Telluride Roundtable: Week Three, Day One–Some Powerful Reflections

Introductions at Telluride Student Summer CampThe day began with introduction ice-breakers as student took turn introducing each other to the bigger group. From the introductions, it was clear that the Telluride Patient Safety Roundtable is hosting an extraordinary group of students this week – Medical Students, Pharmacy Students, and one student obtaining her Masters of Jurisprudence in Health Law. In addition, the Roundtable is blessed with faculty from Colorado, Illinois, Ohio, North Carolina, Maryland, Florida, and California.

Following introductions, the entire group attentively watched the film The Faces of Medical Error – From Tears to Transparency: The Story of Lewis Blackman. Unlike the two prior Roundtables this year, Helen Haskell, Lewis’ mom, was part of the faculty. She offered her own reflections on the events which occurred related to Lewis’ case, and answered questions from students and faculty. At one point Helen made the poignant observation that Lewis would have been the age of many of our students asking the questions. Had he lived, Lewis would have been 27 years old this year. He certainly was gifted enough to attend medical, nursing, or pharmacy school and could very well have attended such a Roundtable.  These observations were not lost on the students today.

In the afternoon, Deb Klamen from the Southern Illinois College of Medicine led the group in a discussion on leadership and the challenges students face in their day-to-day studies, and early clinical rotations. Small group discussions allowed the students to share their own leadership styles, as well as the leadership qualities of those they admire. Over and over a common, yet essential, leadership trait was described by students and faculty – COURAGE – the courage to confront those engaged in unprofessional and unsafe behaviors in a way that could avert future harm to others.

For the last exercise of the day, the students broke into two groups to engage in the now famous [infamous?] teeter-totter egg game. In an ironic twist the first group actually completed the task in the allotted time without breaking the egg while the second group suffered from a last-minute hesitation and injury to the eggs precariously placed below the ends of the teeter-totter. In almost all prior exercises, the first group most commonly fails while the second group learns from the debriefing and missteps of the prior group.

Most importantly, Dave Mayer led the two groups in reflections following the exercise and gave them an opportunity to understand the power of effective, clear, concise and goal-oriented communication tested through this “gaming” situations. The applicability to healthcare was clear to all.

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8 Responses to Telluride Roundtable: Week Three, Day One–Some Powerful Reflections

  1. deniseneal says:

    It was impossible not to be touched by the story of Lewis Blackman spoken by his mom Helen Haskell. My emotions went from anger to sadness as Helen spoke of the many times she asked for help and was ignored. How often do we really listen? Are we following our own agendas, worried about ourselves or are we focused on what is best for our patients? Do we really stop to question if we have thought of everything? Have we looked back when questioned about the care we give to think about the worse case scenario and ruled it out or are we just looking at the surface to afraid to of the possibility we could be wrong. Or maybe we are too afraid to ask for help for fear we will be looked down upon. Listening and communication and teamwork could have saved the life of Louis. Putting Louis first could have saved his life.
    Denise

  2. jbsfsu says:

    Yesterday was great!
    I had two thoughts that stuck in my mind as the day went on, both of which came from the Lewis Blackman video. The first was “systems operating for their own benefit”. We discussed how this mentality leads to a kind of circular flow, instead of a linear goal of providing competent patient-centered care. I think an additional layer is the fact that whenever we lose sight of the patient’s needs we provide sub par care that is not patient-centered and also not cost effective. I know health care costs is not the main theme for this week but I couldn’t help but think about how in Why Hospitals Should Fly they addressed that when the patient is being made the number one priority, costs don’t skyrocket. The other way I see it is that critical thinking and problem solving are free. I don’t want to lose sight of the fact that no amount of tests can replace those skills. Whenever a physician thinks their way through a patient’s issues, drawing on not only their expertise and knowledge but that of the other care providers around them, you are able to create a patient-oriented plan of care and potentially minimize the risk of exposing the patients to unnecessary tests and procedures. By doing so you are reducing costs and more importantly reducing the patient’s risks. I think from my perspective the ideal way to manage patient’s effectively is to use diagnostic tests to augment the thoughts. When you have a system that does not effectively hone in on the end goal of competent patient-centered care, I feel you would not be as apt to go through that critical thought process and so the knee-jerk response would be to fire off a bunch of tests. Again, and I think it was reiterated in the book multiple times, it’s not necessarily a problem of bad providers but of bad systems.

    The second thought from the video, and one that I have learned in the past but now have a more profound appreciation of, is the concept of when providing patient care it’s always important to ask “what’s the worst it could be”. We typically use this in our med school training to help us think through cases, but I’m not sure how well that translates in the real world, whenever there is a tendency towards confirmation bias and availability bias. Again, I’m not slamming anybody for relying on their past experiences to make critical management decisions, but it is always best to move forward with the understanding that “I may be wrong, this could be something else, I have to continually process new and existing information to make sure we are on the right track”. Instead, complacency or excessive reliance on those biases can increase the time to correct diagnosis and treatment. I appreciate the “what’s the worse it could be” statement even more now after hearing Lewis and Helen’s story. I remember on my surgery rotation thinking about how many times I saw a post-op ileus, and how available it is in my mind.

    Anyway I’m looking forward to another great day today!

  3. tjoseph2 says:

    The teeter-totter exercise brought out some of the best leadership in all of us. We formulated a plan, kept open lines of communication between all of use and accomplished the task with plenty of time to spare. I was ecstatic and giving high fives all around when Dr. Mayer suddenly challenged us to think about how we could have done better! It was not good enough that we had accomplished the task in less than the 10 minutes of time we were allotted. Now we had to think about how we could have done this better. I was stunned because all I wanted to do was celebrate our win. However, as we started to tease out where we we had some issues, it was clear that we were, as a team, capable of doing a better job than we had done. We could have talked less and streamlined our communication. We had some potential sources for mistakes which we did not thoroughly think through and create a back up plan for. Our other colleagues who were not on our team also offered some suggestions. At the end it was clear that no matter how well we had done in the past, there is always room for improvement.
    This same theme came about during our listening workshop today. Dr. Mayer had acted the part of a surgeon who was displaying empathy and showcased both bad and good examples. Although his good example was “good”, Helen quickly pointed out that it could be improved upon. This reminds of an Gawande article in the New Yorker (http://www.newyorker.com/reporting/2011/10/03/111003fa_fact_gawande?currentPage=all). We can constantly look for areas of improvement in our practice and we should search for these areas relentlessly. It also may be a good idea to get some coaching on that improvement.

  4. Cokkoe says:

    We hit a LOT of interesting topics in the past couple days. Here are a few that I’m continuing to think about:

    Informed consent: We watched a video documentary today about an otherwise healthy and young patient who had developed a sudden onset of seizure activity, whereby the diagnostic workup led to an inconclusive brain MRI suggesting a choroid cyst v. artifact. With literature available at the time suggesting an association between choroid cysts and sudden death, the primary care physician made a referral to a neurosurgeon, who suggested that the best plan of action was the placement of a ventricular drain, followed by removal of the choroid cyst. Despite hesitation on the primary care provider’s part, the patient consented to placement of the drain without a full explanation of the procedure and its risks and benefits. A second informed consent was obtained for the cyst removal while the patient was heavily sedated with pain medication, and again without a full explanation of the procedure of perceived benefits v. risks. Not only were these components missing from the consent process,but the physician, it turns out, had done very few of these procedures but was not willing to admit to his limitations or the limitations of the medical facility. Without informing the patient and family of these limitations, he also precluded a discussion on alternative treatment options, and the potential for shared decision making. In the setting of provider inexperience, the patient suffered significant irreversible brain damage, and procedure-related complications that led to his eventual death. Later, physicians determined that the cyst was not a cause of his seizures. This was a shocking video to me.

    While I always thought that the informed consent process was vital to shared medical decision-making and, frankly, a cumbersome way of getting a patient to agree to a medical procedure that the medical team thought would be needed, I had never thought of it as an important part of empowering patients in their medical care and in their own safety. My first reaction to this video was to blame physician payment structures that incentivized unnecessary medical procedures. However, one telluride participant made an excellent point that, while we can’t expect every patient and their family to be aware of the informed consent process and their right to information about the risks and benefits of a medical procedure, it is important that physicians and other health care providers are active in creating a culture of “transparency.” Although the patient/family may not even be aware that they can ask questions about their medical care, we as providers need to empower them to be open to asking questions and being involved in their care. In the documentary, the patient’s parents did not know to ask more about the procedures and assumed that the physician was acting only in the best interest of the patient to prevent imminent death. Had the neurosurgeon had an honest and open conversation about the procedures with the patient, they would be able to decide what level of risk the patient wants to take on in the context of perceived benefit. This would have prevented the grave medical error.

    Helen Blackmon made an excellent point during another part of the day, but also along the lines of patient empowerment. She said the patients have a very unique perspective of what works and does not work in a medical system and should be key stakeholders and participants in discussions to improve patient safety and healthcare system structure. Indeed, I can think of many instances where different services think they are operating optimally within themselves, but are not communicating to each other, leading to miscommunication, error, and lower patient satisfaction. Patients may have very unique insight on how to make the system better because they’re experiencing everything first-hand and yet are removed enough from the individual services that they can see how well the system works as a whole.

    The other topic that has been interesting to me is leadership. At this point in my life, I’ve worked with many different types of people and many different projects. However, I had never taken a survey on my leadership style and how to work with different types of people. I’ve learned that I need to be more perceptive of the leadership or learning/working styles amongst the team members of my group, and employ effective management strategies to motivate people with different styles. In my naiivity, especially right out of college, I thought that people were all like me – motivated by the same incentives, productive with the same working and learning styles. In positions of leadership, I tried to develop the same relationship with everyone, and that did not always work to optimize team productivity and motivation.

  5. jm4ptsafety says:

    As with several of the other group sessions here at TPSER I have found that implications of the teeter-totter exercise wider than I first expected. I originally was met with the basic challenge and desire not to disappoint my group members as well as a desire to validate my faculty’s decision to select me as a candidate. I remember trying to reason through the physics very quickly but soon realized there was a team of others that had a unique perspective and skills in regards to this task. Before the year I would have met this realization with a bit of defense; mostly stemming from my insecurities about my capabilities that become especially evident when surrounded by those more capable. However this past year of clinical rotations has taught me that each member has a valuable insight to bring to the table, even if they are simple or soft skills that are often overlooked. This final adjustment or attention to detail is sometimes what brings all the effort home; it can be the most meaningful part of a patient’s experience (especially important as our culture becomes increasingly driven by patient satisfaction scores). Ideally I see each member taking different roles depending upon the day or situation, and avoiding falling into a pigeon hole and performing the same role repeatedly. I think this can help increase worker satisfaction as well as avoid the circular nature of medical care that Josh described above.

    So, with that in mind, I approached the new team experience with a new sense of openness and willingness to see what each member could offer. I was proud of my team from the beginning in the sense that we seemed to be on a similar page. We started in a disorganized manner, spouting off ideas and weights and then as the idea was coming into my mind (and a few others I could tell based on their hesitancy) two people said, “Wait lets identify our leaders.” From there we knew who was to lead and things seemed to roll along smoothly. (I will say that while I believe there were factors that allowed us to work well together throughout the exercise, e.g. identifying the leader, allowing the front line to communicate directly, Bella’s taking a step back to get a new perspective, part of me wonders if we didn’t just get lucky and have the right coordination of personalities; are effective teams born or created? Can they be both?). Participating in this exercise forced me to identify my strengths and weakness as a team leader and a team player. I realized that I chatter to much, and may be too authoritative. And that balancing silence and respect for worker autonomy with authority is important. Additionally, I had to confront my discomfort with taking on a leadership role and forcing myself to be instructive and confident when my and other’s reputation was on the line (although this was only theoretical since I know this is a safe environment).

    Watching the other group perform was equally as enlightening. The one thing I keep returning to was the loss of their second egg. The board started to sway and went down to slowly and slightly that several of us watching were unsure if the egg had broken or in the board stopped a few millimeters above it. When several of us yelled out in disappointment that the egg had been broken those on the board let out a groan and immediately started jumping off the board. I wanted to freeze them all mid-step as I could see the other egg “patient” in a precarious position. It was too late though, they hadn’t formulated a contingency plan prior to the event. It was such a good experience to see firsthand not to “throw the baby out with the bath water.” in other words how important it is to see every opportunity to improper a care process/experience or to save a life- how important it is to keep the faith and not let one error/mistake increase your vulnerability/chance of making a second. It can be difficult especially given the delayed gratification of this career. It can be hard to accept that after 3 years of rigorous education and training I am nowhere close to seeing the fruit of my labors, that instead I am only beginning to understand what my next step toward this goal of patient safety should be. This week is helping define that next step tremendously.

  6. Ashley Colletti says:

    The opportunity to watch the Lewis Blackman video in the physical presence of his mother had a tremendous impact on me. Sitting directly behind her, the emotions Helen experienced as I painfully watched her relive the series of events that lead up to Lewis’ death made the film seem even more real. I took many good points away from our discussion that followed the film, things that will change the way I will practice medicine and lead a healthcare team in the future. Mindfulness is key. In my first year of medical school I was taught how to develop a differential diagnosis: the lack of careful thought in Lewis’ cases allowed physicians to jump to unsupported conclusions that cost Lewis’ life. The mentality to always consider “what’s the worst it could be” is a point well made. Each and every day in the hospital I witness physicians ordering thousands of dollars of expensive workups and tests that are not indicated for the patient’s condition “just to be sure nothing is missed” so I find it especially frustrating that not one of Lewis’ physicians ordered even an abdominal xray, at the least. The culture that results in poor communication between members of the healthcare team needs to change, particularly inexperienced residents being afraid to obtain a second resident’s opinion or relay concerning clinical findings to an attending physician or a floor nurse who documents her concerns in the chart but does not communicate them directly to a physician. Within the past year, however, I’ve heard a senior resident telling a junior resident not to hesitate to call him if in doubt, even if he was at home. I’ve seen countless nurses drop what they’re doing to be at the patient’s bedside to participate in rounds. I want to thank Helen for having the courage to effect positive change by being here to discuss the tragedy of her son’s death first hand with us.

  7. akhanwalkar says:

    Some thoughts on the last couple of days:

    The teeter-totter exercise was a valuable lesson in teamwork, communication, and clear leadership. As a member of the second team, I recognize that the first team had much clearer direction from the leaders and as such operated more effectively as a team. Speaking for myself, I acknowledge that I was rather passive in providing directions, partly because we hadn’t exactly established defined roles. To be fair, part of the reason is that we were hoping to make “systems changes” that would better protect the “patient” (i.e. egg) from harm – moving the board off the cinderblock entirely, or rotating it to the long axis of the cinderblock, or assigning individuals to hold the board from dropping onto the eggs as people climbed on. Unfortunately, these systems changes were against the rules! Nevertheless, we should have more quickly and decisively applied a contingency plan with clearly defined roles.

    On a different note, I found the two videos we watched to be extremely powerful and moving. For me, they highlight the power of the personal, eliciting an emotional response in a way that numbers, statistics, and graphs have more difficulty doing. While I have been well aware of some of the problems in our healthcare system, I had never witnessed such a personal appeal for change. I felt frustrated and angry as I watched the events transpire in both movies – whether due to poor system design and false assumptions made in Lewis’s case or a total lack of patient/family involvement and consent in Michael’s. Both Lewis and Michael deserved better. We have discussed the challenges of mobilizing people who are otherwise apathetic on issues of patient safety and healthcare quality – personal stories and appeals such as these may have a powerful impact when charts and graphs do not.

  8. Rose says:

    You could definitely see your skills within the work you write.
    The sector hopes for more passionate writers such as you who aren’t afraid to mention how they believe. Always follow your heart. Rose

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