Reflections to Bring Back to Vermont – Day 1

Some things to bring back to Vermont:

1. Both patients and those in the medical profession are lost in the hierarchy of medicine. Patients may not know who to contact when things get out of control. They may not understand the hierarchy of medicine and may not know who is actually treating them. In the same way, but on the opposite end of the spectrum, those in the medical profession are also lost in this hierarchy. They know this hierarchy and are a part of it, but choose to not speak up due to fear of repercussion.
2. Lewis Blackman was a victim of medical hierarchy nearly 15 years ago and his story was retold and relived here in Napa this week by his mother Helen. This was all in an effort to teach us in the medical profession a valuable lesson – that being lost in the hierarchy results in helplessness and hopelessness.
3. Medical errors can be caused by many things. One being premature closures, which are “a type of cognitive error in which the physician fails to consider reasonable alternatives after an initial diagnosis is made.” This leads to ~40k-80k misdiagnosis a year. Premature closures may occur because physicians fail to ask themselves “what is the worse it can be?”
4. In 2014, the average cost of claims cost $110k. 80% of claims favored the physician, meaning that each “lost” claim was approximately $550k. Surprisingly, there was no correlation between the presence or absence of medical negligence and outcome of malpractice litigation (Brenner et al).
5. Activities:
   1. Safety Moments – stories of patient safety successes, failures, or close-catches – are a great way to bring more exposure to patient safety to students.
   2. Dominoes game – demonstrates the need for communication between those in the health profession
6. Pun: Tibia = to be
   1. Example: You don’t have tibia so mean!