It is already a very emotional first day at Telluride as I re-watched Lewis Blackman’s story as a senior resident. Two years ago, prior to any patient encounters, I first watched it as an intern, incredulous at the turn of events. At that time it baffled me how health care professionals could diminish patient and parental concerns so callously, and how so many errors could pile up to lead to a tragic outcome. As an intern I vowed to never allow such reckless practice to occur under my watch. As a senior I reflect on how many vital sign abnormalities I let go, errors I let happen, and lives I let slip through my fingers.
As an ER resident, the acuity of illness is higher than other specialties and inherently the potential for medical errors. Two years ago, my naive intern-self entered residency with the goal of committing no preventable medical errors and now I sit here disappointed that I did not achieve this goal. I also realize that specific nuances delineated in the film that I promised to not let get by me have; something as simple as dismissing an abnormal vital sign or blaming a piece of equipment. Early in our careers we must all realize that our goals should not be NO medical errors as this is impossible, but MINIMAL errors. Perhaps if I thought this two years ago I wouldn’t feel such failure today.
I vividly remember my thoughts as well as the vocal comments of certain colleagues when we first watched the film as fledgling physicians. And today I realize that we were all wrong, that we went on to be dismissive of certain issues and concerns, and all have experienced poor outcomes. I implore my senior resident colleagues to re-watch the film and reflect back on how we felt prior to putting our hands on a patient, what our goals were, and the physicians we have become. I also ask medical students and junior residents to be mindful that mistakes are inevitable and rather than pretend that they won’t occur, expect them, and think how can they be anticipated.