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
While technically already in Breckenridge, I’d like to share the thoughts and key moments that led me here:
I first heard about the Telluride experience from a classmate of mine from the BU School of Public Health several years ago. The stars never aligned as far as scheduling, but I feel that I have now reached the point in my training where I want to focus my energy on the patient-centered care I entered medicine to improve. I have been exposed to patient safety events since long before I entered medical school and became part of this tribe. A great uncle was the victim of an OR fire many years ago. A close family friend and mentor went with undiagnosed and ultimately rapidly progressive head and neck cancer until persistence and a patient advocate got him to the NIH. I was taken to a urologist/chiropractor/acupuncturist… Continue reading
Wow what a great 3 days the Telluride Experience has been thus far. My eyes have been opened to the small, innocent miscommunications that can ultimately lead to patient and caregiver harm. Whether it is the missed after hours critical lab value or the anchoring bias causing us to miss diagnose Angina for GERD, no one is invincible to the patient safety events we have been discussing this week.
However, with all of the amazing lessons learned and the strategies to improve communication, I can’t help but feel defensive after each case and video we discuss. Maybe it’s because 90% of the patient safety events are surgical or procedural and I am one of the only surgeons in the room? Maybe it’s because not too long ago I was the intern having to work up abdominal pain in a post-op patient? I feel emotionally exhausted every day because of the… Continue reading
Getting to know the histories of Lewis Blackman and Michael Skolnik, showed me how an error can affect the life of many and the wound that despite all treatments and solutions is there for the rest of their days. Transparency, since day 1, is an important stone to set a good relation with patients and their families.
Nobody deserves a wall of silence when there is a father, mother, son, sibling, any human been involved in a medical error as Mrs. Gibson stated in our visit to Arlington Cemetery. Every soldier that rest in this place had a history well known by their bothers in arms and their families, every patient and their families deserve to know without delays all the details regarding adverse events.
The experience of Mr. Gentry, as a former negotiator, was very illustrative when comparing his former job with the effective communication tools that we… Continue reading
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
It is already a very emotional first day at Telluride as I re-watched Lewis Blackman’s story as a senior resident. Two years ago, prior to any patient encounters, I first watched it as an intern, incredulous at the turn of events. At that time it baffled me how health care professionals could diminish patient and parental concerns so callously, and how so many errors could pile up to lead to a tragic outcome. As an intern I vowed to never allow such reckless practice to occur under my watch. As a senior I reflect on how many vital sign abnormalities I let go, errors I let happen, and lives I let slip through my fingers.
As an ER resident, the acuity of illness is higher than other specialties and inherently the potential for medical errors. Two years ago, my naive intern-self entered residency with the goal of committing no preventable… Continue reading
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
While premature closure may be related to process factors, like inexperienced providers and lack of oversight, it may also be built into the hierarchical structure of medicine. As a patient is evaluated by ascending providers, the amount and nature of information that travels up the hierarchy diminishes. For example, the comprehensive history and physical performed by the intern or medical student is filtered based on the experience of the senior resident, which may be further distilled when presented to the attending physician.
I needed a few days after being at Telluride Summer Camp to let the experience settle in. It was a whirlwind of heart-wrenching stories, connections, and thought-provoking discussions. As a second-year resident, I came to Telluride with the baggage of a traditionally difficult intern year, with the baggage of having lost my grandfather due to a multitude of systematic medical errors, and the viewpoint of having been a nurse prior to medical school. I needed to see a room full of people that don’t accept the phrase, “that’s just the system we’re in.” I had grown tired and had half-way accepted that answer, so it’s amazing to see the influence that a group full of inspired professionals can do. Every time I spoke to someone new I was blown away by their dedication and drive. Every person in that room, from all types of training… Continue reading
My mind was reeling with ideas and questions after the first day of the conference. Where to start? There’s so much we can do. It was both exciting and paralyzing. Today, I was especially interested to hear Mr. Nance’s discussion of his book. I had this sinking feeling I might hear, again, that we’re not doing enough. We’re not safe enough, smart enough or reliable enough. We need to change everything, and fast. Starting with x,y,z (work less, decrease distractions, don’t come in tired). If aviation could do it, what’s wrong with our field?
I had settled in for the boom, but instead was given encouragement, strength, and validation. Medicine IS difficult; there are complexities unique to our field. I’m (usually) very happy to be a doctor. The acknowledgment of its challenges felt like grace. It was a comfort to find that familiar passion… Continue reading