Telluride @ Napa Day 1 Reflection – ‘Only the Family Knows All’

My experience at Telluride began with an intellectual discussion over drinks with a doctor of nursing practice student and a second year resident. It astounded me that I had the opportunity to casually listen to and learn from these experienced medical professionals who held the safety of their patients in high regard. It was great to hear that while we still have a ways to go, there is hope in changing medical practices through the younger generation of doctors and nurses. It set a positive, hopeful tone on the rest of the conference experience.

The quote that stuck with me the most from my first day at the conference was from the Lewis Blackman story. Helen Haskell states that after her son’s death, she was expecting the hospital to call her because she was the only one who knew the whole story. She witnessed the doctors’ premature closure, the difference in night & weekend care vs. weekday care, and the myriad of professionals who cycled through to treat Lewis.

As a first year medical student, I have shadowed many different specialties, including ICU rounds and surgeries. During those experiences, I was never truly made aware of these patient safety issues that exist. I would follow the resident or attending as they checked on each patient, assuming he or she was delivering the best care possible. However, once I was forced to be the support system for a patient as two of my classmates suffered health problems, I witnessed firsthand the problems that Helen Haskell reported. One of my close friends was brought in on a Friday and seemed to get much worse over the weekend just because of lack of care. Not one of his friends or family members was able to reach an attending or get any information on his progress. Luckily he was able to leave mid-week, but his experience in the hospital was extremely negative.

Additionally, my college roommate was the victim of premature closure many times throughout the years. In her first year of college at Georgetown University, she was diagnosed with autoimmune hepatitis. While she had it under control, she proceeded to have many flare-ups of pain both related and unrelated to her initial diagnosis over the years. Each time she called her specialist or went to the hospital, every doctor would report that her symptoms were related to her hepatitis and to continue her current treatment. She found the experience extremely frustrating, and for a while, she refused to go to the hospital when her pain would return because she assumed they would make the same diagnosis. 5 months ago, she had an appointment with her hepatologist because she had been suffering from peripheral edema for the previous two months. When she arrived, the physician discovered my friend’s blood pressure was over 200/100 and immediately sent her to the ER and later transferred her to an inpatient service. It turns out, she now had moderate to severe lupus. No one had noticed that her kidneys had not been functioning correctly, each time attributing her lab results to her hepatitis. As her main support system in DC, I sat with her through her stay at the hospital and was blown away that something like this had occurred. I realized that it was a systemic problem that led to this premature closure, and not the actions of just one doctor. She is currently stable and taking her treatments, but I worry to think what would have happened had it progressed any further.

I believe that the Lewis Blackman film and patient safety issues should definitely be incorporated into medical student education. If I had not been alongside my friends as they were patients in the hospital, I would have continued to live in ignorance of these problems.  Therefore, for the students who have not had to witness the negative patient safety issues in the hospital, their education needs to explicitly state the presence of such problems to help budding physicians stay aware of the potential consequences of their mistakes and take the necessary steps to avoid it. I look forward to learning more in the next couple days at the conference.