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.



The Halo Effect

By now, many of you have started to read Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care by John Nance. If not, you are in for an engaging read that starts by sharing the unfortunate story of the worst accident in commercial aviation which occurred at the Tenerife airport in 1977, killing 583 passengers aboard two different 747s and influencing cultural changes to aviation and other high reliability organizations around the world.

The author’s assessment of this event told through his character Dr. Jack Silverman, highlights the communication and cultural missteps that contributed to the unfortunate outcome–one of which being The Halo Effect. The Halo Effect, defined by psychologist Edward Thorndike’s empirical research, is the cognitive bias where people seen as knowledgeable or highly respected in a given area are given deference across the board. In the Tenerife example, neither the co-pilot nor the engineer challenged the highly decorated pilot, because he was “who he was” even though it is thought they had information that could have changed the outcome.

While aviation has changed dramatically over the past 30+ years, evolving into an exemplary model of what a high reliability organization looks like, health care still has a long way to go. The Halo Effect is just one aspect of the predominant healthcare culture which remains hierarchical in nature, and often devalues the contribution of those less experienced or lettered even though all involved in a patient encounter–patient, family, nurse, allied health professional, pharmacist, student and physician–have something of great value to offer.

Can you share an example of a time you had something to offer to a patient encounter, but held back because you thought an attending or senior physician would not welcome your comments? Or because you thought they must know better? Was there a time you pressed on in light of the perceived consequences? How did your choice impact the patient’s experience?

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