I think big and dream bigger but have been told many times in my life to stop doing so. My grade 10 careers advisor told me to aim lower when I expressed an interest in studying medicine, a male physician once told me that training a woman was like training half a doctor and I’ve even had a family member tell me that women joining the workforce are responsible for the downfall of modern society. Despite this, I’m now in medical school and will one day soon achieve my dream of becoming a doctor.
Over the last few days I’ve been given the skills and knowledge to undertake projects that improve outcomes for all patients; I’ve been empowered to make a change. Unfortunately these things take time, you need to carefully plan, analyse, monitor and assess. You need a specific problem to tailor your specific, well researched solutions and I am sure in the months and years to come I will use the things I’ve learned and the frameworks provided to make change happen. However, at this point in time, my goal is big and broad, it’s in no way specific and while I’m prepared to to do my due diligence and execute some high quality, quality improvement projects once I find my focus, right now I just need to do something. Improvements to patient safety education shouldn’t have to wait for me to specifically define the problem in a measurable way or wait to get ethics approval. It can’t wait, not while I know there are things I can be doing that will have some impact right now.
Don’t get me wrong, I know we need to improve patient safety, safely by following the right processes and procedures but today I am going rouge, I am not going to wait. Like a hungry Roundtable delegate on the hunt for a burrito I am going to take action. Tonight I will email my contacts and state my case to ensure that patient safety is on the agenda of every student-run educational conference in my state this year. Additionally, I will push to have a safety moment at the beginning of each event my medical society hosts. Lastly, because I can’t be everywhere at once, I will make a time to train others in my medical society so they too can be safety coaches and start getting the word out about this important issue.
One day soon (when step 1 is behind me), I will start the research and do it the right way but I won’t sit ideally by in the mean time. Watch this space.
In its 1999 report, To Err is Human: Building a Safer Health System, the Institute of Medicine (IOM) concluded that medical errors, particularly hospital-acquired conditions, may be responsible for as many as 98,000 deaths annually, at costs of up to $29 billion. Suddenly, quality healthcare and patient safety became central, public concerns in the United States. According to the Institute of Medicine (IOM; 2000), medical errors accounted for between 48,000 and 98,000 deaths annually in the U.S. At that time, medical errors were considered the eighth leading cause of death in the U.S.; more prevalent than deaths from breast cancer, AIDS, or motor vehicle accidents.
I started my practice in medical education in 2000 at Southern Illinois University College of Medicine. At that time we were creating a new and robust, medical curriculum. Similarly to other medical schools, however, we had just a few lectures in this content area. By 2003, quality and safety had become central concerns in the U.S. Communication failures were identified as the root cause of the majority of both malpractice claims and major patient safety violations, including errors resulting in patient death. The Joint Commission found that communication breakdowns were the root cause of 60% of medical errors, 75% of which resulted in death. 2,034 errors, which means 915 people died as a result of a communication error in 2003. Clearly it was time to get serious.
It was 2005 when I joined the University of Illinois Chicago College of Medicine faculty in the medical education department. I had the opportunity to engage with faculty members seriously interested in training learners in patient safety. For two years, I worked with this team to create and deliver lectures and simulations, co-lead a patient safety elective, and was invited to attend the Telluride Experience.
In early 2007, we were in the middle of creating a patient safety institute to deliver a formal curriculum on the subject. One of my goals was to create an online, degree-granting patient safety leadership program. 6 months later, the Master of Science in Patient Safety Leadership (PSL) proposal was created. Once it had been approved by the various required entities, the curriculum was created by our team of patient safety experts. In fall 2008, the first cohort of learners began; however, this was only the beginning. The PSL program was very successful and applications were rolling in. The learners couldn’t get enough learning and we were getting rave reviews. Despite the program’s success, however, I found a letter from the Senior Dean for Medical Education that said they no longer needed my services.
So the journey continued… Thankfully, I had received opportunities from other medical schools. As the Associate Dean for Medical Education at the University of Cincinnati College of Medicine (UC), I had the opportunity to work with an amazing faculty and a very talented Senior Dean for Medical Education, Andrew Filak. Within 20 months, we created a new, contemporary, four-year medical school curriculum, which was awarded full accreditation from the Liaison Committee on Medical Education. . During these very busy years, we created an Institute for Healthcare Improvement (IHI) Open school and embedded safety, quality, and leadership into the curriculum. With other deans from nursing and pharmacy we implemented interprofessional sessions for medicine, nursing, and pharmacy learners. Each year, I also attended the Telluride Experience as a faculty member and continued to bring learners from UC to the events. One day, I picked up the phone and everything changed again.
It’s 2013 and the original PSL team is back together again; this time in Baltimore, MD and the District of Columbia. Despite 14 years of experience in medical education, I was amazed by how little quality and safety training was provided in medical and nursing schools nationwide. Basic training is required by accreditation bodies, but it does not adequately prepare the physicians and nurses for the complexity of medicine in today’s world. While some positive changes have occurred, we are still battling the same issues.
A little over a decade later, medical errors are now the third leading cause of death and account for more than 400,000 deaths per year. Recent studies have reported that as many as one-third of hospitalized patients may experience harm or an adverse event, often from preventable errors. Unfortunately, competencies for optimal patient care outcomes in the clinical environment include knowledge, skills, and attitudes in critical disciplines not traditionally trained in medical or other health science programs. Frankly, it’s hard to imagine that one can provide ‘care of the entire person’ if attention to quality care and patient safety is missing.
The absence of such training leads to medical errors – a serious problem that affects not just patients but also the health care workers involved. Many good physicians, nurses, pharmacists and other health care professionals have left the field due to depression and lack of support from their colleagues. Even more unfortunate, a growing number of health care professionals take their own lives each year when involved in a preventable medical error.
It’s 2017 and we have created a solution to this pervasive crisis. I worked with Georgetown University and MedStar Health to create a new Executive Master’s Degree in Clinical Quality, Safety and Leadership (CQSL).
CQSL unleashes a systematic, evidence-based education that will achieve striking results in safety, quality, reliability, and healthcare value. With a learner-focused environment the CQSL program will equip learners to become leaders in the advancement of safety science and quality healthcare. The curriculum includes online asynchronous coursework, simulation, team training, and one onsite residency. The inaugural class begins in fall 2017.
Health-care practitioners and leaders need new skills and attitudes to meet the changing needs of patients in a medical environment that has complex multilayered systems, informatics, assessment, outcomes, and quality indicators. Secondary to these changes, health care has become a high-risk industry. As Yukl (2002) noted, “A vision is seldom created in a single moment of revelation, but instead it takes shape during a lengthy process of exploration, discussion, and refinement of ideas”.
And so the Journey continues…
Finishing medical school is about looking back to your time as students and looking to the future as new graduates.
It’s the future I want to focus on. Medical school is just part of the continuum of medical education. You’ll keep learning new facts and new techniques. You’ll even find that as years pass and knowledge increases some things you learned in medical school have become obsolete or outdated, overtaken by new information.
But some things never change. One of these is the need to always put the patient first. It sounds so simple, but there will be many temptations to put the patient’s need lower on your list of priorities.
Many events and people will influence you. Some of these events will be errors you or others will be involved in. Most errors are not the fault of an individual, although the individual may be the last factor in a string of contributing causes. Most errors are the fault of a system where the safety of the patient is not always paramount. And when they do occur, they should always be seen as opportunities to learn and improve.
The people you meet and work with can influence you. Not all will be good influences. Some will be arrogant, some will cut corners, some will ignore protocols, some will not show respect for their patients or for other health professionals. Some will not put the patient first.
You’ll meet others who treat staff and patients with respect, who aren’t self-promoting, who sit at the bedside to talk with patients, who listen, who understand the value of other members of the care team, who want to learn as well as to teach and who put the patient at the centre of every decision.
Both groups have the potential to be role models, particularly if they have strong personalities or are much more senior than you. So pick you role models with care. Decide who you want to be like and who you don’t want to be like.
Here are my 10 tips for new graduates, tips that will help you right through your career, but more importantly, tips that will help your patients, giving them good care and keeping them safe.
- Never forget that patients are vulnerable.
- Remember that you are the guest in your patient’s illness.
- Listen to your patients. “What’s the matter with you?” is a good question but your care will be better if you also ask “What matters to you?”
- Use simple, clear language with your patients, remembering that good communication involves listening.
- Work collaboratively with and learn from nurses and allied health professionals.
- Admit your mistakes and use them as opportunities for improvement.
- Don’t accept standards and behaviours that aren’t in the best interests of the patient. The standard you walk past is the standard you accept.
- Keep learning, stay up to date.
- Never let people put you on a pedestal. Stay humble.
- Always put your patient first, never forgetting that “It’s all about the patient”.
Have a wonderful and fulfilling career.
One increasingly important realization by healthcare professionals is the need to both engage and encourage patients to participate in their care. The following story of recovery and healing from double mastectomy surgery is told by Ev, a grandmother of nine, mother of three and wife to husband Will of 44 years. I asked Ev and Will to share their story because, I was fortunate to be included in Will’s weekly updates during and after Ev’s surgery. Each message not only gave reassurance to family members near and far that she was doing well, but ended with an inspirational blessing for all; the family’s faith first and foremost in Ev’s healing process. Their faith was a silent but strong part of the care team, and their strength as a couple was a beautiful testament of what teamwork and love can do for a marriage and the trials that life presents.
I include Ev’s words unedited, as she hopes they will help another breast cancer patient facing a similar surgery–to find answers to questions, insight to questions they may not know they have, and to find the same peace be it through faith, a loving caregiver or a skilled care team. Ev had all three–the trifecta of healing for her, and as a result, many, many happy people including her nine happy grandchildren, Ev’s daughters, and her partner in life, Will.
What do I do now? I was growing quiet impatient with follow-up doctor visits regarding questionable mammograms, ultra sound screenings, MRIs and biopsies during the 4 years since I was first diagnosed and treated for breast cancer. My husband, Will, and I were also seeing physical changes (dimpling and caving in of the skin) which was now occurring in the breast where lymphedema was prominent and seemed impossible to alleviate. I had gone to physical therapy and done exercises at home for two years. It didn’t work. The lymphatic system in the breast barely worked. The left breast tissue was ruined by radiation and very angry. My practical problem was regarding bras—being size E and weighing 148, I could barely tolerate wearing any bra I tried.
Dr. Moline, my original breast surgeon, said she could do nothing to fix the angry tissue except a mastectomy. She explained that it would be completely paid for by my existing insurance “to make the situation right” after cancer had struck. This was a big factor in my deciding whether or not to have a mastectomy. My oncologist advised me to have a double mastectomy to alleviate further testing of both breasts– “Nothing there, nothing to test.”
Dr. Moline gave me the names of three plastic surgeons. I choose the first and only one I visited. Dr. Williams was very clear, gave us several options, and sold my husband and me on the benefits of a double mastectomy with Tram Flap reconstruction of both breasts; this would all be done in one day during 10 hours of surgery. Dr. Moline would do the double mastectomy and Dr. Williams would do the Tram Flap with the help of her team.
Will was in total agreement. He was positive and started plotting what I might need for this huge surgery. We purchased a leather electric recliner not only for sitting but for sleeping the first week home. The electric mechanism was very helpful. Will purchased a hand-held shower hose with nozzle to fit in our shower and found a folding chair I could sit on for the first showers.
Our faith is very important to both of us so we relied on the Promises of God to make decisions, to live each day and not worry or loose the feeling of peace. Our family, neighbors, and church friends prayed, brought food, sent cards and flowers, (even new PJs), called and visited. Their sense was not of dismay or, “What are you doing?” Attitudes were positive and they seemed to believe and say, “You’ll get through this!” Three pastors visited us and read Psalms and assured us God was with us.
The day of surgery was a breeze for me. A hospital chaplain said a prayer for us before I went to surgery. Will was sent home and the hospital nurses and doctors called him every 2 hours with good updates. Our house is only 10 minutes away from the hospital so he was close. I remember seeing him about 8:30 pm. I was certain no surgery had been performed on me because I felt no pain or nausea. All I really felt was quite a bit of stiffness. I was checked every hour to make sure the blood vessels that had been moved were successfully reconnected and working to nourish the tissue that had been moved from my belly area to the breast area. I had nine drains. I was down to five drains when I left the hospital 5 days later. I lived on ice chips the first couple days, moved on to clear liquids, and ate a salad later on. I was able to get up and sit in a chair the third day. I remember moving myself that very short distance by myself; Will remembers it differently (he assisted). The nurse helped my attitude about getting up by saying, “The first time is the hardest, and after that it gets easier every time.” She was right. It did get easier. I walked slowly into the hospital bathroom and had a shower on day four. The nursing staff and doctors could not have been more professional. I tried to follow all the rules. I was a little bent forward for a couple days.
At home, Will removed all the smaller rugs on hardwood floors from the recliner to the bathroom. He had learned at the hospital from the nurses, how to empty, measure, and clean the drains. I had completely cleared my schedule and did nothing but rest, eat a bit, and sleep. Will was a remarkable nurse once again. He was willing and able to help me and brought his sense of “get it done” with a cheerful attitude. I was unable to keep track of my meds: Oxycodone for a few days, Ibuprofen 600 MG, and Acetaminophen, so Will took care of dosages and times. That was so helpful. Our closest friends and our family were updated daily with a quick sentence or two by email of my progress. Will was able to keep them informed and they appreciated a quick update. All the drains were removed by the end of the second week after surgery. The metal lanyard that held the drain bulbs against my belly was one of my only irritations. Metal is pretty hard. Do they make a plastic one?
I’m back doing most things except lifting much. I can’t lift my grandchildren but I can hold my 3 month old granddaughter. I can reach most things in my kitchen but found weeding last week a bit of a challenge. I have started taking my walks in the park where it is flat.
I am so delighted I had this big surgery. The chance for breast cancer is gone. A reduction in my breast size is also a huge blessing. A caring support group and husband not afraid to help with the recovery process make it all that much easier. I know for sure a top team of doctors can do successful surgery and make you comfortable, but God is the One who heals.
Over the last five days in Telluride, I have gotten to know an awesome group of 26 medical and nursing students. You clearly will play key roles in changing patient safety in constructive ways. As Dr John Toussaint (ThedaCare Center for HealthCare Value, Appleton, WI) suggests: “How can we provide high quality care unless we provide a base of safe care.”
Various descriptors come to mind. Compassionate. Caring. Thoughtful. Very smart. Respectful. Self-reflective. Genuine listeners. Open to learning and sharing new ideas. Passionate. Willing to live your values in speaking up, decision making and problem solving. Mindful. Inclusive. Thirsting to know more about patient safety….and you did.
You became good friends, bonding, getting to know and care about each other as human beings without labels or titles or tribes. It is clear you are patient and team focused and became even more so during our indoor and outdoor classroom work, social times and the big hike.
Telluride and the mountains are beautiful. Y’all have an inner beauty that will continue to serve you very well in all you do.
I didn’t want our time together to end, especially when several commented that this experience has been life-changing. I am desirious of staying in touch as you take your individual learnings and feelings forward and to helping you in any way I can.
I continue to encourage you to always live and to role model your True North. You will be seriously tested.
I wish each of you many blessings! I am honored to call you friends….
Following are leads from Resident Physician reflections after attending the first 2016 session of the Telluride Experience. Links are included back to the original posting on the Telluride Experience blog. Thanks to all who so courageously offered their stories from the front lines of care so that others can learn through them. It is by sharing our stories that we free another to tell theirs as well.
The Magic In Transparency
This phrase struck me as the perfect way to describe an experience I had my intern year. My first continuity ob patient had a fetal demise at 34 weeks. She was the first patient I had followed from the beginning of her pregnancy. I performed her dating ultrasound at 9 weeks. Unlike many of my patients, she and her husband faithfully came to every prenatal visit. She did not smoke, use drugs and followed the dietary guidelines. Her husband was the chatter one of the duo, while she would calmly take everything in at our visits. They both teared up when I told them they were having a girl at the 20 week ultrasound. They told me her name was Emma. More…
I was not going to share this but have been inspired by the courage of others around me. So thank you!
…In the first few days of Residency, we had a mandatory “Emotional Harm” meeting. I thought it was nice of them to do and always a good reminder. It focused on the empathy towards the patient and not losing our empathy when getting in the rhythm of dealing with similar situations and cases over and over again. I loved that they did this. This is something that is so important to remember and necessary to address.
Looking back however, I just wonder what about my emotional harm? Where are my resources? In this first 7 months of my residency experience two Senior Attendings committed suicide. I did not know the first, but I certainly knew the second. While there was heartfelt sadness and memorials to honor both, there was nothing else. No counseling offered to employees, no conversations, no checking in after some days, nothing at all. More…
Humility and Humanity
Humility and Humanity. This phrase stuck with me from Dan Ford’s talk. From medical school through residency it is drilled into us to be confident, un-phased, unemotional , these qualities are attributed to professionalism and success. Doctors are supposed to be infallible , so when we face an adverse outcome thats what we do instinctively. We become distant, listening to Helen, Sorrel and Dan thats the exact opposite of what patients need. Alienation only leads to prolongation of suffering for the patients family as well as the caregiver. Moving forward I hope to make these values a foundation of my practice.
Reading all the stories from my peers encouraged me to share as well, this was an amazing group of people and faculty. My first ICU night rotation as a PGY-2 I admitted a patient in DKA and septic shock. More…
The following is written by Guest Author and Patient Advocate, Carole Hemmelgarn
In the months of March and April I had the opportunity to take two amazing trips; one to Doha, Qatar and the other Sydney, Australia. Do I feel fortunate to have visited these incredible places? Absolutely! The irony is, however, I would not have been in either location if my daughter Alyssa’s life had followed its natural course.
I was invited to both places to be part of the faculty to teach patient safety and behavior change to the young emerging scholars in the fields of nursing, pharmacy, medicine and allied health. While these young individuals are regarded as our future patient safety leaders they represent something much more to me. They give me hope. Hope that we can start fixing a broken healthcare system by breaking down the hierarchy, improving processes and communication skills, creating resiliency, and learning to provide support and care to our very own healthcare providers. They are also the generation giving hope to patients and families; making sure we are at the center of care, and that our voices and stories are heard, listened to, and acted upon with dignity and respect.
Earlier this year I told my sister that 2016 was the ‘year of hope’ for me. People will tell me they want me to be happy, but I struggle to understand what happiness is or means. Hope, however, is something I can wrap my arms around. I can hope to see a beautiful sunrise while out running, to watch a smile spread across my son’s face, and to see a child exiting a hospital knowing they are leaving better than when they entered.
There is an incredible aftermath when you lose a child to medical errors. It is a topic rarely discussed and one no one can ever prepare you for. Grief is a journey; a journey without a beginning, middle or end. While those of us who have lost a loved one never want you to experience this overwhelming pain we would like you to understand why happiness may take time in returning, or hope may be the best we can ever do.
When I teach these young scholars, I share part of Alyssa’s story because it helps connect the head and heart, and we need to put this piece back into medicine and caring for patients. Every time I speak about Alyssa, I give a piece of myself and my hope is that you take this piece and use it to make change. The future of patient safety resides in hope because hope is not found looking down or back, it is only found looking up.
Each of our Telluride Scholars adds their own voice and passion to the patient safety movement that continues to need attention. The following are most likely words of unintentional inspiration from Anna Elias who shows what one individual can accomplish when they care deeply about a cause, and dare to dream they can make a difference. Anna is absolutely right — Watch this space! — her space, because she is on her way to great things!
You can also link to the Telluride Blog where Anna originally posted this piece.