I must admit – I came into the trip feeling just a little bit defensive. As I read the beginnings of “Wall of Silence”, I felt like many of the (devastating, horrible) patient stories focused on what a specific doctor did/did not do. The stories involving trainees stated that the patients didn’t see “a real, fully trained doctor.” I felt blamed. While some errors were egregious, others seemed totally plausible in daily care, and I struggled to identify how I could make sure I do better every time.
As we discussed and examined the details of Lewis Blackman’s story, I noticed our focus begin to shift. Yes, his doctors made mistakes. His interns did not raise alarm bells or order tests that should absolutely have been performed. But rather than just dwelling on personal responsibility, we also discussed other ways in which the medical system as a whole failed Lewis, resulting in a failure to rescue and ultimately his death.
Through that discussion and those that have continued since, we have repeated a theme that has stuck with me – erring is unavoidable. We’re only human, after all. This is at once a jarring and comfortable point to remember as a relatively new provider trying to avoid causing harm. However, it also a critical one to recognize if we are going to make any change. Pretending that we don’t make mistakes prohibits us from learning from them. It puts us on a high horse where we don’t respect and invite the input of others. And it leads to a cycle of dangerous, repetitive errors.
I plan to take this lesson home – to be more open about my own vulnerability, and to encourage others to speak up if they make an error themselves or see one in action. And, importantly, to remind myself and others that this is not about the blame game – to make progress, we need to be on the same team.