On May 10, at the KGH Connect conference in Kingston, Ontario, I met Dr. Brian Goldman; we both spoke there. In 2011 he gave this 19 minute TEDx talk in Toronto; please watch it. It’s stunningly clear, grippingly told, and extremely important to understanding the real truth about medicine: it’s complicated. Really complicated.
Doctors make mistakes. Can we talk about that?
He gave me a copy of his book The Night Shift, a chronicle of one night in the ER where he works. The night’s cases are interspersed with the stories and experience that come to an ER doc’s mind with every new patient who comes in. I’ll write more about the book soon. First, as preparation, please spend 19 minutes watching this. What did you learn? Any new thoughts?
These are my real-time thoughts while watching Brian’s talk:
Interesting distinction between healthy and unhealthy shame, one that never arose in my decade of mens work, where shame was one of several themes (in a general, not medical context). I would say that shame is not ever healthy, distinct from potentially useful, for it’s what we do with feeling shame that becomes healthy or not.
I was surprised, when writing my book, to feel increased compassion for providers. My heart goes out to the honest ones—who I believe outnumber the dishonest ones who those who have suffered severe medical harm cite in their activism. However, whatever heart feeling I have regarding these problems is severely challenged when basic fixes (like compliance around disinfecting hands, like the failure to train for and become expert in communication algorithms) go unattended to daily, yearly, for decades. As a patient-family member turned advocate/activist, how much obstinacy can one endure before experiencing hardening of the emotional arteries?
Only providers can solve their cultural problems around denial (and sleep deprivation); in this regard I feel utterly helpless to help them. I wonder what effect providers who have decided to show up at participatory conferences have on their peers—or perhaps they are in the process of morphing into a new group, and in so doing do not yet have peers.
Mostly I wonder, how does a puzzle piece locked tightly in the middle of a puzzle shake up the whole of the puzzle?
As always, I love your perspective, Bart… not much to say, but always thought provoking.
> I was surprised, when writing my book, to feel increased compassion for providers.
That itself will sound surprising to people who don’t know your work – say a bit more, please, enough to clarify what you mean.
OK (I tend to go light on loading online comments with horn-tooting includes).
I wrote Notes from the Waiting Room: Managing a Loved One’s (End of Life) Hospitalization, 2/3 about managing any hospitalization and 1/3 about revisioning end of life in order to die in peace—like we all say we want but, I regret to say, know little of how to accomplish and do less toward it. All this came about after my parents’ 3 week terminal hospitalizations 14 months apart, festooned with errors large and small, for a supposedly somewhat prepared family, who thought they learned the ropes the first time, and where the 2nd death was precipitated by nosocomial MRSA. 8 years on, still at it, I developed a crazy end of life rap and a new work that everyone will hear about soon. All at my website.
Regarding increased compassion for providers, I *think* I remember that arising out of realizing the very stuff that Brian conveys in his talk. What a terrible quagmire for good people to live with and under, both professionally and personally. Just awful. No sane sensitive person would wish it for others. Like I wrote above, it’s a puzzle—but I wonder that medicine built that puzzle piece by piece over generations.
I want to note, too, that my orientation around this scene is middle of the road at this point in my life. I’ve experienced, as a family member, enough medError to have become activated. But not enough to paint the entirety of medicine with a black brush (some activists have and do).
I’ll say, too, that I most dislike crummy systems; have since my teen years. So my compassion stems also from imagining working under a crummy system and does NOT extend to personally crummy choices, behaviors, evasions.
Dr Goldman’s story is moving and we need many more like his to understand how to shift the culture and systems toward learning. I do think that the embers of change very likely have to come from within medicine but I think there is a very real role for everyone that is part of the culture-including nurses (that’s what I do), administrators, other types of providers, payers, and most importantly patients and their families.
Some of our efforts to reduce errors may not be helpful. For example, the demand to bring certain errors to zero may have counterproductive, unintended consequence of covering them up (maybe not blatantly, but through more subtle ways like redefining the error) because so much rides on “going to zero”. Surely, no one wants those types of errors (wrong limb, objects left in surgery, a bed sore, etc) to ever happen. But we must be able to learn from when they do happen to advance the systems within which people do their best to do best. Every participant in the culture has a role to play in opening up our most terrible secrets.
I don’t know any provider that goes to work in our incredibly complex systems, wishing to make a mistake.
Hi Lisa. What’d help me help medicine would be if medicine, in all ways, took responsibility and acted accountably when errors occurred. Personally I’m far less interested in apology than ownership (full when appropriate, shared with patient-family members when appropriate). This would look like immediate, attentive actions to stop, reverse, and remedy the error at zero cost to the patient-family, insurers (unless “provider medical indemnity” insurance was purchased and in effect (is this even available—like homeowner liability in case someone slips on your snowy steps?), and no cost to taxpayers (full cost to the providers). This is what happens in every other business or enterprise either service or manufacturing. I know that people don’t go to work with the idea of making mistakes this day. But when patient-family members are left holding the bag and the costs—immediate on ongoing, well that’s just not fair nor right. I know much of this is above a nurse’s pay grade, hence the deep conundrum.
Hi Lisa – I don’t see what your point is. Did he say anything about efforts to reduce errors, or did he suggest that anyone goes to work wishing to make a mistake?
Bart and Dave. I think my message was not clear. First, I wholeheartedly support Dr Goldman’s thesis that we need more transparency in order for our systems and people to learn from errors and importantly near misses. So yes, he was addressing errors (the notion that providers can/cannot bat 1000). lMy point is that shifting a complex culture cannot come from one participant in a culture. When individual accountability is the issue, then certainly the individual should take responsibility. However, the type of mistakes that Dr Goldman referred to very often are a product of the complex systems within which individuals practice. Nurses are deeply involved in keeping patients safe, keeping patients and their families at the center of care and helping fix systems-all well within our pay grade. I simply had hoped to expand upon the conversation begun by Dr Goldman’s Ted talk.
> shifting a complex culture cannot come from one participant in a culture.
Absolutely! By definition, in my view, a culture is a set of persistent *conversations* among multiple people. That’s why they say “Culture eats strategy for lunch.”
> the type of mistakes that Dr Goldman referred to very often are a product of the complex systems within which individuals practice.
Agreed on that, too. My book’s appendix is titled “Stop the denial” about just that sort of thing: medicine is complex, and for the most part people work without a net.
Well done.