As our time comes to an end, I reflect on all that has happened in the past couple of days. Watching films such as The Lewis Blackman Story and Bleed Out and Dr. Goldman’s TED talk left me in a state of shock, disbelief, and fear. How can such an advanced nation accept a system that can have such devastating outcomes? We spend so much money on pharmaceutical research to develop new therapies, but somehow, we still lose so many patients to our healthcare system. If patients and families who can speak English fluently and have high levels of health literacy encounter so many devastating errors and have difficulty navigating our health care system, I can only imagine what patients and families with low health literacy are facing in our current system. I fear being a healthcare provider in a punitive system that seeks to put a band-aid on a major systemic issue by often placing the blame on one individual. Blaming one individual without spending the time to complete a proper investigation drives many great employees out of medicine. Sometimes, an investigation may reveal an incompetent or unethical individual, but most of the time, it reveals communication errors. Without a proper investigation, the same mistakes will occur repeatedly if the errors are to due flaws in human factors engineering. If we drive the individuals who make mistakes out of medicine, then we will be left with no health care providers. Errors are ubiquitous, and front-line workers can determine the flaws and design a safer system with the proper support.
However, I am also walking away with hope and inspiration. The Telluride Experience Session showed me that there are leaders in healthcare who are trying to change the status quo, and I am excited to be part of this change.