IF YOU SEE SOMETHING, SAY SOMETHING!!!!!

Being a part of the 2017 Telluride scholars is definitely an experience that has changed my life forever, not to mention my practice as a physician. My experiences the last 48 hours have given me a whole new perspective on patient safety and i intend moving forward to be the ”change i seek”

As residents and nurses, If we have patient safety concerns, we need to speak up. If you see something, say something, that might save a life.

I find it very disheartening, the irony of harming the very people we set out to heal. Truth of the matter is a lot of people fall through the cracks in our poorly integrated health care system and they need people to speak up for them. Patient improvement should be at the core of every provider. There is always room to grow and to learn from our mistakes.

We need to… Continue reading

The Tribe

Reflecting back on the last 48 hours, I realize that I had no idea what I was getting myself into. I was planning on learning a lot of lessons that I could take back to my medical school and hospital system (which I have), but I was not expecting the bonds and community that we would build at Telluride this week. Residents, nurses, fellows, medical students…it’s an impressively broad, interdisciplinary group. And while it always feels really nice to develop these connections on a personal level, I think that it is something I need to take more seriously than I did at summer camps in high school. I’m going to need these people. When I get back to my hospital system – and adjust to a new one for residency next year – I’m not going to somehow feel or be more influential than when I left for… Continue reading

Changing Surgical Culture

Most people think of surgeons as more disconnected from their patients than other fields, something we saw in the video where the neurosurgeon didn’t communicate well with the patient or his family. Even among many of the students I know who want to be surgeons, they believe that if they are skilled enough at their job, they don’t need to have a great relationship with their patient because only the results matter. However, when we realize error is inevitable, we see that while the results may go the way we did not intend, we can almost always still have that open and honest relationship with our patient that can help us move forward after the error has happened. The surgeons I look up to the most rebuke the idea of skill over connection, saying that they need to have the best relationships with their patients because of how invasive they… Continue reading

Always about communication

Time and time again, medical errors and bad outcomes get traced back to failure of communication. Today, the story of Michael Skolnik illustrated how lack of honest and transparent communication between a surgeon and the young man who, along with his family, entrusted his life to him resulted in a devastating brain injury that left him forever disabled and his family forever scarred. It truly is tragic to think that an honest open conversation could have avoided all of this.

In a different way, our teeter-totter activity illustrated how great things can be accomplished when teams embrace the concept of “barrierless communication” emphasized in the book “Why Hospitals Should Fly”. By having every team member, each with a unique perspective, share their thoughts freely and openly with one another, we were finally able to succeed as a whole in a task that appeared so daunting not much earlier. After… Continue reading

Patient advocay

Day two was equally as packed and we again started with a very moving yet tragic patient story of Michael Skolnik who lost his life because of a lack of proper informed consent – the medical system designed to keep him alive, failed. I am reminded of the Swiss cheese model of accident causation highlighting the systematic failures that led to Michael’s preventable and unfortunate death. There were so many opportunities during his care that if a proper system check were in place, he may still be alive and well. His story is a painful and humbling reminder that as physicians, and, more broadly, as caregivers, we have an unbreakable commitment to our patients and we must always advocate for them because at the end of the day, the care we provide is for the patient.

Our patients (and/or their families) must make the ultimate and final… Continue reading

Listening

Michael Skolnik’s story sparked many emotions for me. I thought of how often we as health care providers don’t really listen to our patients and their families. We often assume that we know what is best for the patient because we have the scientific knowledge to understand their disease and how to manage it. At times, we push our own agendas and expect our patients will go along with whatever we recommend to them. We may even become irritated if they disagree with the plan or proposed procedure.
I think that Michael’s story shows how important stopping and listening is. Patients and their families have a right to decide what they feel is best and we do not have the right to take that away from them. As we brought up during a discussion today, it is even important to give patients the option of choosing no treatment or only… Continue reading

Incentives in Health Care

I think I’m a pessimist. I have come to believe that most things in this world are driven by the incentive to make money. I imagine that current HROs such as aviation are driven by the high cost associated with failure, but such analyses are not readily available in health care. The idea of creating a high reliability organization in health care appears to oppose the current constant push to increase productivity in hospitals. However, improving outcomes, decreasing litigation, increasing compliance, and decreasing complications should inevitably decrease costs to hospitals. By presenting these ideas from the cost decreasing aspect, I wonder if we could align our interests towards patient safety and quality improvement with the purely economic interests of policy makers and care organizations. We would be able to incentivize existing leadership in our organizations by speaking their language, rather than trying to change the game. Cost analysis of… Continue reading

Delivering the news of death

  • After portraying the role of a provider informing parents of their child’s death, I have new perspective of how challenging delivering such information could be. So a patient has just died and now you have the hardest job of all, telling the family. As a nurse I have been in the room as a provider informs a family that the patient died but never have I been the one to give the news. Everything in that moment when delivering such news matters including ;displaying empathy, being honest, body language, and even moments of silence. While portraying the role as provider delivering the news of death, I couldn’t help but think in real life how do providers not find themselves emotionally drained. The first patient is dead and in many ways by delivering to the family the news of death, the second patient dies too right in front of you. Thus,… Continue reading

What is it that you want?

Today was difficult. Listening to how communication can go so wrong so quickly is intimidating. As a nurse, I thought healthcare allowed people to choose their desires. Michael and his family were never given that option. The neurosurgeon never gave them an alternative… he said this is what Michael needs to survive and that his family trusted that the neurosurgeon had Michael’s best interests at heart. I can keep going on about all the terrible things that happened, but I’m not.

We need to make a practice change. As a nurse, I’m going to start giving my patients the options to make more decisions about their care… and I’m going to start educating my patients on the healthcare system and what they can do to be informed. When I do an admission, I’m going to start asking them the tough questions- do you have a medical power of attorney?… Continue reading

That Creeping Feeling…

First of all, I want to say that Richard’s presentation was so phenomenal today. I distinctly remember hiking up the San Juan mountains in Colorado at last summer’s Telluride conference after a great session the day before thinking, “I’ve found my people.” It really is a special thing. I still see one of the other alums every now and then at hospital meetings and it literally warms my heart to hear his name and that he is doing great things at his home institution.

We talked a lot about informed consent and a patient’s understanding of their own experience in the healthcare system. As a primary care physician, I couldn’t help but wonder how Patty’s son’s primary care doctor felt about the horrific outcomes of his patient at the hands of a surgeon who probably didn’t need to operate in the first place, someone he tried to… Continue reading