Open Honest Communication

Day One Reflection

::SIGH:: As a graduate student who does online blogging daily it is rare that I don’t know how to start a discussion, today is the exception. There are so may factors that I want to touch on;

  1. I appreciate hearing from the different professions on the many viewing and stories we heard today. I am not currently at a major teaching hospital and wasn’t aware of the mounting pressure and expectations that exist among medical students/residents.
  2. One of the quotes I took to heart today was “Develop mindful engagement to have situational awareness to help create a sustainable safety culture through a shared medical model.”
  3. Another quote that I feel will become almost my mantra is that “change comes through disruptive innovation”

After hearing Lewis’ story, the shock of Carol’s daughter, Alyssa, and then the movie ‘To Err is Human’ I am left very frustrated and almost helpless. It’s overwhelming… Continue reading

Safety is more than preventing physical harm

I have to admit, I was skeptical when I was first asked to attend this conference. As a psychiatry resident in my last year of training I have been confronted on a daily basis by patients placing themselves and others in unsafe environments and situations. Between seeing patients who heavily abuse substances and then get into arguments with loved ones or god forbid get into a car, to patients who shun the comforts of home because of profound paranoia about their home environment, I have always thought of the hospital as a safe place for psychiatric patients.

However, on a daily basis we are faced with a patient population who all to often cannot advocate for themselves or when they attempt to do so are written off or unfortunately flat out ignored. In a bigger way, patient safety is integral to good patient care because by allowing our patients to… Continue reading

Failure to Rescue: The Story of Lewis Blackman

An Interdisciplinary Viewing

As a surgery resident, I had a different reaction to the the film “The Faces of Medical Errors…From Tears to Transparency: The Story of Lewis Blackman” than some of my fellow scholars. This is absolutely the value of viewing and discussing it in such a forum, as every perspective highlights specific opportunities for improvement.

As our interdisciplinary discussion highlighted, Lewis’ death was the unfortunate result of a broken system.  Lewis was a 15 year old undergoing a new repair for pectus excavatum.  The first systems issue brought up by his mother, who remains a strong patient advocate, was the informed consent process surrounding a new “low risk” surgery.  The pectus repair was technically successful, but issues started intraoperatively.  He was making minimal urine during the case and after.  He received multiple doses of toradol, up to post-operative day #5, with minimal oral… Continue reading

Day 2 Reflections

What to say….what a powerful day, full of emotions. Today and yesterday were difficult for me. They brought back memories that I didn’t want to revisit, painful memories. Losing a child is so painful. Losing a child because of preventable mistakes is unacceptable.

The faculty are so amazing, so strong, I don’t know how they do it. I have not been able to move past losing Sebastian. His death broke me and my wife. We were crushed, walking through life without really living, just existing. For me, it was like being underwater. I felt like I was always drowning, over and over again. Then I just stopped feeling, stopped caring about anything. I didn’t want to feel anymore, I didn’t want the tears anymore. It took me a long time to get back to living life again.

I remember family and friends trying to make us feel better. They would… Continue reading

a part of someone’s story

How many talks on patient quality and safety have I seen where numbers are quoted (18% of GDP, 3rd leading cause of death, 26th in mortality) but stories are left out? Numbers have their place, to help policymakers and advocates for health system redesign (like me) to make a rational argument for change. I’ve been compelled by these numbers for years now, and in fact, I’ve decided to make a whole career out of making those numbers move toward equity. But it’s been a long time since I reflected on the stories that originally brought my attention to the world of patient safety and quality. Reflecting on that this week, I think I’ve missed those stories.

A story has a particular power to compel, because it reaches out and reminds you that you’re human. I think we humans derive much of our meaning from life by seeing ourselves as part… Continue reading

Biggest Fears

Moving forward when I reflect upon what scares me the most, its being responsible for the death of a mother or child.  It’s knowing that either due to my inability to act or my acting/operating in an inappropriate manner that led to the death of a patient.  My worst nightmare is having to confront a patient and or family to let them know that irreparable damage has been done on my watch… to my patient…. to someone they care about.  How do you/they  move forward from that devastating news?

A few months ago I was a part of a post mortem cesarean section.  The mother coded early one morning on the floor after being admitted the previous night for pneumonia.  Nursing and staff was alerted after family noted the patient seizing in her hospital room.  ACLS was initiated and the patient was briskly… Continue reading

Day 1 Reflection

First day at Telluride- Discussing Uncertainty  
One topic that stood out to me during discussion on day 1 was the topic of uncertainty.  I’m currently in my last year of residency and as I reflect on my years of medical school and early years of residency, I can say that I did NOT do well with uncertainty back then.   It was seen (by others, and pressure on myself) as a weakness if I was uncertain of a correct answer to a question, or diagnosis, plan etc.  And honestly, uncertainty gave me personal anxiety.  Now, as a senior resident, I was recently told by a few faculty that it’s one of my strengths when I openly and honestly admit to my uncertainty of a diagnosis or plan. It’s OK to know when to ask for help or additional guidance as a trainee. Or when you… Continue reading

Day 1 Reflection- Advancing Communication

Why are health professionals not listening to the concern of the patient?  A major theme from yesterday was advancing communication to prevent harm and address harm. We often take for granted that we have the ability to use effective communication. We started the day watching a video about leadership, which I thought was pretty powerful. I had not thought much about the following as I have thought about leadership styles. To lead, you have to be on the level of the follower or there will not be a movement. We continued on to watch the Lewis Blackman story. Diagnostic errors ignited my passion for patient safety when my mother in law passed away from a missed pulmonary embolism. As I continue in my medical journey, I want to always remember the phrase “What is the worse it can be?” to avoid premature closure and conformational bias. From the video,… Continue reading

To Err is Medicine: Margaret Duncan

I am a person who makes mistakes.

I am a student who makes mistakes.

One day, I will probably be a doctor who makes mistakes.

The first two statements are acceptable things, not life-altering, except perhaps mine. There comes a point in my career where suddenly, though, this intrinsic part of me that results in me spilling barbecue sauce on myself or tripping on the same sidewalk crack everyday or misremembering a famous person’s name could be the difference between life and death.

There is a clear divide where suddenly, moments of forgetfulness could become moments that change everything.

This is terrifying, all the more so because I know how hard I’ve tried to not spill things or not trip in important situations, and I still end up with a blotch on a white shirt or a slightly grazed knee on concrete. This is okay when my human-ness only causes… Continue reading

On tribal hierarchy

On tribal hierarchy

On day one of the “Academy of Emerging Leaders in Patient Safety” conference, we started by watching a video featuring a patient’s mother who brought up the tribes of healthcare (doctor tribe, nursing tribe, etc) and the role that the element of hierarchy played in her son’s unfortunate outcome. In healthcare, we often witness two of mankind’s most primitive motivators – the desire to care for others and the drive to survive. The “doctor tribe” is predominated by competitive, type A, detail-oriented individuals, and deference to the hierarchy is one of our tribe’s oldest traditions. In the patient safety community, the need to address this specific tribal tradition is frequently discussed. Knowing that old habits die-hard brings up a number of questions: Is hierarchy still alive and well? How can it be addressed? How receptive will the tribe be to solutions proposed by external parties?

Take a… Continue reading

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Telluride Experience 2020 Dates

BRECKENRIDGE, CO:
CMF Session One*: 6/8 – 6/11
Bennathan Session Two: 6/15 – 6/18
Session Three: 6/22 – 6/25

WASHINGTON, DC/MD:
Session Four: 7/22 – 7/25

*Session exclusive to the COPIC Medical Foundation Residents.