by Amy Abramowitz
– I love this perspective today. It is so easy as a resident to get burnt out and to think of yourself as bricklayer or as building a wall. However, there are moments that bring you back to the big picture and remind you of the impact you can have on a patient’s life and on the health care system. This week as been reinvigorating and a great reminder of why I went into medicine and how meaningful our work can be.
– The heartbreaking stories of moms losing their children due to medical errors has been particularly affecting. I am the mom of a toddler and am very hormonal and pregnant with my second child. These stories remind me to cherish time with my family. They also remind me to continue to speak to families as fellow parents and think… Continue reading
by Mike Wroten
Day 1 Reflections:
“What’s the worst it could be?” A Failed Communication
As I recount the stories from the day, the idea that resonated with me the most was “what’s the worst it could be?” As healthcare professionals we’re ultimately tasked with doing everything in our power to protect our patient’s from the worst case scenario. As I’ve reflected on our small group conversations, I think the worst case scenario may have nothing to do with pathophysiology, but more simply flawed communication. Keep the lines of communication open.
Day 2 Reflections:
I am extremely grateful to be amongst so many bright, compassionate and thoughtful minds this week. I feel invigorated and inspired by the ideas and discussions we’ve had over the past 2 days. The thing that excites me the most is the impact our actions will have on the future of healthcare.… Continue reading
by Janice Park
This probably isn’t the normal sentiment to hearing John Nance speak. He gave us an incredible talk about patient safety and summarized many of the important points he made in his book, Why Hospitals Should Fly. He told us stories about hardened surgeons and flight disasters, explained why our system cannot function the way it does. But as he spoke to us today, I couldn’t help but experience this enormous wave of relief.
Why? Here is an experienced pilot explaining to a room full of residents, medical students, and nurses that the way we practice medicine is unsafe because it relies on every single one of us to act in individual perfection, which is humanly impossible. He asked us whether any one of us had ever been taught that we are allowed to be imperfect, and no one raised a hand. This entire model of… Continue reading
by Amy Abramowitz
A few thoughts from another full day:
– Finding joy and meaning in the workplace – This is so crucial to providing safe and high quality care. Every team member must feel that their role is important and must be empowered to speak up when they are worried about a patient. The past few days have made me think about how important it is for me as a physician to empower and listen to members of my team.
– Data should include attitude measures, what people think and feel about what you are trying to change – It is so critical when you are in a leadership position to understand the goals and concerns of people whose behavior you are trying to change.
– I have been thinking more about the role of psychiatry in quality and safety. Psychiatrists face many of the same… Continue reading
by Luke Perkins
A lot of this week’s conference has been discussing how big of an issue patient safety is in our medical system. We are far from perfect and have even accepted that perfection is not achievable. This is certainly a dismal state of affairs in many respects. We have a culture where patients are in danger far too often.
Somehow, we are supposed to ignite a change. How does one do this? How do we make a new normal? We have no choice but to start at the grass roots. It can begin with educating our colleagues, in addition to our patients, regarding the very oath we take as medical professionals. “First, do no harm.” We must treat their diseases, while at the same time protecting them from ourselves.
We, each as individuals, cannot accept the patient safety risks, without seeking alternatives. We must push our departments. We… Continue reading
by Ariel Finberg
There have been many pearls of knowledge shared with us during these last two days; all invaluable tools to help us as new leaders change the face of healthcare. My favorite bits of wisdom however came out of two of the games we played, the domino game yesterday and the teeter-totter game today. In the midst of the silliness, it was incredible to see how quickly and effective a quick debrief in between sessions was.
We started the domino game and failed almost immediately. After our allotted time, we met up to discuss what was a strength and what could be improved on for the next session. This quick 2 minute debrief COMPLETELY changed the outcome of the next two rounds. We were able to effectively communicate and work together to successfully complete the puzzles. The same thing occurred with the teeter totter game. We had… Continue reading
by Vidya Viswanathan
At the end of today’s session with Lewis Blackman’s mother Helen Haskell, I was really struck by her observation during the course of discussion: “Confidence kills.” In the documentary, Haskell also says of her son’s tragic death due to medical error, “He died because he was in the hospital.” As a rising fourth-year medical student, it stands in such stark contrast to the message I’ve gotten in my training, especially on rounds. Rounds often feel like a way to tie each patient up in a nice box with a fancy bow and meticulously ignore the true messiness that we are professionally obligated to address. Even as fresh, inexperienced students, we are taught to make a persuasive argument in our presentations and to always craft our presentation to fit our leading diagnosis. When we list differential diagnoses at the end of our presentations, the team often interrupts… Continue reading
AELPS17 Day 3
This programme continues to be a transformative experience today. What most stood out to me today was that even when we were free to go out on our own and talk amongst ourselves as we visited Arlington National Cemetery and The National Mall, conversations about patient safety and quality improvement continued among participants. This group seems to be very dedicated to the task of protecting patients from harm and I’m sure that its members will serve as leaders in this field. Another striking yet solemn moment was Rosemary Gibson’s speech in Arlington, which gave us a visual representation of the scourge of patient harm, such that if each person who perished at the hands of medical error were to be buried in Arlington, that they would need a new cemetery of that size every year.
AELPS17 Day 4
Over these few days, we have heard the ins… Continue reading
by David Mayer, MD
Last week was the first of three annual Patient Safety Summer Camps for graduate resident physicians in 2017. Each year, I learn from the resident scholars who attend about the current safety challenges and barriers they face on a daily basis as they both try to deliver safe care to patients, and learn to become good physicians. Over the last few years, however, I have noticed a growing concern among our Telluride Scholars, a theme that centers on the overall well being of resident physicians in the healthcare workplace.
Last week, discussions around resident well being reached an all-time turning point, during an interactive presentation on Care for the Caregiver programs led by Crystal Morales from MedStar Health. During the presentation, Crystal asked the residents to think back, and remember the first patient death that happened while under their care—not from a medical error, necessarily, but… Continue reading
Being in the Air Force myself I really appreciated John Nance’s ending story about his time flying C-141’s. I can appreciate the A1C’s fear in speaking up against a Lt Col, especially since he has no actual flying experience. Co-pilots in the AF constantly struggle with correcting senior officers during flight. Like surgeons they to embrace the god-like aura and often think they are above criticism. I agree with John in that the AF is making a great commitment towards true leaders. They’ve also started 360 feedback which is a way for these senior pilots to get feedback from everyone they fly with.