Why are we afraid to admit we are human?

By Betsy Mramor, M2 MUSC

It seems like common sense for us to realize that we will all make mistakes at some point in our careers. So why are we so afraid of admitting this when it happens? Are our own egos so big that we can’t admit we are human? Why is it that this same humanity that our patients and society expect of us disappears in a mistake. By not talking about these mistakes we continue to allow society to form these unrealistic perceptions that the healthcare field is perfect. I believe that in order for the culture to change; this perception needs to be broken.  There is no other way for this perception to change unless mistakes are brought to the table, discussed, and proactive measures are taken to correct them. Sweeping them under the carpet will only end up reinforcing this perception of the perfect healthcare system. Not only will this perception be reinforced, but also the unacceptable behavior of hiding or covering up mistakes.

I was so happy to hear confirmation of my thoughts from Cliff. Earlier in the week, Cliff had told us a story about how he lost his first heart transplant patient. He told us how shaken he was afterward. So shaken that he came home and told his wife that he had a 100% mortality rate. The next day he was asked what he told his next heart transplant patient. He told us how he was completely honest. He told the patient it was his second time doing the surgery and he lost the first patient. I keep trying to place myself in this patient’s shoes. Would I let this physician do my own heart transplant? Even with odds not in his favor;  I would have let him. For myself, there is a feeling of comfort and safety that comes from someone willing to admit that he is just as human (imperfect) as me.

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Bad person or bad system? by Aubrey Samost M3, UMass

I am a system engineering graduate student, and I firmly believe that the vast majority of bad outcomes in health care are due to good people working in bad systems. However, today when watching the story of Michael Skolnik’s death after three years of complications from neurosurgery I felt like I had just seen one of the rare cases of a truly bad person in the health care system.

For those unfamiliar with the case here is the two-minute synopsis. A previously healthy 20 something year old male presented to the emergency room after having a syncopal episode. A head CT shows what may be a colloid cyst with no evidence of increased intracranial pressure. An MRI is done and may show the same colloid cyst. Michael and his parents go to see a neurosurgeon who immediately admits him to the neuro ICU. He gets the family to sign a consent form that they barely understand and places a bedside VP shunt to drain the possible excess CSF.  Next the neurosurgeon told the family that Michael needed to have the cyst removed. He said the  procedure was small and glossed over any possible complications.  The parents felt they needed more time before signing the consent form for the procedure, especially after feeling like they had been deceived with the last procedure. Later that day the surgeon returned, and, finding Michael alone, had Michael sign the consent form despite the heavy doses of opioids that he was on. The next day the surgery goes ahead with terrible results. Michael suffered severe brain damage and had nearly every possible complication, none of which the family was prepared for because of the terrible informed consent process. After three years, Michael finally died of these complications from a surgery that it turns out he may never have needed.

As the story unfolded it felt like the neurosurgeon constantly placed his own needs ahead of that of the patient. I was so angry that he seemed to force the procedure on the family and patient never mentioning alternatives. Maybe his motivations were financial or maybe he just felt he needed the practice with this procedure, but it always seemed to me that he prioritized doing this procedure despite it not being in the best interests of the patient. On the other hand, perhaps he wasn’t truly evil in intention but just had terrible clinical judgement and truly believed that he was helping the patient by performing this unnecessary procedure. Regardless of which of the above might have been the truth – evil intentions or incompetent medicine – my blood pressure was surely elevated by the end of this film because I was so angry.

As we discussed this, I realized I wasn’t alone in my anger. One of my colleagues pointed out that it practically felt like murder what had happened to poor Michael. As I was listening to these comments and reflecting on my own, my blood pressure slowly lowered and the systems engineer in my started to speak up. The documentary we watched was meant to highlight the importance of the informed consent process and show that it was poorly done in this case. However, none of us ever asked why the neurosurgeon performed such a poor informed consent. What other factors may have led him to mess up this process so badly? As with any complex system, the answer is multifactorial and more complicated than it initially seems. The following are some of the ideas that I considered. I haven’t got the facts in the case to support these; they are really just my own theories and possible explanations, but it forced me to think beyond my initial gut reaction of blaming the surgeon.

-Financial incentives are misaligned: insurance pays you to do a procedure, not to advise the family and patient to not undergo said procedure. The need to get paid could certainly have biased this surgeon into pushing strongly for the procedure.

-Time constraints: The surgeon was most likely in clinic or the OR during normal business hours when Michael’s family was visiting. After the surgeon was done in the OR he could come up to see Michael and get the consent form signed but that did not align with family visiting hours. Therefore, the system could have acted against him being able to give the family the opportunity to go through the informed consent process and instead forced him to get Michael to sign it alone.

-Culture: Many of my colleagues remarked after seeing this documentary that they rarely or never saw an informed consent properly done. What the neurosurgeon did here was just another example of normalized deviance. If everyone else in the hospital was signing consent forms this way, is it any surprise that he did?

-Administrative pressures: Perhaps this was the only full-time neurosurgeon in this hospital and he was under a lot of pressure from administration to not shunt business to their local competitors. This pressure could make him feel unable to turn away a case even if he did not feel totally comfortable doing the operation.

Overall, I have no idea if any of those above system ideas are correct or played any role in this accident. However, by the time I finished thinking through these theories, I felt that we as a class had been missing the most important question. If we want to prevent informed consent failures in the future, we need to ask why he failed to obtain a true informed consent. And when we answer this question, we need to consider the possibility that any neurosurgeon in the same position might have reacted that way because of the pressures the system exerted on him or her. Only then can we change the system to prevent a well-intentioned young surgeon from falling into the same trap and hurting a vulnerable patient and family.

I attached a picture of a basic diagram of this system as it impacts the neurosurgeon’s decision to operate in my fictional system.

Trust and Safety in Medicine: Part 2 by Matthew Waitner M2 Georgetown

Perhaps, as Terry Fairbanks said yesterday, we should look not to our individual pursuits but the healthcare system that is in place.  Individually, we are each committed to the reason we put on the white coat – to cure, heal, and do our best to care for each of our patients.  And yet collectively as a system we are failing to provide that very goal.  How is it possible that such dedicated individuals are systemically failing – it would appear to be impossible, and the numbers certainly show that its more than just a few bad apples.  Perhaps our system needs to be overhauled.

I was struck at the insight that Dr. Fairbanks shared.  As a human factor engineer he explained that every other system in the world accounts for the natural errors in humanity.  There are fail-safes embedded in most systems to catch the errors before they cause undue harm.  Such fail-safes are not present in the culture of healthcare.  While every hospital is claiming to be patient-centered, we often fail to see the humanity within ourselves.  I am firmly convinced at this point that a systemic culture change is the only solution to our never-ending problem of patient safety.  Dr. Fairbanks made it clear that skill-based errors (or better put, automated errors) are the key to controlling our out of control safety issues.  In fact, as a first year medical student we learned in our neuroscience course about types of memory: short-term, declarative (semantic and episodic), procedural, priming, associative, and non-associative.  The last of these (non-associative learning) is when someone is habitually exposed to the same event over and over again that the event is done by rote.  This should sound familiar, as it’s the same as skill-based tasks that require automation or limited cognitive input in order to be achieved.

From my class example, this is when you live over a flight path (which I actually do), and you tune out the sound of the overhead planes because you hear them every few minutes.  Every once in a while a plane will fly lower causing a louder that normal event that triggers you to notice them again, and again with habituation it disappears from your thoughts.  So it is clear that our mind can become habituated by automated responses that require little cognition, and it is only when there is a difference that your routine is noted.  Hence is the case discussed today of the NICU heparin incident – habituation caused major medical errors.  I am fascinated by the idea that this system error could have been avoided if there had been a slight difference (a different shaped vial, a different drawer, any change from the expected norm).  Dr. Fairbanks would argue that this is how well-meaning, caring professionals make simple mistakes that cost lives – and it is not the individual practitioner, it is the system involved regardless of how mindful we may be.  That same error was noted in the book “Why hospitals should fly” when the flaps were not engaged yet 3 people confirmed a 15,15 green (indicating the flaps were extended) – it was the expected result and therefore it was what was seen.  These sorts of systemic errors are where the most margin for improvement can occur – because like any job, medicine becomes routine and we become habituated, and our brains are physiologically wired to become habituated.

To say this conference has been insightful would fall short of its true meaning in my eyes as a future medical professional.  These past two days have shown me that our profession is far from perfect (even though each of us strives for such), and requires some major safety overhaul before the public catches wind of our missteps.  In fact, I’m not sure how much longer we can pull the wool over their eyes before they catch us red-handed, and I’m not exactly sure how we have been fooling them for as long as we have.  The numbers are out there, the mistakes make headlines, and yet we are still more trustworthy than a stranger on the street, and we deserve no such pride.  As medical professionals, its time to put egos aside and start doing what we swore an oath to do: do no harm.

Reflections on Telluride East: Day Three by Lynne Karanfil, RN, CIC

Loved the discussions on high reliability. Healthcare can learn a lot of lessons from the US Navy as Dave Mayer pointed out. If you want to see our Navy in action, you only need to go to Facebook. Each vessel has a Facebook page that they post how they do some of their operations. Below is a link to the carrier USS John Stennis. They also share their thoughts on leadership as well. We don’t have to go to far on seeing how to do things safer! Sometimes the answers are in our own backyard.

https://www.facebook.com/#!/photo.php?v=10152313797947334&set=vb.110454772346710&type=2&theater

Telluride Day 2 Reflection by Yimei Huang Pharm.D Candidate 2015

The day started with Dr. Cliff’s “railmen story”–Listen to the Rhythm. I was deeply impressed by Dr. Cliff’s kindness to, and caring for others, whom he does not know and may never know. Not only did he give extra notice to the things easily overlooked as a passerby, but he also carried out his caring despite the inconvenience to himself. I was thinking to myself what in the world could stop this devoted man from becoming extraordinary? He is so caring to the world outside of his expertise, then what level of caring does he pay to his field? I was also reflecting on myself on how far I am behind him as for the caring heart—-how often I overlook what’s going on outside because I am already quite full with my own business?

A fun thing for today was Teeter Totter Game. This was my first time playing the game personally, and I really enjoyed the moments when our team worked so closely for a common end. At those moments, I felt so supported, accompanied and comfortable to come up with and share ideas with my teammates to work out a better plan. We were successful, but it was not the outcome itself that is dearest to me. It was the process before, during and after that 10 minutes. I would say every team has achieved this process and experienced the similar feeling as ours.

The most emotional and thought-provoking activity of the day was discussing the film “The Story of Michael Skolnik”. As I said in the meeting, I am curious to know what measures have been taken in the past ten years to improve. What has been done to cut off the unnecessary incentives that make surgeons desire to do procedures and even induce patients to agree? What has been done to guarantee a second-point checker for the clinical decision even when patients themselves do not have the second resource accessible? What has been done to ensure that risks are thoroughly informed rather than partially? How well is the fact of surgeon’s expertise and experience honestly communicated to patients? How often does it still exist that assuring patient of one senior surgeon to win their signature but actually carrying out the procedure by his/her student? Maybe taping or video taping the informed consent conversation would help? Maybe a consultant meeting with everyone involved in the case would help? Maybe a written form of patient’s teach-back document files to the supervision level would help? Where are we getting right now?

The day ended with a recap on Dr. Cliff’s Listen to the Rhythm. What an inspiring day!

Trust and Safety in Medicine: Part One by Matthew Waitner M2

George_WashingtonI have been participating in the Telluride East conference taking place in Washington, DC since August 1. In the whirlwind two days I have been barraged by information, struggled through leadership, boggled by safety concerns, and simply overwhelmed by my own emotions.  To put it bluntly, this is the most interesting two days I have spent all summer, and even though I am exhausted, I am beyond stimulated by the experience of this conference.  One minute we are hearing from Paul Levy on negotiations and the next we are working on teamwork and leadership in a teeter totter game with 9 teammates, a 2×8, a cinder block and 2 eggs.  Suffice to say this is truly a hands on and experiential learning experience like none other.

In reflecting on the past two days I have stumbled upon many thought trains (thanks Cliff), but one that my psyche continues to grapple with is the following conundrum: How can the medical community as a whole commit so many errors as to kill nearly 100,000 patients yearly (for at least 13 years according to the IOM), and still be considered one of the most trustworthy professions in the country?

All I have to say is, whatever PR firm is handling healthcare’s interest deserves some large bonuses for pulling off this feat.  Nurses, Pharmacists, and Doctors all top the list here in the US according to the most recent Gallup poll in November (http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx), nurses rank #4 and physicians #6 in Australia (http://www.readersdigest.com.au/most-trusted-professions-2013) and doctors rank #1 in the UK (http://www.gponline.com/News/article/1171314/Poll-reveals-doctors-trusted-profession/).  Seriously – this PR firm not only succeeded here in the US, but internationally as well.  I am stunned because on average (in the US) we kill 272 people per day due to medical errors which is the equivalent of two Boeing 737 crashing each and every day (total capacity per 737 = 137).

According to today’s presentation by Terry Fairbanks, we have a 1:616 adverse incident rate as a field – akin to bungee jumping in safety, while other professions soar in safety comparatively.  How could we possibly still believe then that healthcare professionals are still worthy of the patient’s trust? My only conclusion is that we as a profession do not deserve such accolades until we get our house in order and focus on patient safety.

What continues to be mind-boggling about this conundrum is that the population polled must have had some interaction at one point or another with the medical field.  Healthcare touches nearly every life in the country either directly or indirectly, and yet we are still given the distinct honor of being one of the most trustworthy professions.  This is even after Press Ganey scores (indicating mediocre treatment in the hospital, as any front-line employee will indicate), after outrageous hospital acquired infection rates (about 1.7 million yearly according to the CDC), and our dismal rate of iatrogenic death previously discussed.  Why are people not more outraged at these numbers?  As a future physician, these numbers are staggering and show that truly patients should not trust our professions.  So, truly, whatever PR firm is handling medicine must be doing one hell of a job and be making a killing in the process.  Seriously though, these numbers and our perception are at complete odds with one another and deserve to be honestly considered.

The only conclusion I have been able to draw from this analysis is that the healthcare profession has been given nearly implicit trust by our patients, by simply putting on a white coat, and we have done a horrible and dismal job of accepting that trust and caring for our patients safely.  Again I ask, where is the outrage?  Are people not doing the math? Where is the expose on 60 minutes or 20/20?  Frankly I’m surprised anyone trusts us at all, and if we are going to continue to receive such trust, we best make some changes fast to ensure that this trust is correctly placed.   From my perspective, somewhere in our profession, we have determined that while patients are the reason we exist, they are not to be treated as having such power.  Instead of being patient centered and safety conscious, we have turned healing into a business focused on doing more and caring less.  I am appalled as a future professional that this has been allowed to occur.  I, as many others reading this blog, came to this profession in order to diagnose, heal, and comfort people in their most dire need.  How could our profession have lost sight of our reasons for entering the profession in the first place?

Stay tuned for Part 2…

Collections of random thoughts for the day

Loved the discussion on communication and the different styles. When we were in groups for the case study, it struck me as interesting that the behavior of the surgeon in one version was not “bad”, but it still changed behaviors, and not in a positive way. Also, I was thinking about how I would feel if I were Naomi or Tess? I was thinking it would be hard to “rock the boat”, especially in a time-sensitive situation like an operating room, and especially at the end of a long shift / procedure.

I really like what Cliff had to say about why do we keep trying to hide information, when he was referring to his operation record. It is so true. We are all so egotistical, proud, scared, and a host of other emotions.

I like the thought of looking at the hazards, and not just the extreme cases. I think we do not talk about near misses, and these are huge learning opportunities for staff, as well as for thinking about system improvements. I appreciate the comments around “mindfulness”, and especially the dialogue between Gwen and Terry. I think I probably see things a little differently than Terry, but that is okay. I think of it this way. If a nurse is not mindful, goes on with some tasks, rather mindlessly, there is an increase for potential error. However, if a nurse is mindful during these tasks, I believe there is less chance of error.

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