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Connect the Dots—March 2016

Burke, Alson K. MD; Lovejoy, David A. MD; Cuff, Ryan D. MD; Chescheir, Nancy C. MD

doi: 10.1097/AOG.0000000000001327
Contents: Connect the Dots…

Financial Disclosure The authors did not report any potential conflicts of interest.

“Connect the Dots” begins with a brief comment on an article from an issue of Obstetrics & Gynecology selected by the Editor-in-Chief. The next author “connects” a piece that relates in some way to the synopsis she/he received. She/he then sends her/his “connection” only to the next author. The three authors making connections are members of the ACOG Junior Fellow Congress Advisory Council.

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Intimate Partner Sexual Assault: Traumatic Injuries, Psychological Symptoms, and Perceived Social Reactions

Obstet Gynecol 2016;127:516–26

The Parisian system for caring for people who have been victimized by sexual assault is centralized. The authors describe a single site where forensic examinations, counseling, and follow-up are performed. From 2008 to 2011, these authors gathered data on 767 female victims and describe outcomes. The article adds to our knowledge about sexual assault victims in general, and the authors make the point that female victims of sexual assault by a current or former intimate partner carry the same psychological sequelae as those who are victimized by strangers or acquaintances. In addition, women who are assaulted by intimate partners are at higher risk for extragenital injury than are those who are assaulted by other types of assailants.

Although it is possible to believe a 1-month follow-up rate of only 38% is a study flaw, this is not a controlled study and, in this vulnerable population, such a follow-up rate is impressive. Female victims in Paris who intend to or have gone to the police are more likely to know the assailant than not. Further, we see an all-too-familiar pattern of repetitive assaults by intimate partners.

There are some issues in women's health that cannot be studied meticulously. These data are hard to collect, much of it is qualitative, and the results are descriptive at best. Nonetheless, what the authors have shown us is that sexual assault is a horrific crime and that, in some measure when it is perpetrated by a current or former partner, it can be all the more horrific. And at the end of the day, we are all Parisians.

Nancy C. Chescheir, MD

University of North Carolina, Chapel Hill, NC

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Intimate Partner Violence Experienced by Physicians: A Review

J Womens Health (Larchmt). 2015 Oct 15. PMID: 26468760

Reflecting on Dr. Chescheir's comment, I thought, “If we are all Parisians, how does intimate partner violence (IPV) affect us as obstetrician–gynecologists?” Although we are trained specifically to screen for and support victims of violence, we often forget that we are not immune to IPV.

The authors reviewed the sparse literature available on IPV experienced by physicians. They found that physicians self-report lower rates of IPV as compared with the general population, which may reflect concerns about the stigma of self-reporting among their colleagues. Physicians may feel shame about the fact that we are trained to recognize IPV yet can still fall victim. Additionally, health care providers may screen women of status less effectively out of fear of offending them. The authors also remind us that physician victims may face societal resentment of their position of influence as well as less empathy for and disbelief of their situation.

The authors describe how IPV exposure affects clinical practice, including the suggestion that physicians affected by IPV may have lower rates of screening their patients. Additionally, the authors cite the effect of IPV on diminishing both job performance and satisfaction. Effectively supporting our colleagues who experience IPV is important for their well-being as well as for patient safety. Female physicians report being victims twice as frequently as men, and, in a field with an increasing proportion of female practitioners, we may have more colleagues who have experienced IPV than those in other specialties do. We must continue to raise awareness, screen effectively, and work to prevent IPV, including among our physician colleagues.

Alson K. Burke, MD

University of Washington, Seattle, WA

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Disclosing Medical Errors: The View From the USA

Surgeon. 2014;12:64–7

If one were asked to stereotype a single personality type that overwhelmingly encompasses physicians, with little hesitation one could safely say the majority of us are Type-A perfectionists. Although heartbreaking, it is not surprising that, as physicians, we often self-report lower rates of IPV than the general population. Our fear of embarrassment, the perception of weakness, and the anticipated judgment of our peers all play a role. These same concerns similarly play a central role in the challenges surrounding physician and hospital disclosures of their medical errors.

In this article, the authors discuss the challenges, benefits, and disclosure programs currently affecting the medical error transparency debate in the United States. The authors empathize with the reputational and legal concerns of physicians and hospitals after a medical error. However, this empathy is tempered by the evidence demonstrating that full disclosure appears to decrease both the risk and severity of malpractice litigation while also creating a culture of safety that ultimately leads to improved quality of care. The growing interest in ensuring transparency has led to the creation of formal “Disclosure, Apology, and Offer” programs. The article cites two once-novel programs, one implemented at a Veterans Affairs Hospital and the other at the University of Michigan, both of which demonstrated statistically significant decreases in litigation and liability payouts as a result.

Research has long proven the hesitation of physicians to disclose their errors. Although our Type-A personalities may resist the disclosure of our mistakes, we must remember that to err is human. The decisions and discussions that follow will define us as either selfish or selfless in our patients' eyes.

David A. Lovejoy, MD

University of Kentucky, Lexington, KY

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South Carolina Unanticipated Medical Outcome Reconciliation Act

S.C. Code Ann. §19-1-190

Full disclosure after an unanticipated or adverse medical outcome is gradually becoming our professional standard. Disclosure and apology appear to limit subsequent medical malpractice litigation. The act of acknowledging errors and saying “I'm sorry” is powerful—but is it also an admission of guilt or liability? Should physicians worry that, “…anything you say or do can and will be used against you in a court of law”?

In 2006, the State of South Carolina enacted the Unanticipated Medical Outcome Reconciliation Act. This law holds “that in a claim brought by or on behalf of a patient allegedly experiencing an unanticipated outcome of medical care, certain statements, gestures, activities, or conduct expressing benevolence, regret, apology, condolence, mistake, or error made by a health care provider or his employee to certain persons are inadmissible as evidence and do not constitute an admission of liability…” At present, 36 states, the District of Columbia, and Guam have enacted similar “apology laws.”

In acknowledging errors, physicians and the institutions they represent are providing transparent explanation and meaningful understanding to patients and families about the nature of unanticipated outcomes. Acknowledging and apologizing after unanticipated outcomes is our reminder that medicine, like error, is human. Apologies are pleas of empathy, not pleas of guilt.

Find out whether your state has provisions related to apologies and medical professionals at:

Ryan D. Cuff, MD

Medical University of South Carolina, Charleston, SC

© 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.