The films telling the stories of Lewis Blackman and Michael Skolnik served their purpose of putting faces on medical errors very well. More than once I found myself struggling, and failing, to keep my tears from running as the stories were told. It is one thing to know that hundreds of thousands of people die due to preventable medical errors each year; it is a whole other thing to observe one or two of those deaths closely as a human tragedy. One may want to reverse the order of the sentences in Stalin’s famous quotation into “a million deaths is a statistic; a single death is a tragedy”, just so as to remind oneself of how devastating each single one of those “numbers” are.
As tragic as they were, the deaths of Lewis and Michael were [arguably] not totally in vain, thanks to their dedicated families and shrewd professionals who cared deeply about preventing such tragedies from happening again. Even if one doctor learns something from these sad stories or only one error is prevented by the legislation passed in South Carolina (and of course we know the impact is much larger than that), something positive has been born from these disastrous incidents. I, for one, find it very difficult to ever forget these stories and I think I’m not the only one.
Nonetheless, there are thousands and thousands of people whose stories are never remembered because they are never told in the first place. At the very best, they may be counted as one of the “numbers” in those large national statistics if someone acknowledges that their deaths were because of preventable medical errors. I am talking about many patients who do not have families as devoted, educated, and resourceful as those of Lewis and Michael. I am talking about patients who cannot even tell if a medical error has happened and even if they do, they are not taken seriously. I am talking about chronically institutionalized patients, homeless people, undocumented immigrants, and inmates. I am talking about patients with intellectual disability, severe mental illness, substance use disorders, and personality disorders who are known to create negative feelings in caregivers and who have been historically stigmatized and neglected.
For caregivers, it is a very normal and understandable human reaction to get frustrated with or tired of “difficult” patients who suffer from psychotic disorders, manic episodes, or borderline personality disorder, to name a few. What is not acceptable is such feelings interfering with proper, empathic, and reliable medical care who these patients are entitled to as much as any other human being, if not more.
If I want to take one thing with me from Telluride, I will take the responsibility of advocating for such patients being treated in my institution. How? That might be the subject of another post.