It’s been about 7 months since I left Turf Valley and all the amazing people at the Patient Safety Conference.  Not many days have passed that I haven’t thought about my experience, the lessons we learned together or about the larger issue of quality and safety. You really would be hard pressed to go through a day of medical training without encountering something we could make better, safer or be more transparent about. Sadly it’s still a topic that struggles to find its way into our medical curriculums. The week of shared passion in Turf Valley around safe quality care is something I will always carry with me, but I only wish it was a passion I could spread more easily. We have a long way to go before the curriculums everywhere are turned on their heads to reflect the flat hierarchies, transparent communication and error reporting that we so desperately need to instill in our future physicians. I’ve found great opportunities and outlets to discuss my newfound passion and I know the growing group of Telluride Alumni will only serve to spread these messages even further.

Today in particular I am reminded on the importance of quality care of transparent communication and medical errors. In the same 7 months since I left the conference my grandfather has been struggling with constant symptoms that seem obviously to point to a bladder or prostate cancer. Following along as a family member I can see the frustrations our systems causes. He’s a sharp guy and my family is well educated – though not medical professionals – and still everyone (myself included) has been confused through the entire journey. Assured it was a bladder infection he pressed on through several rounds of antibiotics eventually undergoing a bladder scope and further blood testing. All the while never informed of any possibility beyond a unitary tract infection. He encountered physicians in the hospital and outpatient setting nearly a dozen times throughout these months. The communication and hand off between doctors was poor, the system was muddled with confusion and communication was nonexistent . Its something that seems like it would be so easy to handle, especially as a medical student. It’s not. It’s not easy in any way for the patient, for the family, I don’t think it’s even an easy system for the physicians to function in.

After 4 rounds of attempting to treat the symptoms as a UTI, after an X-ray, a scope and multiple sets of blood work and still no answers we switched providers. A repeat of the initial scope revealed a very high grade anterior prostate cancer – understandably missed by routine screening but unforgivably missed by 7 months of encounters with the healthcare system. Seven months of taking pills, having side effects, of changing his lifestyle, of making appointments, of collecting medical bills and finally a repeat of a test that was initially done months prior reveals the diagnosis that should have been obvious all along. How can we do so poorly? It’s no one physicians fault, but we have a bad system. We do not communicate well, we do not follow patients well and we just don’t always take good care of people. It terrifies me that I am working my way towards a career in a system that does such a poor job at times, because I – like the others before me – only want to do the best to treat my patients in the best possible way. I won’t let it terrify me though, rather inspire me to do better, to communicate, to listen, to speak up, to find and learn from errors. I will do better.