Second Day at Telluride East

The past two days have been filled with some educational moments that have helped me gain personal insight into patient quality and safety. I’m hoping these experiences will serve as tools to make me a better physician in the future. I’d like to reflect on a few of those moments.

We began yesterday with a film about Lewis Blackman, a 15 year old patient who died as a result of a series of post-surgical medical errors. This film told the story from the perspective of Lewis’s mother, Helen, who stayed with her son all throughout his fumbled medical care in the hospital and tried desperately to save him from a system that was failing him.

One of the most powerful quotes in the movie was made by Helen, who said (and I’m paraphrasing), “Had my son been anywhere but the hospital, he would be alive today.”

The film put a face on the problem of medical error and therefore humanized the issue. The need for a solution takes on a powerful impetus when you personally identify and empathize with the victims of medical error. It’s one thing to look at statistics and analytics describing the people affected by medical error, but when you can recognize the personal devastation that a lack of patient safety can cause a family, then you feel much more empowered to act because you recognize the significance of change.

To further drive home the significance of the film, David Mayer shared with us the story of a conference he attended with hospital CEOs, where after watching the film, every CEO acknowledged that in their hospital they had experienced a patient case exactly like Lewis’s case.

This film served as a springboard to begin our exploration into patient quality and safety.

Our presentations, small group discussions, and team activities examined different aspects of patient safety and quality. From these, two insights for me:

  1. In order to create a safer healthcare system, you need to first create a tiered system that anticipates and then corrects medical errors.
  2. This system needs to be predicated upon open, honest, and effective communication between doctors, nurses, and patients.

Considering these two things, we currently have underlying norms in the hospital that work against the success of this system. Here are some of those norms:

  1. Cultural segregation of doctors and nurses into two separate groups rather one coherent team. The doctor takes on the role of a hero, in that he is expected to always be perfect in his ability, above reproach and alone in his decision making; and the nurse takes on the role of a martyr, in that she is told to toil tirelessly and without question even in conceptually ambiguous patient situations.
  2. Culture of individualism taught during medical education and perpetuated through competitive residency selection process, independent contracting of physicians and private business practices.
  3. Our own human fallibility that causes us to deviate from safety protocols in the face of stress, make conclusions based on cognitive bias rather than real information, and underestimate our likelihood to cause an error.