Day 2: Today is your lucky day

It is hard to believe it is only my second full day here at Telluride because I feel like have learned at least a week’s worth of material. Perhaps it is because the topics that have been covered have kept my mind reeling and constantly thinking even after we conclude the formal discussion for the day. We started off the day with possibly one of my favorite lectures I have ever attended by Dr. Dave Mayer about transparency. This lecture was so effective for me because Dr. Mayer included some stories I do not think I will ever forget.

In one of his stories, he told us of an experience in which a wrong sided surgery occurred. The patient was draped and ready for a right-sided hernia repair, but as the resident began, he made a left-sided incision. When the attending came in, he expressed that he thought this was a right-sided hernia repair and upon realizing his mistake, the resident fainted. This story echoed similar stories shared in John Nance’s book “Why Hospitals Should Fly.” It made me think about how we are all human and no matter how good our intentions are for the patient, we are bound to make mistakes. Should the resident have known what side the surgery was on? Sure. But the reason he made an incision on the wrong side was not because the resident was a bad physician, it was because he was human and humans, no matter how perfect we try to be, are inevitably going to make some mistakes.

I started thinking about the Swiss cheese model and how important having a structure in place that expects these mistakes to happen is. For example, when the resident walked into the OR thinking this was a left-sided hernia repair, if there was a timeout in place this probably would have caught that mistake, reminding him the surgery was on the right side. Dr. Mayer continued with the story expressing how, as the anesthesiologist for this surgery, he was dreading signing the patient out after he had fully woken up. This surgery had violated the patient and harm was done to him so he was expecting the patient to be mad. However, the patient was sitting in the bed smiling. When Dr. Mayer walked in, the patient explained “Today is my lucky day!” and went on to explain how he was so lucky because the surgeon caught a hernia on his left side too and fixed it as well as repairing his right side.

Realizing the horrible lie that had been told to the patient Dr. Mayer stood there for what he said felt like an eternity, responded, “Today is your lucky day,” and then walked out the door, shaken by what just happened. This story had me in disbelief. It was hard to understand how this could happen in a hospital where I would expect to be safe and if a mistake did happen, I would expect honesty. But instead, professionalism was violated on many levels. After this story we got into a great discussion on why transparency can be so hard and also what benefits it can have. I learned that although it is natural to want to resist transparency because it may feel like it will challenge your competency as a physician, and threaten what you have worked so hard for, there are many more benefits. Trust, self-respect and even financial benefits come with transparency. This was an important lesson to learn and one I think every health care provider needs to be educated on.