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.
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.
As in Doha, SolidLine Media was along to capture the stories being told at The Telluride Experience: Sydney! Thanks to Greg, Michael, John, Ali and team for pulling this short video together utilizing movie magic across the continents in time for the Minister of Health herself to view it live in Sydney, at the Clinical Excellence Commission’s reception for students and faculty before we returned home last week.
Truly a great team effort by all to bring the reflections and voices of change to life.
Today’s post is by Guest Author, John Nance, Telluride Experience Faculty, Author and ABC Aviation Consultant
Having had the delightful experience of attending and working with all of the sessions of the Telluride Experience this summer, I’ve spent some time since returning from Napa thinking through the scope and the effectiveness of what we all came together to advance: The goal of never again losing a patient to a medical mistake or nosocomial infection.
It may well sound hackneyed, but in fact I think all of us as faculty mean it to the depth of our beings when we say that the medical students and residents and nurses – all of those who joined us – are truly the best hope of changing the course of a noble but tattered non-system that slaughters people at the rate of 50 per hour. That does not mean that existing healthcare professionals cannot or will not embrace the dramatic changes that are required to keep patients safe, because, indeed, thousands are passionately involved in just such efforts. It does mean, however that the opportunity for leadership from the newer members of this profession will be critical, from the small and subtle gestures, to the grand and sweeping reforms.
And the potential for meaningful leadership, of course, is why those who joined us were selected in the first place, and what we expect of them from here on: Courageous leadership steeled against the oppressive influence of the status quo.
Having participated in this battle for patient safety for nearly a quarter of a century, I can say with some degree of authority that no matter how many presentations, discussions, articles, consulting hours, or other efforts are thrown at the problem nationally, creating a major cultural change is perhaps an order of magnitude more difficult when you’re surrounded by the very environment you’re needing to alter. Coming together at a distance – especially in a resort atmosphere, or in the incredible beauty of Telluride itself – is an important element in achieving transference of ideas, concepts, goals, and determination as free of dogmatic and traditional thinking as possible. And, of course, catching people at the beginning of their careers before the insidious influence of cultural rigidity has been allowed to take root and oppose change, is an equally important key. I know of no better forum than this, and I’m truly honored to be a part of it.
And so we came together and told you horrifying stories that made us all cry, exposed young learners to the realities and predictability of professional human failure, and rubbed all our noses in the reality that a profession whose routine operations count as the third leading cause of death in America does not possess the ethical choice to resist meaningful change.
But at the end of the day – and our time together – it all comes down to taking those small sparks of understanding and recognition and fanning them into flames back home, never forgetting that every hospital room, scheduled surgery, ambulance arrival, admission, or diagnostic test involves a fellow human who is as entitled to the highest standard of care and caring as your own family.
From a very personal POV, I thoroughly enjoyed meeting each of our participants this season and pushing the quest forward, and I look forward not just to next year, but to hearing how the seeds we all helped sow will sprout and change the landscape of American healthcare.
It is happening…and it is growing. A newer generation of caregivers – young physicians, nurses, pharmacists and other allied health professionals – are stepping up and starting to make a difference. Many of them understand and appreciate they will soon be the gatekeepers for high quality, low risk, high value patient care. They seem to be taking this responsibility seriously – more seriously than I and my older generation colleagues did at their age. They stay connected reading new information shared through social media outlets. They are doing regular literature searches for new articles on quality, safety and value. They want to learn and understand.
The reflective post shared below by Rajiv Sethi is just one of many similar posts that come from our Patient Safety Summer Camps. These young learners don’t just write reflections…they take their reflections and use them to research and learn best practices related to the topic in question. They want to learn, they yearn to learn.
There are days when many of us feel we are slogging uphill, going nowhere and will never live to see the changes so badly needed in healthcare. Working with these young caregivers revitalizes the faculty, just as much as the students are energized and educated around patient safety. Spending time to both educate and learn from the young is so important to the future of healthcare, but also our future and the future of every patients.
Published July 28, 2015 | By Rajiv Sethi
Having only been at Telluride Experience: #AELPS11 for a day, I hadn’t imagined I would have learned so much. We covered a variety of topics with important patient safety learning points. I am so grateful for the opportunity to be here and share the experience with so many motivated individuals keen to be change agents.
I wanted to focus on one of the key moments for me: The Story of Lewis Blackman (http://qsen.org/faculty-resources/videos/the-lewis-blackman-story/). We were very lucky to have Helen Haskell (Lewis Blackman’s Mother) with us and I am so grateful to her for sharing her story. So many issues were raised during the video and I was able to draw many parallels to health care in the UK. For example, the issue of reduced staffing levels on the weekend (see link). The consequences of this can be severe as was found in a study published in the BMJ, Day of week procedure and 30 day mortality for elective surgery… where patients undergoing planned surgery were more likely to die if they have their operation at the end of the week. The new plans proposed by Jeremy Hunt (Health Secretary) to increase staffing provision at the weekend in the UK are causing much controversy, recently culminating in the hashtag #IminworkJeremy (staff posting pictures of themselves at work at the weekend).
Another issue I wanted to focus on may seem rather obvious, but as a student I believe is one of the easiest things to incorporate in daily practice; the importance of health care professionals and students introducing themselves fully to patients. In the story of Lewis Blackman, there was a lack of communication and identification of the team involved in the care of Lewis. As a result his family were unaware of who best to raise issues with.
There is so much to learn from this story but I want to end reflecting on Dr Kate Granger’s hashtag #HelloMyNameIs campaign. On her blog she describes herself as a doctor and terminally ill cancer patient musing about life and death (Click here for story). She has done remarkable work in encouraging health care staff to introduce themselves to patients, with support from over 400,000 staff in over 90 health organizations including many NHS trusts. Only recently did I see a lot of the standard hospital name badges at Guy’s and St. Thomas’ NHS Foundation Trust (where I train as a medical student at King’s College London) being replaced with bright and colorful #HelloMyNameIs name badges. Although it may sound simple, the impact on the patient experience is phenomenal.
Our final session of the 2015 Telluride Experience kicks off in Napa, CA this week. Once again, the learning began by sharing the Lewis Blackman story, and we were fortunate to have Helen Haskell as part of the faculty to lead discussion after the film, along with Dave Mayer. Having been part of the team who created the film, and having viewed it more times than I can count, I am always in awe of the new ideas each viewing inspires. A large part of that inspiration arises from the conversations and stories that are shared by attendees after they hear the story.
Today, there were many excellent comments but it was something Natalie B, a nurse practitioner and educator, mentioned about the fear junior healthcare professionals hold of getting chewed out by healthcare leaders that often prevents them from speaking up when they are unsure. (See her post Transparency and Vulnerability=Scary! on the Telluride Blog). The second inspirational comment came from our newest faculty member, Kathleen Bartholomew, also a nurse, who pointed out the need for a greater sense of urgency around adopting a culture of safety above all else. She continued by pointing out that 900 similar case like Lewis’ occurred in the single day and a half since our group arrived at this meeting.
This begs the question that, shouldn’t delivery of care always be about putting the patient first versus the care provider’s ego or fear of jeopardizing a career? This phenomenon is far from limited to trainees too, which is of even greater interest. Perhaps an interesting model to consider would be to have medical and nursing schools recruit, train and accept only the most courageous students versus those with the best MCATs or test scores. It would be nice to weed out those who would/could put their own professional well-being before that of their patient at any level.
The reminder of the need for a greater sense of urgency was both valuable and validating. There have been times when it has been hard to watch Lewis’ story yet again, knowing errors related to healthcare hierarchy and culture continue to occur again and again. Helen shared that on November 6th, it will be 15 years since Lewis died–was killed–if we’re being honest. She pointed out that all too soon he will have been gone from her life longer than he was alive. This is a hard fact for all of us to hold.
One of the greatest values to the Telluride Experience is infusion of the mindfulness and ire into the minds of young healthcare trainees that comes from hearing these stories. It is both that will be needed for real change. We need providers at all levels of training who are more afraid of harming a patient than of being chewed out by a dysfunctional healthcare mentor. I would challenge those going into healthcare, as well as those already in healthcare, to be prepared to put the patient first, always. Those who are unsure this is something they can do might want to consider a different career path.
One of the conscious strategies behind the content created at MedStar Health is to inspire high reliability practice and patient centered care locally. Dave Mayer has always insisted we share as much of that content as possible with our colleagues across healthcare, as well as with young healthcare learners and resident physicians during the Telluride Experience. The piece referenced, Please See Me, was released in April of 2015, and was shared this week in Telluride. Following is a wonderful reflection from the Telluride Blog entitled, Forgetting Our Purpose, by one of our medical student scholars on the value she found in this piece. To see additional student reflections from the first session of the Telluride Experience for 2015, go to: www.telluridesummercamp.com/blog
Colleen Parrish is a Telluride Scholar, and rising M2 at the
University of Oklahoma
Throughout today’s sessions, one thing that really hit home for me as a student was the last video we watched created by the MedStar team. Within the video, it brought up a point that I think we as students tend to forget – especially those within the first 2 years of medical school or those within the most book heavy, patient free part of their healthcare curriculum. In the video, the doctor mentioned that she had memorized all the muscles and bones within the body, and gone to school for x number of years in order to take care of this particular patient; she had spent all this time and energy, sleepless nights, and damaged personal relationships in order to be a great caregiver for him.
This really resonated with me, especially with the recent completion of my first 2 years of schooling. I realized that within this period of books on books and lectures on lectures, we as students tend to forget our purpose – our “true north” if you will – of personally caring for and improving the overall well-being of our patients, our fellow humans. Without that constant reminder of why it is we are investing such time and energy into learning about bugs and drugs and such absurd sounding things as poop charts, we tend to veer from our true north into a path of “jadedness” and even resentment. If we can take the time everyday to remind ourselves of why we are doing all this, perhaps by watching videos such as this one or “Empathy” from Cleveland Clinic or by simply writing ourselves a letter that we read in moments of stress and frustration as we watch our peers in other professions begin to have careers and families, if we can bring ourselves back to our purpose even within the classroom I believe we can all be not only more effective healthcare providers but happier ones.
I’m reminded of an article, [from The Atlantic, For the Young Doctor About to Burn Out] that I tend to turn to that helps remind me a lot of the deeper issues of the stress and burnout of physicians. It’s more of book review perhaps, but it really resonated with me as to a different perspective on how we can get distraught within our beloved training and professions.
Once again, we gather in Telluride to talk, teach and learn about new ways to shape safety culture within medical and nursing learning environments by educating the young! The mission and hope of our Telluride Summer Camps (now part of the Academy for Emerging Leaders in Patient Safety) has always been to inspire the future leaders of healthcare to hit the ground running armed with an understanding of what it means to truly make patients part of every healthcare conversation, and to keep them safe in the process. Follow their reflections during the next ten days on the Telluride Blog.
The deadline to apply for 2015 sessions of The Academy for Emerging Leaders in Patient Safety: The Telluride Experience has been extended to February 15th! Medical students, nursing students with less than 10 years experience, and resident physicians can apply online at The Telluride Experience website by clicking here. Dates and locations include:
- In Telluride, CO: For Health Science Students-June 7th-11th and for Resident Physicians-June 12th-16th.
- In Napa, CA: For Health Science Students-July 26th-30th.
- At Turf Valley Resort in Ellicott City, MD: A combined session for Resident Physicians and Health Science Students-July 8th-12th.
Students who are accepted receive a full scholarship covering room, board, transportation voucher & all educational costs. Resident physicians accepted to attend should be sponsored by their program. Expected faculty for 2015 include healthcare and patient advocate thought leaders:
- Founder–David Mayer, MD
- Curriculum Director–Anne Gunderson, PhD
- Aviation Consultant and Author–John Nance
- Leadership Coach and Author–Paul Levy
- Founder, Josie King Foundation–Sorrel King
- Director, Foundations of Doctoring Program at University of Colorado–Wendy Madigowsky, MD
- Healthcare Advocate and Author–Rosemary Gibson
- President, Mothers Against Medical Error–Helen Haskell
- Founder, Citizens for Patient Safety–Patty Skolnik
- Director of Undergraduate Education, Clinical Excellence Commission–Kim Oates, MD
- And more…
Join us in our 11th year and become part of a preeminent and growing alumni network while developing the skills and knowledge to be a patient safety leader of tomorrow!
We have recently been reminded just how powerful the pen remains in stirring the hearts and minds of men and women around the world. And, we have often discussed on ETY how stories can change ideals, culture and even societal norms. With this knowledge in mind, we wanted to share the following opportunity offered by one of our Telluride Experience sponsors, The Doctors Company Foundation, in Partnership With The Lucian Leape Institute at The National Safety Patient Safety Foundation. This patient safety centered organization and partner is once again hosting a Young Physicians Patient Safety Award and essay contest for young physicians in training interested in sharing their story related to a personal experience with patient safety through the 4th year of medical school. The deadline to enter an essay is 5pm ET, February 2nd, and additional information on entering can be found below, as well as at the Doctors Company Foundation website.
Our Telluride Alum have been blogging and reflecting with great depth on wisdom gained in only the early years of their healthcare careers regarding just how complex an issue all things patient safety related can be. The hope is that at least a few will share their stories, along with their writing talents and passion for patient safety via this venue! Excerpts of essays from 2014 winners can be found in the ETY post, Sharing the Doctors Company Foundation 2014 Award Winning Essays. These winning essays have already served as safety moments in a large health system, as well as inspired peers to think and act differently when it comes to keeping patients safe.
In brief, The Doctors Company Foundation Young Physicians Patient Safety Award recognizes young physicians for:
…their personal insight into the importance of applying the principles of patient safety to reduce the incidence of medical error. Individuals are invited to submit essays about patient safety events they personally experienced during clinical rotations. The essays will be judged by a panel selected by the Lucian Leape Institute of the National Patient Safety Foundation (NPSF). Six winners will be selected and each will receive a $5,000 award, which will be presented at the Association of American Medical College’s (AAMC) Integrating Quality meeting in Chicago, June 2015.
- As of July 1, 2014 applicants must be either a 3rd or 4th year student in an American medical school
- Award is for the best essay explaining your most instructional patient safety event during a clinical rotation-one that resulted in a personal transformation
- Award will be presented by The Doctors Company Foundation at AAMC’s Integrating Quality meeting in Chicago
- Essays will be judged and winners selected by panel identified by NPSF, all review committee decisions are final
- In 500-1,000 words describe the most instructional patient safety event you experienced, one that resulted in a personal transformation. The essay should have an emotional impact on the reader and provide a lesson that is transferable to other medical students and medical professionals.
- Explain how the event impacted your learning and growth and how the experience will help you to provide the safest care to your current and future patients. You must include examples of how to improve any system errors or processes that contributed to the adverse patient event and explain how you will ensure that the changes are implemented.
Description of relevant events for the essay includes any patient safety event, including “near misses”. A patient safety event is a process or an act of omission or commission that results in hazardous health care conditions and/or unintended harm to the patient. The event is often a consequence of a systems failure or error. Examples include medication related errors, communications errors, health care – associated infections, medical record errors, identification errors and delays in responding to critical diagnostics.
Essays must maintain the confidentiality and integrity of the patient and location of the event. Please use fictitious names and locations in the essay.