First and foremost, I’d like to thank all the leadership, instructors, and patient families for having me and taking the time out of thier busy schedules to share with us their valuable information and experiences. I will echo what Rick said yesterday in that this conference definitely re-ignited that fire in me to change our culture in Medicine and put the focus back on patients and their safety and well-being. When I go back to my slightly younger self to think of how I expected to be as a physician, I never thought of the negative effects I could have on patients, I only thought of myself as a healer. Then I said to myself, “OK, I can change my ways and improve myself so that I am better aware of errors around me or because of me, and correct them before they do real harm to… Continue reading
I just returned from an amazing week in Telluride where I not only learned a lot but was also inspired and reinvigorated by the group of colleagues and faculty I met. One of the most surprising things about the week was that despite our varied backgrounds and geography, we all came together with a common set of interests and experiences (sometimes bad ones) determined to make changes moving forward in our practice. Thank you to everyone I met this week.
Here are the main lessons I learned during the week as well as some fantastic quotes from the group…
1.) Start every meeting with a story (it’s all about the patient!)
2.) The way we treat nurses when they bring a concern to us that ends up being wrong, is often more important than when they bring a concern that ends up being right (respect and appreciation are… Continue reading
Day Two At Telluride Patient Safety Summer Camp
Today’s final discussions revolved around what three tangible things we as residents can do when we return to our respective programs to improve shared decision-making and improve our ability to communicate in the case of patient harm. I was very encouraged that there was actually very little variation from each of the breakout small groups. We all seemed polarized to some very clearly defined, and what seemed like obvious, solutions to improved patient safety in our respective corners of the world.
The opportunity that I see after completing this exercise is that although we can all make small incremental changes in our respective practices, how can we reshape the practice of medicine to make our small individual changes part of a bigger and more permanent cultural change? If all 28 of the scholars would communicate with 10 colleagues about the importance of… Continue reading
My Fellow Telluride Patient Safety Gurus,
What an incredible week! I have been so fortunate to be surrounded by such a brilliant group of people leading change all over the country. You have all inspired me and energized me to go back and promote the mission that we have all set out for ourselves- create a system that is patient first.
Inspired by Rick’s proverbs reminding us all that we are teachers and it is our responsibility to share the knowledge that we have gained to improve our systems, I’ve come up with an idea on how to approach teaching informed consent to our fellow residents.
But how do we teach?…How do we teach hundred of grown adults, physicians, those set in their ways with their own ideologies and beliefs that may or may not contradict yours. How do you teach change?…
Here’s my attempt:
Create an “Informed Consent Checklist.”… Continue reading
I had an amazing first day in beautiful Telluride, CO! It was so great to get to meet my fellow MedStar residents and the host of other residents, physicians, and staff members. It is so rewarding that we are all here for a common cause and I feel grateful to be involved. I really enjoyed Paul Levy’s negotiations lectures. I realized that negotiating is something we do on a daily basis and may even be doing so without realizing that it is even a negotiation! It was helpful to step away from clinical scenarios and approach the topic from a different perspective. I can’t wait to take back what I’ve learned, and am excited for day 2!
In discussing the case of Lewis Blackman today, I could not help but think about the importance of good transfer of care. If the on-call weekend resident had a better understanding of Lewis’ immediate post-op progress (or lack of), the gradual change in his vital signs and exam may have sent up red flags sooner. It is easy to become overwhelmed with the number of unfamiliar patients one must cover as an on-call physician. One may not appreciate the subtle changes in a patient’s status when there is just a snap-shot view of the situation. We have all fallen victim to this, and the situation is worsened by sleep deprivation. I can recall a case when a patient had subtle labs changes over the course of her stay for preeclampsia. To the covering physician, these labs seemed relatively stable and the patient was sent home. She returned the next day… Continue reading
I would like to start by saying thank you to everyone who made any single effort to make this amazing work about patient safety. I actually had a great experience this first session. I was really touched by Lewis Blackman’s story, as it made me look deeper into how easily a human life can be lost due to our mistakes. I think I learned a lot about how to be a better negotiator and I will absolutely use what I learned on a daily basis to get the best and safest care to my patients. Thank you again! I am so excited to get more out of this camp.
Just finishing my first 24 hr call as “the” senior resident and Chief, I began my journey into Telluride completely exhausted. I was fully aware of my limitations as a human being, and my heart was still pounding thinking about the 18 patients whose lives had been entrusted to me overnight. However, I was joyful. I was not only going to a beautiful place that seemed to be the inspiration for all of Bob Ross’s masterpiece paintings, but also a place where I had hoped to develop and mature as a doctor–“Doctor” as defined by its rudimentary latin origin, “to teach”.
However, today’s experience was life changing. Today it was reaffirmed to me… Continue reading