We Have Met the Enemy and He is Us

Having just concluded another inspirational week of learning at our Telluride Patient Safety Roundtable and Resident Summer Camp, I couldn’t help reflect with our faculty on all the amazing and passionate young caregivers who were with us. Thirty resident physician leaders, each chosen by medical center leaders from across the country, actively engaged with international leaders in patient safety and patient advocacy, with the goal of making patient care safer. All of our faculty commented that the experience and passion of the residents grows each year, many citing the influence of past Telluride Resident Scholars who have led change and served as role models at their institutions.

However, what all of us also noticed is the growing frustration shared by many of these resident leaders. Their personal stories describe a health system that is totally broken – poor or little communication among care teams, disruptive and abusive caregivers, extreme work demands and pressures being put on them to get things done even when it means putting patients in harm’s way. Some shared that on call, they are being asked to care for as many as 50-60 patients while also having to admit new patients to their units with little or no support – a set-up they say all too often causes patient harm. Others shared their fear in calling for guidance from higher level care providers due to an underlying culture that says “you are weak and inadequate” if you call someone for help even though that call and assistance could save a life.

Many also shared their personal “silent hurt” after being involved in an incident that harmed a patient. Telluride provides a safe environment for attendees to share personal stories they cannot share at their own hospitals. While a number of institutions have started care-for-the-caregiver programs, this growing “second patient” concern among our resident physicians is not being addressed. I would like to share one of the many reflective posts authored by one of the residents this past week on the Telluride Summer Camp blog – this one by Nicholas Clark, a resident physician at Children’s Mercy Hospitals and Clinics of Kansas City. I had the opportunity to visit CMH last year – they are doing great work in safety and quality – their commitment to patient safety was again very evident in the five days I got to spend with Nicholas.

Where is our support… On Wednesday 6/11 we discussed the case of “Sally,” a 9-year-old girl who died because of medical errors. Regardless of how you look at it, this is a tragedy. In our discussion, the presenter described why this resident was “set up to fail.” The resident had undergone numerous emotional battles in the prior months on the wards and in the ICU, had struggles outside of the hospital, and ultimately quit the residency program as a result of Sally’s death, but there was not one discussion on Wednesday about how we should care for our residents.

Unfortunately, this resident’s story is all too common. Many of our Telluride attendees sympathized with the resident outlining how similar their experiences have been to Sally’s resident. I too can look back and see myself in that position. It is well documented in the literature that residents, regardless of profession, develop higher rates of depression and suicide than the general population as a result of our profession. Up to 20% of residents and medical students will face depression, and up to 74% of residents will face burnout. Those residents who battle with depression are six times more likely to cause medical errors than those residents who do not suffer with depression.

While it is easy to point the finger at the resident or the system for causing medical errors, and, at the same time, provide support for the family and the patient, there are few programs in place that support our residents and medical students. These are individuals who choose the medical field to cure pain and suffering, not cause them. When residents discover that, despite their best knowledge, skill, and intention, they harm someone, it is absolutely devastating! Do not get me wrong. I completely agree that we should first tend to the patient and family that have been affected.

However, we cannot forget about the second patient that was harmed – the resident. We need systems that automatically fire to debrief residents when harm occurs so they can learn from the event. We need systems that automatically fire to find systematic solutions to the problem so no other patient is harmed. We need systems that automatically fire to provide support for patients and families who suffer harm. However, we also need systems that automatically fire to provide emotional support for our residents when they are involved in a case of patient harm. Finding that you were part of the cause for patient harm can have a devastating and lasting effect on a resident. Residents are already a set up for depression which, as mentioned, is then a set up for further medical errors. These two perpetuate each other in a never-ending cycle. We need to break the cycle. We need support!

The stories shared by many of the residents reminded me of stories I have read about the psychological effects many wonderful and courageous military personnel suffer due to combat stress and personal events that have changed their lives. These are some of our top residents, chosen because they are Chief Residents or leaders among their peers. If they are struggling, how are others surviving? Our resident physicians are our future. They enter healthcare hoping to heal and do good things. Instead many finish their training traumatized and changed for the worse. They carry psychological scars that continue to haunt them for years…and they struggle with why they chose the field of medicine as a career. As Nicholas asks “Where is their support?” To be continued…