Rosemary’s presentation this afternoon was so incredibly moving. After breaking up to tour the area individually I stood along the bluff overlooking the cemetery feeling ashamed to be part of an industry that causes so much harm. I was also feeling shame for not honoring my mother during our moments of reflection.
Fifteen years ago my mother nearly died after a complication from a cardiac procedure caused a massive internal hemorrhage. My parents never blamed anyone. In fact, my mother continued to see one of the doctors involved in her case long after the near-fatal technical error, despite symptoms of severe blood loss being missed at her post-op appointment just hours before she crashed. What my mother chose to do was become a patient advocate at the very hospital where she was a victim of medical error. She’s an inspiration to me and a big reason I’m drawn to this work.
I also want to honor the memory of the patient’s I’ve lost. Crystal’s presentation this morning struck me in that I hadn’t thought of my first patient death in a long time – an overdose on heroin and fentanyl by a person who, in my eyes, only had high blood pressure to worry about. I had no idea she was struggling with substance use and addiction. I don’t think I ever asked…I definitely never suspected.
A couple of years ago, one of my family medicine co-residents started a tradition on the Day of the Dead of sharing the stories of our patients who’d died (anecdotes about their lives, how we felt when we found out about their death – really anything we wanted to share). While not all residents wanted to share their stories out loud with others (as we found out today, it takes a lot of bravery to honor those who have died out loud), most found the time very useful and spent it journaling or sitting in quiet reflection. It was an excellent opportunity to turn sorrow and shame into positive energy and something I will continue to do on a regular basis.
Nothing is more powerful than a story, whether it’s changing a culture or just reminding ourselves why we get out of bed in the morning. The best way to honor those we’ve lost to medical error is to continue doing to the work we’re doing and reach out for support when we hit a roadblock. You now have about 60 more lifelines than you did before this conference…make sure you use them!