being optional throws a kink in all of that,” says Leighton Ku, PhD, MPH, director of the Center for Health Policy Research at George Washington University School of Public Health and Health Services in Washington, D.C.

The ongoing open enrollment in insurance exchanges will make up part of the total. But in states that are not expanding Medicaid, the number of newly insured patients may not compensate for the DSH reductions. Robert Berenson, MD, a senior fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy, says the resulting net loss could put some hospitals under additional financial strain.

"There will be pressure within the states from hospitals and from the business community to expand Medicaid because, otherwise, they’re bearing the burden of it,” he says.

Bryn Nelson is a freelance medical writer in Seattle.

The question of whether health insurance equals healthcare access is complicated in the roughly two dozen states that have chosen not to expand Medicaid—an option granted by the U.S. Supreme Court in its June 2012 decision that upheld the law’s main tenets. Even with the federal government paying the full cost for the first three years (decreasing to 90% by 2020), some states have argued that the economic burden will be too great.

According to a recent analysis by the Kaiser Family Foundation, roughly five million uninsured adults may now fall into a “coverage gap” as a result. In essence, they will earn too much to be covered under the highly variable Medicaid caps established by individual states but too little to receive any federal tax credits to help pay for insurance in the exchanges. With limited options, the report suggests, they are likely to remain uninsured.

Safety net hospitals also may be squeezed between conflicting state and federal Medicaid priorities. During the initial Affordable Care Act (ACA) negotiations, hospitals agreed to $155 billion in cuts over 10 years, including sharp reductions in Disproportionate Share Hospital (DSH) payments, in anticipation of seeing a significant decrease in uninsured patients. Despite lower DSH payments, the hospitals expected to recoup the money through more Medicaid or private insurance reimbursements.

"The Medicaid expansion being optional throws a kink in all of that,” says Leighton Ku, PhD, MPH, director of the Center for Health Policy Research at George Washington University School of Public Health and Health Services in Washington, D.C.

The ongoing open enrollment in insurance exchanges will make up part of the total. But in states that are not expanding Medicaid, the number of newly insured patients may not compensate for the DSH reductions. Robert Berenson, MD, a senior fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy, says the resulting net loss could put some hospitals under additional financial strain.

"There will be pressure within the states from hospitals and from the business community to expand Medicaid because, otherwise, they’re bearing the burden of it,” he says.

Bryn Nelson is a freelance medical writer in Seattle.

The question of whether health insurance equals healthcare access is complicated in the roughly two dozen states that have chosen not to expand Medicaid—an option granted by the U.S. Supreme Court in its June 2012 decision that upheld the law’s main tenets. Even with the federal government paying the full cost for the first three years (decreasing to 90% by 2020), some states have argued that the economic burden will be too great.

According to a recent analysis by the Kaiser Family Foundation, roughly five million uninsured adults may now fall into a “coverage gap” as a result. In essence, they will earn too much to be covered under the highly variable Medicaid caps established by individual states but too little to receive any federal tax credits to help pay for insurance in the exchanges. With limited options, the report suggests, they are likely to remain uninsured.

Safety net hospitals also may be squeezed between conflicting state and federal Medicaid priorities. During the initial Affordable Care Act (ACA) negotiations, hospitals agreed to $155 billion in cuts over 10 years, including sharp reductions in Disproportionate Share Hospital (DSH) payments, in anticipation of seeing a significant decrease in uninsured patients. Despite lower DSH payments, the hospitals expected to recoup the money through more Medicaid or private insurance reimbursements.

"The Medicaid expansion being optional throws a kink in all of that,” says Leighton Ku, PhD, MPH, director of the Center for Health Policy Research at George Washington University School of Public Health and Health Services in Washington, D.C.

The ongoing open enrollment in insurance exchanges will make up part of the total. But in states that are not expanding Medicaid, the number of newly insured patients may not compensate for the DSH reductions. Robert Berenson, MD, a senior fellow at the Washington, D.C.-based Urban Institute, a nonpartisan think tank focused on social and economic policy, says the resulting net loss could put some hospitals under additional financial strain.

"There will be pressure within the states from hospitals and from the business community to expand Medicaid because, otherwise, they’re bearing the burden of it,” he says.

Bryn Nelson is a freelance medical writer in Seattle.

Click here to listen to more of our interview with Dr. Lenchus

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Dr. Harte

Six years ago, after I had been in clinical practice for almost a decade, my career took several unusual turns that now have me sitting in the position of president of a 500-bed, full-service, very successful community hospital and referral center. While that has inevitably whittled my clinical time down to a mere fraction of what it used to be, I still spend a lot of time “on the dance floor,” although the steps are different at the bedside.

Whether you spend your day going from patient to patient or meeting to meeting, over time it’s nearly inevitable that you will lose some perspective and appreciation for the hospital settings that we have chosen to spend our careers in. From time to time, whether you are in clinical medicine or administration, take the time to step off that dance floor and get a different perspective, to reflect upon our hospital environment. It’s a critical skill for “systems-based thinkers.” Take a minute to reconnect and appreciate some extraordinary things about the places we work in.

Here are a handful of my own reflections:

Hospitals are remarkable places. Lives are transformed in hospitals—some by the miraculous skills and technology available, and some despite that technology. Last week, I saw a 23-week-old baby in our neonatal ICU, barely a pound, intubated, being tube-fed breast milk, with skin more delicate than tissue paper. When I was a medical student, such prematurity was simply incompatible with life.

We also walk patients and families through the end-of-life journey. To organize families and patients around such issues and help them find a path toward understanding and closure is a remarkable experience as well.

The difference between a good hospital and a great one is culture, not just “quality.” Over Labor Day, I went to my parents’ house outside Cincinnati. When I arrived, near midnight, my mother greeted my three children and me and then announced that she had to take my father to the hospital. Evidently, he had a skin/soft tissue infection that had gotten worse over the last couple of days, and when contacted that evening, his physician had made arrangements for him to be admitted directly to a nearby community hospital. It sure seemed to me that it would make more sense for me to take him to the hospital, so off we went.

I will say at this point that the quality of his care was fine. He was guided from registration to his room promptly. His IV antibiotics were started and were appropriately chosen. A surgeon saw him and debrided a large purulent lesion. The wound was packed, and he started feeling better. His pain was well controlled, and he went home a few days later with correct discharge instructions. There were no medication errors and no “near-misses” or harm events.

Yet, on that first night, no one was introduced by name or role. On the wheelchair ride up to the room, we passed at least six employees—four nurses or aides, a clerk, and a housekeeper. No one broke away from what they were doing (or not doing) to make eye contact, much less to smile or greet us. This hospital has EHR stations right in patient rooms, and the nurse and charge nurse stood in front of the machine, where we could hear them, complaining about the EHR. No one was able to step back from “the dance floor” of the minute-by-minute work and acknowledge the bummer reality that my father was going to spend Labor Day weekend in the hospital. And this is at a well-regarded community hospital, well-appointed with private rooms, in a relatively affluent community, with resources that most hospitals dream of. I left that night disappointed, not in the quality but in the culture.

Empathy matters. At the Cleveland Clinic, all employed physicians are now required to take a course called “Foundations of Healthcare Communication.” I recently took the class with about a dozen others. Our facilitator led us through several workshops and simulations of patients who were struggling with emotions—fear, uncertainly, anxiety. What struck me in participating in these workshops was our natural tendency as physicians when in these situations to try to “fix the problem.” We try to reassure, for instance, that a patient has “nothing to worry about,” that “everything will be fine,” or that “you are in good hands.”

While these statements may have a role, jumping to them as an immediate response misses a critical step: the acknowledgement of the fear, anxiety, or sense of hopelessness that our patients feel. It’s terribly difficult, when surrounded by so much sickness, to stay in touch with our ability to express empathy. Therefore, it’s all the more important to be able to step back and appreciate the need to do so.

Change is difficult—and hospitals are not airplanes. In healthcare, we are attempting to apply the principles of high reliability, continuous improvement, and “lean workflows” to our systems and to the bedside. This is absolutely necessary to improve patient safety and the outcomes and lives in our communities, with comparisons to the airline industry and other “high reliability” industries as benchmarks. I couldn’t agree more that our focus should not just be on prevention of errors; we should be eliminating them. Every central line-associated bloodstream infection, every “never event,” every patient who does not feel touched by our empathy—we should think of each of these as our industry’s equivalent of a “plane crash.”

As leaders, however, it’s critical that we step back and remember that healthcare is far behind in terms of integrated technologies and decision support—and more dependent on “human factors.” We are more complex, more variable, and more fallible.

A nurse arriving on his or her shift at my hospital is coming in to care for somewhere between four and seven patients, each of whom have different conditions, different complexities, different levels of understanding and expectation, different provider teams and family support. I am not sure that the comparison to the airline industry is appropriate, unless we level the playing field: How safe and reliable would air travel be if, until he or she sat down in the cockpit, the pilot had no idea what kind of plane he would be flying, how many of her flight crew had shown up, what the weather would be like on takeoff, or where the flight was even going. That is more similar to our reality at the bedside.

The answer, of course, is that the airline industry has made the decisions necessary to ensure that pilots, crew, and passengers are never in such situations. We need to re-engineer our own systems, even as they are more reliant upon these human factors. We also need the higher perspective to manage our teams through these extraordinarily difficult changes.

In Sum

I believe that the skills that successful physician leaders need come, either naturally or through self-selection, to many who work in hospital-based environments: teamwork, collaboration, communication, deference to expertise, and a focus on results. I also believe that the physician leaders who will stand out and become leaders in hospitals, systems, and policy will be those who are able stand back, gain perspective, and organize teams and systems toward aspirational strategies that engage our idealism and empathy, and continuously raise the bar.

From my 15 years with SHM and hospital medicine, I’ve seen that our organization is full of such individuals. Those of us in administrative and hospital leadership positions are looking to all of you to learn and showcase those skills, and to lead the way forward to improve care for our patients and communities.

Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.

Dr. Harte

Six years ago, after I had been in clinical practice for almost a decade, my career took several unusual turns that now have me sitting in the position of president of a 500-bed, full-service, very successful community hospital and referral center. While that has inevitably whittled my clinical time down to a mere fraction of what it used to be, I still spend a lot of time “on the dance floor,” although the steps are different at the bedside.

Whether you spend your day going from patient to patient or meeting to meeting, over time it’s nearly inevitable that you will lose some perspective and appreciation for the hospital settings that we have chosen to spend our careers in. From time to time, whether you are in clinical medicine or administration, take the time to step off that dance floor and get a different perspective, to reflect upon our hospital environment. It’s a critical skill for “systems-based thinkers.” Take a minute to reconnect and appreciate some extraordinary things about the places we work in.

Here are a handful of my own reflections:

Hospitals are remarkable places. Lives are transformed in hospitals—some by the miraculous skills and technology available, and some despite that technology. Last week, I saw a 23-week-old baby in our neonatal ICU, barely a pound, intubated, being tube-fed breast milk, with skin more delicate than tissue paper. When I was a medical student, such prematurity was simply incompatible with life.

We also walk patients and families through the end-of-life journey. To organize families and patients around such issues and help them find a path toward understanding and closure is a remarkable experience as well.

The difference between a good hospital and a great one is culture, not just “quality.” Over Labor Day, I went to my parents’ house outside Cincinnati. When I arrived, near midnight, my mother greeted my three children and me and then announced that she had to take my father to the hospital. Evidently, he had a skin/soft tissue infection that had gotten worse over the last couple of days, and when contacted that evening, his physician had made arrangements for him to be admitted directly to a nearby community hospital. It sure seemed to me that it would make more sense for me to take him to the hospital, so off we went.

I will say at this point that the quality of his care was fine. He was guided from registration to his room promptly. His IV antibiotics were started and were appropriately chosen. A surgeon saw him and debrided a large purulent lesion. The wound was packed, and he started feeling better. His pain was well controlled, and he went home a few days later with correct discharge instructions. There were no medication errors and no “near-misses” or harm events.

Yet, on that first night, no one was introduced by name or role. On the wheelchair ride up to the room, we passed at least six employees—four nurses or aides, a clerk, and a housekeeper. No one broke away from what they were doing (or not doing) to make eye contact, much less to smile or greet us. This hospital has EHR stations right in patient rooms, and the nurse and charge nurse stood in front of the machine, where we could hear them, complaining about the EHR. No one was able to step back from “the dance floor” of the minute-by-minute work and acknowledge the bummer reality that my father was going to spend Labor Day weekend in the hospital. And this is at a well-regarded community hospital, well-appointed with private rooms, in a relatively affluent community, with resources that most hospitals dream of. I left that night disappointed, not in the quality but in the culture.

Empathy matters. At the Cleveland Clinic, all employed physicians are now required to take a course called “Foundations of Healthcare Communication.” I recently took the class with about a dozen others. Our facilitator led us through several workshops and simulations of patients who were struggling with emotions—fear, uncertainly, anxiety. What struck me in participating in these workshops was our natural tendency as physicians when in these situations to try to “fix the problem.” We try to reassure, for instance, that a patient has “nothing to worry about,” that “everything will be fine,” or that “you are in good hands.”

While these statements may have a role, jumping to them as an immediate response misses a critical step: the acknowledgement of the fear, anxiety, or sense of hopelessness that our patients feel. It’s terribly difficult, when surrounded by so much sickness, to stay in touch with our ability to express empathy. Therefore, it’s all the more important to be able to step back and appreciate the need to do so.

Change is difficult—and hospitals are not airplanes. In healthcare, we are attempting to apply the principles of high reliability, continuous improvement, and “lean workflows” to our systems and to the bedside. This is absolutely necessary to improve patient safety and the outcomes and lives in our communities, with comparisons to the airline industry and other “high reliability” industries as benchmarks. I couldn’t agree more that our focus should not just be on prevention of errors; we should be eliminating them. Every central line-associated bloodstream infection, every “never event,” every patient who does not feel touched by our empathy—we should think of each of these as our industry’s equivalent of a “plane crash.”

As leaders, however, it’s critical that we step back and remember that healthcare is far behind in terms of integrated technologies and decision support—and more dependent on “human factors.” We are more complex, more variable, and more fallible.

A nurse arriving on his or her shift at my hospital is coming in to care for somewhere between four and seven patients, each of whom have different conditions, different complexities, different levels of understanding and expectation, different provider teams and family support. I am not sure that the comparison to the airline industry is appropriate, unless we level the playing field: How safe and reliable would air travel be if, until he or she sat down in the cockpit, the pilot had no idea what kind of plane he would be flying, how many of her flight crew had shown up, what the weather would be like on takeoff, or where the flight was even going. That is more similar to our reality at the bedside.

The answer, of course, is that the airline industry has made the decisions necessary to ensure that pilots, crew, and passengers are never in such situations. We need to re-engineer our own systems, even as they are more reliant upon these human factors. We also need the higher perspective to manage our teams through these extraordinarily difficult changes.

In Sum

I believe that the skills that successful physician leaders need come, either naturally or through self-selection, to many who work in hospital-based environments: teamwork, collaboration, communication, deference to expertise, and a focus on results. I also believe that the physician leaders who will stand out and become leaders in hospitals, systems, and policy will be those who are able stand back, gain perspective, and organize teams and systems toward aspirational strategies that engage our idealism and empathy, and continuously raise the bar.

From my 15 years with SHM and hospital medicine, I’ve seen that our organization is full of such individuals. Those of us in administrative and hospital leadership positions are looking to all of you to learn and showcase those skills, and to lead the way forward to improve care for our patients and communities.

Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.

Dr. Harte

Six years ago, after I had been in clinical practice for almost a decade, my career took several unusual turns that now have me sitting in the position of president of a 500-bed, full-service, very successful community hospital and referral center. While that has inevitably whittled my clinical time down to a mere fraction of what it used to be, I still spend a lot of time “on the dance floor,” although the steps are different at the bedside.

Whether you spend your day going from patient to patient or meeting to meeting, over time it’s nearly inevitable that you will lose some perspective and appreciation for the hospital settings that we have chosen to spend our careers in. From time to time, whether you are in clinical medicine or administration, take the time to step off that dance floor and get a different perspective, to reflect upon our hospital environment. It’s a critical skill for “systems-based thinkers.” Take a minute to reconnect and appreciate some extraordinary things about the places we work in.

Here are a handful of my own reflections:

Hospitals are remarkable places. Lives are transformed in hospitals—some by the miraculous skills and technology available, and some despite that technology. Last week, I saw a 23-week-old baby in our neonatal ICU, barely a pound, intubated, being tube-fed breast milk, with skin more delicate than tissue paper. When I was a medical student, such prematurity was simply incompatible with life.

We also walk patients and families through the end-of-life journey. To organize families and patients around such issues and help them find a path toward understanding and closure is a remarkable experience as well.

The difference between a good hospital and a great one is culture, not just “quality.” Over Labor Day, I went to my parents’ house outside Cincinnati. When I arrived, near midnight, my mother greeted my three children and me and then announced that she had to take my father to the hospital. Evidently, he had a skin/soft tissue infection that had gotten worse over the last couple of days, and when contacted that evening, his physician had made arrangements for him to be admitted directly to a nearby community hospital. It sure seemed to me that it would make more sense for me to take him to the hospital, so off we went.

I will say at this point that the quality of his care was fine. He was guided from registration to his room promptly. His IV antibiotics were started and were appropriately chosen. A surgeon saw him and debrided a large purulent lesion. The wound was packed, and he started feeling better. His pain was well controlled, and he went home a few days later with correct discharge instructions. There were no medication errors and no “near-misses” or harm events.

Yet, on that first night, no one was introduced by name or role. On the wheelchair ride up to the room, we passed at least six employees—four nurses or aides, a clerk, and a housekeeper. No one broke away from what they were doing (or not doing) to make eye contact, much less to smile or greet us. This hospital has EHR stations right in patient rooms, and the nurse and charge nurse stood in front of the machine, where we could hear them, complaining about the EHR. No one was able to step back from “the dance floor” of the minute-by-minute work and acknowledge the bummer reality that my father was going to spend Labor Day weekend in the hospital. And this is at a well-regarded community hospital, well-appointed with private rooms, in a relatively affluent community, with resources that most hospitals dream of. I left that night disappointed, not in the quality but in the culture.

Empathy matters. At the Cleveland Clinic, all employed physicians are now required to take a course called “Foundations of Healthcare Communication.” I recently took the class with about a dozen others. Our facilitator led us through several workshops and simulations of patients who were struggling with emotions—fear, uncertainly, anxiety. What struck me in participating in these workshops was our natural tendency as physicians when in these situations to try to “fix the problem.” We try to reassure, for instance, that a patient has “nothing to worry about,” that “everything will be fine,” or that “you are in good hands.”

While these statements may have a role, jumping to them as an immediate response misses a critical step: the acknowledgement of the fear, anxiety, or sense of hopelessness that our patients feel. It’s terribly difficult, when surrounded by so much sickness, to stay in touch with our ability to express empathy. Therefore, it’s all the more important to be able to step back and appreciate the need to do so.

Change is difficult—and hospitals are not airplanes. In healthcare, we are attempting to apply the principles of high reliability, continuous improvement, and “lean workflows” to our systems and to the bedside. This is absolutely necessary to improve patient safety and the outcomes and lives in our communities, with comparisons to the airline industry and other “high reliability” industries as benchmarks. I couldn’t agree more that our focus should not just be on prevention of errors; we should be eliminating them. Every central line-associated bloodstream infection, every “never event,” every patient who does not feel touched by our empathy—we should think of each of these as our industry’s equivalent of a “plane crash.”

As leaders, however, it’s critical that we step back and remember that healthcare is far behind in terms of integrated technologies and decision support—and more dependent on “human factors.” We are more complex, more variable, and more fallible.

A nurse arriving on his or her shift at my hospital is coming in to care for somewhere between four and seven patients, each of whom have different conditions, different complexities, different levels of understanding and expectation, different provider teams and family support. I am not sure that the comparison to the airline industry is appropriate, unless we level the playing field: How safe and reliable would air travel be if, until he or she sat down in the cockpit, the pilot had no idea what kind of plane he would be flying, how many of her flight crew had shown up, what the weather would be like on takeoff, or where the flight was even going. That is more similar to our reality at the bedside.

The answer, of course, is that the airline industry has made the decisions necessary to ensure that pilots, crew, and passengers are never in such situations. We need to re-engineer our own systems, even as they are more reliant upon these human factors. We also need the higher perspective to manage our teams through these extraordinarily difficult changes.

In Sum

I believe that the skills that successful physician leaders need come, either naturally or through self-selection, to many who work in hospital-based environments: teamwork, collaboration, communication, deference to expertise, and a focus on results. I also believe that the physician leaders who will stand out and become leaders in hospitals, systems, and policy will be those who are able stand back, gain perspective, and organize teams and systems toward aspirational strategies that engage our idealism and empathy, and continuously raise the bar.

From my 15 years with SHM and hospital medicine, I’ve seen that our organization is full of such individuals. Those of us in administrative and hospital leadership positions are looking to all of you to learn and showcase those skills, and to lead the way forward to improve care for our patients and communities.

Dr. Harte is president of Hillcrest Hospital in Mayfield Heights, Ohio, part of the Cleveland Clinic Health System. He is associate professor of medicine at the Lerner College of Medicine in Cleveland and an SHM board member.