Post Telluride Reflection by Matt Starr #TPSER8

I finally was able to get my burrito, but not without trouble. We showed up to town after a long afternoon of biking down the mountain around 5 pm. The problem with that is the taco stand closes at 5 pm. So I raced over to the stand only to find it closed, but the back door, which also served as the entrance, was still open. I ran up to it and asked the man inside if he would make me anything that he hadn’t put away for the day or ran out of. He agreed and made me a burrito and I had no idea what was in it, but I loved every bite. I cannot wait until I get to come back to Telluride again, this place is by far one of my favorite places to visit in the world; the people, the food, the atmosphere, it is truly an amazing place.

My ‘aha moment’ happened when Tim pointed out to me the obvious distinction between the airline industry and medicine. Yes, hospitals should be more like the cockpit, but every time a pilot makes a mistake, it is most likely going to cost that pilot his/her life. However, if a physician makes a mistake, it will most likely cost that patient his/her life. That is why the airline industry has always been faster at implementing change, they major stakeholders in the decision making process are risking their livers with each error being made.

Dr. Angood had been hinting to me all week the problems associated with this kind of standardization in medicine. Medicine and aviation are very similar, but also very different. Every medical case is different in some aspect than the previous. It can be very beneficial to streamline the major processes, but the doctors can’t be afraid to deviate from the standardization because it is very hard to categorize each patient that comes into the hospital into distinct groups.

This past week was a great opportunity to meet some really great people while learning about patient safety. I can’t speak for everyone, but I think most of us really made some great friends here and created a network that will allow us to transform our medical schools and hospitals into safer institutions. I learned a great deal about the current problems the field of medicine faces in terms of patient safety. It seems that every field can improve greatly and every allied health profession (nurses, PTs, OTs, PAs, etc.) can greatly improve…that’s a lot of room for improvement. But I think this conference was the first step in creating the network that we can all build on in the future as we seek to improve patient safety in all of our respected fields.

-Matt

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Telluride Reflections Day 3–Matt Starr at #TPSER8

6/26/12

In my return to Telluride 6 years later, not a lot has changed. The people here are still as friendly as ever and the best taco stand I have ever found is still making the same mouth-watering burritos (pictures to come). However, my journey here is far different than before. This week I have been exposed to a wide variety of people involved in the health care community all wanting to hone in on issues surrounding patient safety.

The discussions that are taking place will one day shape the future of healthcare as patient quality and safety continues to evolve. Ideas are being bounced around and discussed around the clock. I think so far the most profound stories for me were the videos of Lewis Blackman and Michael Skolnik. It is hard to see how easily the medical system can fail so easily, but these stories and those of many others will only help bring change to the medical community.

6/27/12

Today was the best day of the week so far. It started off with an awesome hike up the mountain to waterfall just outside the valley. Before we set off on the hike the camera crew asked me if I would wear a camera around my head that would capture my trek up the mountain. In addition the camera was pointed at my face and not away from it, which was also weird.

It was kind of intimidating knowing that they would be capturing my conversations with everyone as we all went up the mountain. At first nothing really came, but as we progressed through the hike we started conversations that we continually came back to throughout the day. We tended to focus on the notion of how can we make change at our institutions, something that this week was building up to. We couldn’t discuss this topic right away until we had the foundations that were built on the first few days.

The afternoon produced the most productive learning session the group had as a whole. Everyone was contributing their own ideas and thoughts that led to some really great changes that everyone wants to bring back to their institutions. Immediately we all began thinking of ways to stay in contact after the week so that we could successfully implement these changes across all of our schools and hospitals. It was just awesome to see that everyone in the room was genuinely excited about the changes we could make that began in a small room in Telluride. It is a powerful sign about what can be accomplished by medical students when you gather them together and show them that they can make a difference, which was illustrated by the article Wendy gave us about the IHI initiative on surgery checklist.

After a hard day of hiking and discussions a group of us had worked up quite an appetite and so we headed to the infamous taco shack. However, my cravings were not indulged as that stand had closed an hour earlier. But we found the cook and made sure that we would be there tomorrow while they were still open.

The taco stand being closed did not set a bad tone for the night, but in fact was just a minor speed bump in what was an awesome night. After dinner a group of us went into town with Tim. It was fun to hang out with everyone in a social setting just getting to know each other. Four of us stayed down in town until the last gondola ride and Tim stayed with us the whole way. What was even better was that when we got back the five of us didn’t go to bed but continued our conversation of how we can make changes at our institutions with Tim giving us some excellent insight. The leaders of been saying sometime this week we would have our “aha moment” and that moment for me was last night talking with Tim. I have always thought of how standardized protocols (aviation) and lean thinking would be the cure all for medicine. Throughout the week, Dr. Angood had mentioned that maybe that wasn’t always the case, but he had never gone into much detail. However, Tim gave me a great analogy that just shook my current way of thinking (I will post this in a later blog as it requires a little bit more writing).

I’m looking forward to this last day in Telluride, but it is also bittersweet to think everything is coming to an end already. Also looking forward to finally eating my burrito. More to come soon.

-Matt Starr

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