Believe in the Zero … Don’t Let the System Get You Down

The Telluride Conference has been emotionally and cognitively exhausting. However, it has also been rejuvenating and utmost inspiring. The practice of medicine is so much harder than you anticipate. There are so many battles each day working in a broken system.

Your first error that you make in patient care breaks you. I will never forget a patient who left against medical advice with severe HTN in pregnancy. In discussion with the obstetricians, we all agreed to give her hydralazine prior to leaving the Emergency Department. She agreed to return after running her necessary errands. She did not make it to those errands and she returned in less than 10 minutes with dysarthria. I harmed this patient. Thankfully, with her blood pressure returning closer to her baseline, she had no lasting effects. The thought that I had the ability to harm a patient was crippling. As an intern, I swore that I wasn’t cut out for this job. It was nearly impossible for me to go to work the next day. Thankfully, in talking with my fellow interns, attendings and senior residents and discussing what went wrong and what went well, I was able to recover. However, I will never forget that patient. I will never forget the importance of discussing AMA paperwork and informed consent. I will never underestimate the amount of harm we can cause even with something seemingly benign.

We spoke about empathy and learned our generation is impatient. Someone noted that we seem to work in a system that values our efficiency and throughput. There is little value placed on talking with and spending time with a patient. This makes it hard to remember the humanity in medicine at times. Brainstorming with some of the most considerate people I’ve met was a great experience: ‘It’s all about the patient!’; ‘Think of each patient as your parent or child or other family member’; ‘Take a moment to breathe between each patient’ ; ‘Even the most frustrated you can be with a patient is nowhere close to as frustrated they are with themselves.’

Despite the constant battles in our daily work, I took away this message, ‘Be the change you want to see in the world.’ – Ghandi

Don’t let errors cripple you, learn from them and make a change. I have been inspired to try and improve our informed consent procedures in the Emergency Department. I love the idea of video information for a patient in addition to the discussion with the care provider. Maybe this can include an informed against medical advice procedure as well.

Don’t let the system help you forget why you practice medicine. It is a privilege that patients allow us into their lives in such a way. Take a breath and remember that between each patient encounter. I hope that being able to highlight this, spread this inspiration, and remind us of why we do what we do, will help my efforts in RN MD communication in the Emergency Department. Re motivate us to work as a team for the patients.

I also hope to return and teach Patient Safety more effectively to my colleagues with some of these motivating methods such as the Tears to Transparency videos. Standing with a group of leaders who are equally passionate about QPS has reinvigorated me. A friend told me she had an ‘Aha!’ moment when we spoke about why we do Quality Improvement and she heard what I said. ‘It is why we all went into medicine.  Once you know what Quality Improvement is and how to do it, you realize this is how to help people.’ I hope to go forward in my career and help others have ‘Aha!’ moments in regards to Quality and Safety. Together we can get to zero, we just have to believe in it and start acting.

Thank you to everyone I interacted with during the amazing Telluride experience. Also a huge thank you to CIR for allowing me the opportunity. I’ve met a very special group of people I hope to stay in touch with throughout my career. It is an experience I will carry with me to help my practice in medicine.

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