Telluride Reflections by Quyen Nguyen

6/17/2013

One of the most important lessons I have learned from the past three days is the urgency in which we need to act to bring ethics back to the forefront of healthcare systems. Too often the best interests of the patients and their families are put behind financial, legal, and personal factors. It may never be possible to prevent every error, but we have a professional duty to take responsibility and put patients’ and their families’ needs first in the aftermath of a medical error. I wish to express a sincere thank-you to Carole for your courage in sharing your personal story so that future healthcare professionals can learn from it. I hope that each of us will continue this conversation of patient safety to make a difference in patient care when we return to our institutions.

Today I also learned about the concept of anchoring. Anchoring is a practice in which a person’s perspective is biased by the first information given. The tendency of anchoring increases significantly when one becomes tired, fatigued or distracted by any other human factors. The heartbreaking tragedy we have seen in Carole’s and Helen’s stories stems from anchoring bias. As a caregiver, we have to be mindful and avoid bias when dealing with patients. However, after several talks with several medical students and nursing students, I learned that many residents may have to work up to 80 hours/week on average and many times they have to work more than 8 hours in a shift (please correct me if I am wrong). I wonder whether it is possible for one to maintain a clear mind with an objective perspective under these working conditions. Should there be a change to reduce such long working hours in residency programs?

6/19/2013
Yesterday, I went shopping and talked to a cashier in a souvenir shop in downtown Telluride. After I asked her whether she offered any discount for Telluride scientists, we started having an interesting conversation. On being asked what I was there for, I shared with her that I was in a 4-day summer school with medical students, nursing students, and pharmacy students to learn more about patient safety and how to improve healthcare quality. She then told me that since we were learning about patient safety, we should make sure that nursing school teaches nurses how to take blood sample of a patient without pricking her patient five or six times. She suggested that doctors should invent some kind of X-ray imaging on a patient’s arm so that they can test the blood without pricking a patient. We both laughed and I said, “Yeah, why not?” Such an invention may be possible in the future and it would increase the ability to deliver high quality patient care. I thought this is an interesting anecdote of those outside the medical profession on how they perceive those inside.

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We Can Do Better: Telluride Reflections by Madeline Rovira #TPSER9

Wow.  I’m not even sure how to reflect on the amazing day we had today.  From the horrors of the Michael Skolnik case video, to the excitement of being the first group ever to save Stewie (our egg ‘patient’),  to the heartbreaking story that Carole courageously shared with the class, today has been emotional and eye-opening.

So many moments today, as we listened to and became engrossed in the narratives being shared, I found my face scrunched up or my mouth falling open wondering how we could possibly treat our patients and families in some of the ways that we do.  I like to believe that people are good and generally do the best they can.  And yet, hearing about health care providers who ignore and belittle a mother worried about her child, or administrators who threaten a mother who just lost her child to medical neglect, or a physician who performs a surgery he is not qualified to perform, or hospitals that hide medical records containing the truths that could give some closure to a family, I find myself faced with conflicting pictures and refuse to believe that this is as good as we can do.

I am not satisfied with the response that we only know how to prevent the egregious actions taken by the hospital after the appalling death of Carole’s daughter, and that the events prior are just much more complicated and since they are medically related they somehow become less preventable or less in our control.  If this was the case, none of us would be where we are.  I will not, I cannot, settle for this status quo as good enough.  We know better and we have to do better.  The excuse that patients are just so much more complicated and medicine is inherently dangerous is a poor excuse for the suffering and pain we routinely cause.

For as long as I can remember, I dreamed of being a doctor – someone who cures the sick, heals the injured, and returns loved ones to their homes.  In recognizing the chasm between my childhood view of medicine and the reality I am learning more about, I think I am finding the reason why work in quality improvement and safety is so exciting to me, and why I am comfortable not knowing what field of medicine I will practice as long as this is a piece of it.

Thank you Carole for your story – your daughter’s story.  Your courage and resilience is inspiring.

The best advocate

By John Joseph, MS2 Wayne State School of Medicine

We completed the first day of the Telluride Patient Safety Summer Camp and I can say already that I am so glad I took the time to make the trip out. Telluride is a beautiful place and the enthusiasm and passion of the participants and leaders has reignited my interest. The lesson that stood out the most to me today was the video put together by Drs. Mayer and McDonald on the heartbreaking case of Lewis Blackman. His mother, Helen Haskell, fought tremendously for Lewis while he was in the hospital (and she continues to fight the system that killed him to this day) after a routine surgery. She trusted her instincts that something was wrong and repeatedly pushed for more senior physicians to examine Lewis, over and over and over. I was shocked that despite her insistence, that her requests were not honored. I was also horrified to think that if this type of cascade of errors can persist when the patient has a vocal advocate like Helen, what must happen to patients that are alone or do not have advocates that feel comfortable or able to question at all? How many children and adults have died because they did not have someone on their side? This hammered home the need for patient advocates and I look forward to learning more about their roles and implementation later in the week.

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