What is the safest place in the world for people who are sick? Most would say a doctor’s office or the hospital, but that’s because we have learned to accept failure from our medical professionals. There’s an estimated 200,000 to 400,000 preventable deaths a year in hospitals. By preventable, I mean it’s a medical error or series of medical errors that could have been avoided. Add in another 1,000,000 plus preventable errors and we have an industry that has been left unchecked for far too long. We have created a culture where it is acceptable to make mistakes. Not only is it acceptable, there are financial incentives to make mistakes and lengthen patient stays. This isn’t to say that physicians and medical staff are bad people. We try to do the best for our patients. And although we are treated like superheros, we are no better than any other human being. It is in our human nature to make mistakes.
Aviation has struggled with similar preventable errors in previous years. So has nuclear power and several other high stress industries. Society did not accept their mistakes and as a result these industries were forced to change. Aviation and nuclear power had to learn from their mistakes. As a result, they have fixed their systems and minimized their preventable errors to essentially zero. They fixed power struggles, communication breakdowns, created better work cultures, and instituted simple things like checklists/timeouts. In healthcare, we have begun to institute some of these philosophy shifts, but it’s nowhere near enough. We constantly use phrases like “patient safety”, “care coordination”, and “patient centered”, but we can’t possibly understand what any of those mean. If we do, how do we allow these atrocities to continue?
In 2010, I was a junior in high school enjoying a wonderful season of cross country. I was a pretty healthy kid, but all of a sudden I started to feel more fatigue than normal. I would come home from a day of school and just want to sleep. I started becoming irritable, intolerant of cold and warm, and worst of all I was not able to concentrate in class. A few weeks go by and I wasn’t feeling any better so my mom decided to take me to my primary care doctor. I want to start off with the fact that they are great people, but even great people make mistakes. He tells me I should go get some tests on my blood and urine and that was easy enough. The lab results come back and they say I’m a perfectly healthy seventeen-year-old boy. I take it easy on the cross country for a few weeks and I’m still not feeling any better. Throw in the occasional migraine and there were parts of my day where I didn’t want to leave my room, let alone go to school. So I go back and explain to my doctor that I wasn’t feeling better, making sure to stress the severity of my symptoms. If anything, I was getting worse and put on a few pounds. He ordered some more tests, but nothing shows up. When the lab results come back, we start to talk over the next steps. He walks in and accuses me of making up my symptoms since the lab tests couldn’t possibly explain anything else. He says all I want is people’s attention and wants to do a mental health screening.
How offensive is that? (This isn’t to knock down mental health screenings.)
Well long story short, my mom and I weren’t very happy with that news, but go through the screening (which turned out negative) and so we have to go to another primary care doctor with a little more empathy. He orders the basic metabolic panel, but also makes sure to listen to my concerns/complaints and orders additional tests. My TSH levels come back high, I’m referred to an endocrinologist and diagnosed with hypothyroidism. They find a nodule in thyroid which thankfully turned out to be benign and so we start the arduous process of finding the perfect dose of levothyroxine.
I understand that I was such a low risk for hypothyroidism since I was a seventeen-year-old male and so my primary doctor made a premature closure on the diagnosis of hypothyroidism. That’s fine. Humans make mistakes. Six months to a year of undiagnosed hypothyroidism isn’t the end of the world. My situation could have been way worse. It was just the way I was treated in an entirely preventable situation. I felt horrible and I simply wanted some validation, but he sat across from me accusing me of hallucination. Why couldn’t he reevaluate the possibility of something he had preemptively ruled out?
At the end of the day, he’s not the problem. The millions of medical errors that occur at hospitals can’t entirely be blamed on medical professionals. We are all going to commit a preventable error at some point in our medical career. It’s simply the way the system is designed. Our system is designed to kill thousands of people and harm many more.
So even though at first I was angry and upset, I took my negative emotions and channeled them into something positive. A few weeks of levothyroxine, I was feeling much better. School was great and I was back to running and being a normal kid. And finally one day I decided I wanted to do my best to fix this ridiculous system we have come to accept.
That was the day that patient safety chose me.