Day 1 & Premature Closure

The discussion of the Lewis Blackman film raised many issues, the first of which was the problem of understaffing/different staff on nights and weekends. It struck me that a problem of sheer logistics could have such an impact on someone’s health – how we know illness and disease strike to the beat of their own drum, but yet we try to impose our 9-5 schedule onto them. With so much of medicine still at the whim of chance and unforeseeable risks, why would we continue to allow this dangerous practice that is entirely under our control?

Helen’s comment that she was “the only constant” throughout Lewis’s care gets to the heart of the issue for me- when the sole duty of a health care team is to care for the wellbeing of their patients, how can we accept anything less than constant care?

“Premature closure” was introduced in the discussion… Continue reading

Building a Cathedral

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

Telluride Day 2

At the end of day two, one of the most striking realizations (and perhaps most uncomfortable) was how protected physicians are within a system that often fails to protect the most important stakeholder in healthcare: the patient. The Michael Skolnik story, simply put, was a case of a physician who exercised poor judgment and of a patient and family who were not made aware of the alternative courses of action they could take in a complex situation. More tragically, this is a case of a physician who exercised poor judgment in a system that allowed him to do so. One’s natural impulse is to feel anger towards the physician, who seemingly nearly coerced a vulnerable patient into a likely unnecessary procedure. While that anger may rightfully be directed toward that physician (personal accountability and responsibility should absolutely be at the forefront of such a case), investing one’s energy solely into… Continue reading

Breckenridge Day 2 Reflection

We had the opportunity to listen to John Nance, the author of Why Hospitals Should Fly, speak for a couple hours at the end of day 2. This man should be a motivational speaker. He had several great thoughts on medical culture, but one specifically that I thought was pretty profound was the idea of a 3 tier system for reducing medical error. While the concept is simple, it is just another example of how “doing simple better” is a great strategy for reducing error. Medical culture places so much emphasis on making tier 1 (the “practitioner”) infallible, but when you take a step back and think you realize based on everything that we’ve heard this week this seems ridiculous. The vast majority of safety advancements, whether it be in aviation or medicine come from filling the holes in tiers two and three. By placing so much emphasis… Continue reading

Telluride Day 2 Reflection

Our second day in Breckenridge was filled with powerful stories, activities, and analogies which I will keep with me as I move forward in my clinical career.

One of the most important themes that has been referred to in numerous discussions/activities is the ability of simple communication to prevent drastic medical errors and save human lives. During our discussion of the story of Michael Skolnik, in the afternoon lectures on PFACQS and high reliability organizations, and during our discussion of Why Hospitals Should Fly, numerous examples of the power of communication and its ability to prevent medical error were presented. This gave me hope–even though medical error is such a complex issue of systems engineering, if simply emphasizing and training staff members in communication would save thousands of patient lives there is no excuse to continue allowing rampant medical errors. This was an especially key takeaway… Continue reading

THE FACULTY!!!!!

This is the most amazing, emotional and intense teaching conference I have ever had in my life.

where physicians, nurses and patient families use their personal tragic experiences to teach and impact knowledge to us. Each time they have to re-live these events just to let us know the impact of the work we do ant it’s effects to patients and their LOVED ones.

i feel so emotional writing this reflection just imagining how many people all around the world have lost their loved ones because of negligence and lack of communication by health workers.

Attitudes have to be changed !,    communication has to improve ! ,     Teamwork has to be emphasized  !

And this will start with each one of us starting in our own small way to cause that change until the revolution goes viral

We pray for strength for this faculty to… Continue reading

Telluride Day 3

In medical school, standardized attempts at teaching us how to communicate are made but I’ve always been left to wonder how effective such measures are. Can we really teach someone how to listen? How to feel in response to a patient’s words? How to react in such a way that compassion and empathy are assumed rather than indifference? Medicine attracts individuals who inherently have a predisposition to help and to care. Nobody enters into this profession with the intent of cold indifference. However, many do leave this profession desensitized to the pain, suffering, and grief that they encounter multiple times per day. And perhaps it is this latter point that leads to the devolution of perceived empathy.

Of all the lessons learned in this immersive experience at the Telluride conference, it is the lesson that communication, or the lack thereof, is at the center of most errors and patient dissatisfaction… Continue reading

Grateful

The word that comes to mind on day three of the Telluride Experience is grateful.  I am grateful for the opportunity to be here with such amazing participants; grateful that there are people like Dave, Tim, Anne, Kim, Rosemary, Roger, John, and Gwen who are willing to share their wisdom with us and make us rethink what we do, how we do it, and how we can do it better; and grateful that Carole,  Helen, the Skolniks, and the hospitalist who re-enacted his debriefing interview, shared their painful stories and put a face on the human cost of medical error.

My hospital has done a great job of providing its employees with cutting edge tools and education, many of which we discussed here in Breckenridge. I have been trained to use Carolina Cares, TeamStepps, SBAR-Q, CUS words, 6 Sigma, and the list goes on, but in rolling out… Continue reading

Telluride Day 3 Reflection

Over the first two days, we learned a lot about the current problem in healthcare and why it’s so damaging to countless patients and their families. Today, we discussed some of the ways to fix those problems. After learning about how to practice mindfulness and reflection, event reviews/reporting, and open communication with families, I now feel more confident that I have the tools to create effective change in the clinical setting at a grassroots level. This training was quintessential in helping me understand what I can do at such an early position in my training.

Beyond this, the team-building we experienced on the hike really solidified the importance of working together with other like-minded colleagues on issues of patient safety. Although an individual working on improving themselves in a clinical setting is important, encouraging and training others to do so as well is the only way to turn patient safety… Continue reading

Telluride Breckenridge Reflections: What’s the Worst It Can Be?

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

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