“My only regret is that I should’ve called 9-1-1 from my mother’s hospital room.” Or, “We could’ve gotten the appropriate medical care anywhere but where we were, which was in the hospital.” These statements resonate; they cause a twinge of unease for people whose life work it is to tend to the ill, weak, and vunerable. But, these are real statements taken from a film about Lewis Blackman, a bright teenage boy who entered the hospital for an elective procedure and never left.
Lewis Blackman’s story illustrates the brokenness and unachievable nature of the Hippocratic Oath’s first, and most important line. However, it is only unachievable in our current healthcare system. As young professionals, we must disrupt the status quo – dismissing our perceived infallibility and, especially, that of our superiors. This step is the cornerstone to building a culture which truly values patient safety above all else.
Among the sea of new information and inspiring voices from today, I left grappling with one idea in particular. I’m contemplating the role of story telling in today’s data-driven world, where we are rapidly acquiring more analytics than we know how to make sense of.
Recently, during my time doing summer research in Baltimore, I began attending the weekly case conference of the Neuroimmunology department. The presentation of challenging cases was interesting in itself, but the response of the other physicians was what fascinated me most. I’ve been taught the power of the scientific method and evidence-based medicine for as long as I can remember. When the physicians were explaining their reasons for ordering or repeating obscure tests to rule out unlikely diagnoses for these tough cases, he/she almost always started with a story. We heard about that one patient that the physician had cared for as a resident who… Continue reading
As of this evening, we have one full days worth of Telluride curriculum under our belts. I have already come to appreciate the various backgrounds of other members of our group; it contains medical students, nurses, nurses working towards advanced degrees, Ph.D candidates, podiatry students, residents, physicians, and more. If one thing is abundantly clear through conversations with this group, it is that everyone is committed to the best possible patient outcomes! No one here has worked as hard as they have to get to this point in their education or career to provide anything less than perfect medicine. That being said, our medical system consistently provides less than perfect medical care. While the field of medicine is inherently more complex than aviation, the gravity of the broader medical culture’s acceptance of breakdowns in care and resulting adverse events is overwhelming to think about in the terms of aviation. Today… Continue reading
The first day of the Telluride Experience in Napa was very interesting and thought-provoking. I feel lucky to have the opportunity to participate in this event so early in my medical education and I have already learned so much from the faculty and the other participants with varying levels of experience. To be completely honest, although I spend a lot of time reflecting, I find it quite difficult to put my thoughts into writing which is something that I hope to improve through these reflections during my time here.
A topic of discussion today that I found particularly interesting was about mindfulness and the need to second-guess previous conclusions and reassess a plan when new information is discovered. Many people, especially those in the medical field, can be uncomfortable with indecision or uncertainty as it can be difficult to admit that one’s previous assumptions were incorrect or that a definitive… Continue reading
“You can’t solve everything at once. You need to break down big problems into little problems and then solve them one at a time. Do one thing at a time and do it well.”
These were the final thoughts from the first day at the Telluride experience. Medical students, nurses, and residents from around the country had come to beautiful and sunny Napa California to learn about crafting a safer and more effective medical system.
Our first day was busy and full of learning. Through narrative, we connected with the deeply tragic and painful consequences of unsafe care. We reflected on the necessity of incorporating the observations and concerns of patients and caregivers when providing care. Additionally, we explored the deep-seated cultural differences that can serve as barriers to effective doctor-nurse communication and prevent providers from asking for the help they need.
One of the most inspiring moments on the… Continue reading
Today has been an exceedingly informative and moving first day here in Napa! My hope in coming to this conference was to challenge myself to think critically about patient safety issues and garner the skills to create meaningful change when I head back to school in a few weeks.
One of the most interesting realizations for me from today occurred during the domino game. For those who may not be aware of the domino game- there are three roles: the doctor, the nurse and an administrator. The doctor is looking at a picture of dominos oriented in a specific fashion and giving instructions to the nurse who is trying to replicate the image with an actual set of dominos. The administrator oversees the game and keeps track of the time. The game was repeated 3 times, each time rotating roles, and slightly changing the instructions. In the first round,… Continue reading
The healthcare landscape is full of decisions and ‘forks-in-the-road’. The first day of the Telluride Experience in Napa reminds me of the spirit of the poet Robert Frost who so eloquently penned “The Road Not Taken”, one of the most iconic pieces of the English language. We saw today that before each of us is a path that is well paved and cleared for those who wish to rely on comfort for the perfunctory decisions they must make when it comes to patient outcomes while singing to the same tune. The other path of the fork is one that is full of the thick uncertainties that come with any type of healthcare change that benefits the patient but requires great efforts. For Robert Frost, the path less travelled was the source of his adventure into the unknown – the leap of faith. As healthcare professionals navigating the thickets of… Continue reading
Maybe it was because this was the first story we talked about this morning, but the story between the father and son who had cancer was very interesting and emotional. This is not necessarily something I have thought about at length but it has crossed my mind, how would I react if I had a child who was dying or had died. It’s a deeply shaking thought that brings emotions of anger, despair and sadness. I am not usually a very emotional person, I try to think of things as logically and objectively as possible, but this story really got to me. I empathized with the father the narrator talked about how the father was dying along with his son. It is something that no parent should have to experience.
After this first story we heard from Helen. This was another deeply emotional story of a parent losing her child.… Continue reading
In Napa, I am sitting and watching the life story of Lewis Blackman, a life-changing story not only for Ms. Helen Haskell or the healthcare professionals involved in Lewis’s care, but for many especially who are in the health care arena. Lewis communicated to the health care community by his elevated heart rate, uncontrolled pain and his appearance. His mother who was beside him throughout the hospitalization communicated her concerns. But, the health care team listened for what they wanted to hear. The first principle of patient care- believe your patient, was ignored. Lewis was a fighter. He fought for his life for days, but the health care system failed him. If the nurse recognized the inability to record a blood pressure as a warning sign, and the next person who recorded an acceptable blood pressure has not filled the hole as (s)he wanted to or the senior surgical professionals… Continue reading
As someone who thinks in analogies, I found it helpful to conceptualize patient safety through the analogy of how people do not rise in the morning planning to say, drive away from the gas pump with the hose still attached, but nonetheless it is still common enough that there is a website full of pictures of cars with gas hoses flopping out of their sides. Thankfully, I also learned that I can be assured that if it ever happens to me, the industry already anticipates that people will do this and have set up a safety valve system to prevent dangerous gas spillage and are prepared to replace with a new gas hose so that business can go on as usual.
It is mind opening to be introduced to a whole new way of thinking about mistakes that anticipates them head on instead of wishing for them to disappear on… Continue reading