A common thought I have been having over the past two days has been, “This stuff is so powerful, but also so simple.” But that has in turn begged the question, “Why aren’t we doing it?” The story of Michael Skolnik brought these same thoughts to my mind. Thorough informed consent conversations and shared decision making are not inherently complicated, and they have the power to literally save the lives of patients. I felt frustrated, even appalled that the medical community was moving so slowly in addressing these problems, even when simple and proven solutions exist. The common response is that the culture in medicine just runs too deep and that doctors are resistant to changes in behavior. This answer didn’t satisfy me though. How can a group of people so committed to helping patients and to a life of learning be so ineffective at adopting life saving interventions? It wasn’t until later in the day, when we were discussing human factors and designing systems that anticipate human error, that I began to understand why it was so difficult to change behaviors of providers. Most of our current systems do not encourage or reward or even allow for changes in behavior without massive intervention. For example, the simple but powerful process of shared decision making should be readily adopted by all practitioners. It is effective and ethically essential and fairly easy to do. Yet, we have a system that doesn’t give doctor’s time, which is arguably the one thing that is required for shared decision making. We also have a system that has taught providers that if they are too open with patients, the information they share could be used against them in a malpractice lawsuit. We have a system that discourages incorporating patients and their families into the medical team. However, this is good news. While it is difficult to change people and culture, systems can be changed. And that reality gives me hope. We can create and design systems that allow and encourage good people to effect change that will ultimately protect and save the lives of patients.
These first two days have been incredible. The stories have been powerful and the discussions rich. This opportunity to learn from and work with people in so many areas of healthcare has been very meaningful to me. I can’t wait to see what the next few days have in store. I have a lot to learn, but I also have hope. If the past two days have shown me anything, it’s that the future of patient safety is bright.