Tomb of the Unknown Patient

By Roger Leonard, MD

I am grateful to Rosemary for eloquently guiding our visit to Arlington Cemetery – the visual images and mental reflection. I saw the changing of the guard at the Tomb of the Unknown and found another Tomb of the Unknowns for Civil War soldiers where 2111 remains were buried together. I thought of a Tomb of the Unknown Patients. How many patients did I harm during my 40 years of practicing internal medicine and cardiology for whom I am clueless?

Why am I clueless? Like many peers in my generation of physicians, I viewed complications as an acceptable risk in the care we provided. Indeed, by explaining those risks to patients & families, we may have felt absolved. I participated on many peer review committees and this was a common thread, rather than carefully analyzing the medical record and the details of our actions. Were there issues involving communication errors, premature closure, fear of hierarchy, personal embarrassment/reputation, failure to rescue? Was there a missed diagnosis? Was there an unnecessary delay in treatment? Was the operation indicated in the first place? Why is a post-operative infection rate passed off as a known complication, i.e. acceptable within the standard of care? We didn’t believe in true team care with patient & family engagement. We didn’t believe that Zero is possible.

The Academy for Emerging Leaders in Patient Safety: The Telluride Experience changes those attitudes and behaviors. Transparency within the healthcare team and with patients & families through open, honest, bi-directional communication is an ethical obligation. It involves thorough reporting of errors, discovery of causes, multifaceted solutions for prevention, data aggregation and sharing. It includes patient partnership in theses processes. It involves closing the loop with those who reported and with those who experienced harm. The students and resident physicians attending Telluride are the future of medicine. They will change our concept of professional ethics. They will change our outcomes. They will eliminate the Tomb of the Unknown Patient.