Dr. Brian Goldman is right.
We expect a level of perfection from our doctors, nurses, surgeons and care providers that we do not demand of our heroes, our friends, our families or ourselves. We demand this level of perfection because the stakes in medicine are the highest of any field — outcomes of medical decisions hold our very lives in the balance.
It is precisely this inconsistent recognition of the human condition that has created our broken health care system. The all-consuming fear of losing loved ones makes us believe that the fragile human condition does not apply to those with the knowledge to save us. A deep understanding of that same fragility forces us to trust our doctors — to believe that they can fix us when all else in the world has failed us.
I am always surprised when people say someone is a good doctor. To me, that phrase just means that they visited a doctor and were made well. It is uncomfortable and unsettling — even terrifying — to admit that our doctors are merely human — that they, like us, are fallible and prone to bias.
They too must learn empirically, learning through experience and moving forward to become better at what they do. A well-trained, experienced physician can, by instinct, identify problems that younger ones can’t catch — even with the newest methods and latest technologies. And it is this combination of instinct and expertise that holds the key to providing better care.
We must acknowledge that our health care system is composed of people — it doesn’t just take care of people. Those people — our cardiologists, nurse practitioners, X-ray technicians, and surgeons — work better when they work together.
Working together doesn’t just mean being polite in the halls and handing over scalpels. It means supporting one another, communicating honestly about difficulties, sharing breakthroughs to adopt better practices, and truly dedicating ourselves to a culture of medicine that follows the same advice it dispenses.
Yes, this is certainly easier said than done. But as daunting as the task may seem, we aren’t heading into the dark alone. It’s been done before. We aren’t the first people to face this challenge.
The airline industry understands how to learn from its mistakes; it has a firm grasp of best practices for accident avoidance. Pilots, aeronautical engineers and flight attendants develop those practices from examining data about past plane crashes.
Regardless of scale, total damage or mortality, federal investigations reveal the exact series of events that precipitate each crash and provide a methodical account of what went wrong. Crashes are not shameful moments swept under an emotional rug; they’re teachable moments that are examined, diagnosed and learned from.
I understand that airplanes and arteries are vastly different systems. I’m not trying to equate a plane crash with a botched diagnosis — what’s important here is the approach to error. The airline industry has understood, internalized and implemented a system that recognizes human and mechanical failures as important lessons and opportunities for improvement.
The Collaborative Chronic Care Network (C3N) is a project that catalyzes improved patient care. Chronic illness management is driven by the same lessons that Dr. Goldman and the airline industry have brought to light. Dr. Richard Colletti, a C3N collaborator, explains that “the care that a patient gets is not just dependent on how good the doctor is or how much the doctor cares. The care is dependent on the system that the doctor works in.”
Dr. Colletti sees medicine as an ongoing learning process, where patients and care providers actively help each other find solutions on the journey to wellness. This openness makes collecting empirical medical knowledge less of a Herculean effort — it encourages and even facilitates data and care collaboration among networks of doctors.
C3N implements this approach with real action and systemic change. This system is not just a great idea or an interesting experiment; it is a thriving solution that’s changing the lives of patients everywhere. Dr. Colletti has reported that, because of the C3N methodology and practices, 10 percent more children with Crohn’s disease are now in remission.
They note, “By combining large data registries and making them accessible and interactive, it drives action and innovation to create a more reliable and accountable care delivery system for children and their families dealing with chronic gastrointestinal diseases. And with an open-source framework, the project is developing a means to overcome barriers that involve concerns about intellectual property, data sharing and privacy, and medicolegal liability.”
Perhaps, then, a new generation of doctors can eliminate the culture of walled gardens. More and more, we hear experts discuss the same kinds of shame addressed by Dr. Goldman — the healthy shame that can be dealt with, and the unhealthy shame that shakes you to your core and drives change. Transparency in the doctor’s office and a culture that accepts and learns from its mistakes should be a priority for medicine.
Jesse Dylan, Founder of Wondros, Filmmaker, inspired by his son’s illness to found Lybba, at lybba.org, creating compassionate communities of care to redesign healthcare for good. This article originally appeared in the Huffington Post.
I am writing this as a warning to the medical community any ideas of how to get this published?
I had 89 year-old, boarding-home patient with debilitating heart and lung conditions. He refused most recommended medical care. He wanted to go on hospice instead of to the hospital.
He had refused to do lab draws, radiology, specialists, emergency room visits,
and skin care. He did not appear to be declining to the point of meeting
hospice criteria at that the time seen last, and he denied physical
complaints. He did have a chronic area that he scratched on his low back, and
from time to time he would scratch the area open. His last examination of the area revealed no sign of infection or pressure sores. The patient was
seen by his urologist the day before seeing hardtke the last time and the patient
had no complaints. Additionally, he was
followed by a state Registered nurse and a registered nurse that was contracted
by the facility. The evening following that visit the patient developed
bilateral thigh abscesses 36 hours after seeing Hardtke and went promptly to the emergency room. The
emergency room physician told the family that the patient had an infected bed
sore, and it was present for at least a week.
The emergency room doctor missed that he had necrotizing fasciitis and
he was not seen by the surgeon promptly. Surgery occurred four days later when
the diagnosis of necrotizing fasciitis was found. He passed away two weeks later. The infectious disease doctor reviewed
this case stated the wound cultures performed demonstrated an aggressive single
bacterium that can cause the necrotizing fasciitis or flesh eating
disease. Necrotizing fasciitis according
to the literature can grow as fast as 2-3 cm an hour, and is an immediate
surgical emergency in order for the patient to live. The infectious disease doctor stated it was not an infected bed sore
because there was only one bacterium in the culture. He stated bedsores always have multiple
called the police and reported this incident. The Eatonville police transferred
this to the attorney general (AG). The attorney general did an expensive and
intensive two year investigation. They hired a Dr. Locatel from California who works not as a medical provider but as an expert witness. Dr. K Locatel gave the opinion that Hardtke did not look at the patient and Hardtke’s charting was altered. The records do not reflect this opion but will not be evaluated further this unless Hardtke goes to court. The AG also completed a search warrant of Hardtke’s house, took computers, ruined computers, and found that the data base was clean. This was thousands again spent on IT guy to review the data and was huge waste of time and money. Jeff Hartley the lead investigator when entering the house explained to hardtke that he recently did a swat team on a doctor down the road and this is happening to a lot of other medical providers. The cause was attorney general Rob Mckenna, was
running for governor and had a political platform to bolster by helping the vulnerable
adults. According to the AG’s website vulnerable adults could not refuse care. If the providers followed state and federal laws allowing a competent patient to make decisions to refuse care, then they were allowing self neglect and abuse.
This flies in the face of federal and the state laws that state a competent person even though they are vulnerable still
has the right to refuse care. The Department of Health (DOH) had a team of
medical providers review this case as well. They have medical understanding and of the
laws that regulate health care.The DOH changed the charges to allegations and stated no formal discipline was indicated. A Newton’s plea was made which meant Hardtke did not feel she was guilty but wanted to take the states offer to avoid court costs of $100,000. She would have to fight DOH and AG. This is not covered by malpractice. She was charged with a misdemeanor level three criminal mistreatment for failure to provide the basic care needs for a vulnerable adult.
This was inaccurately reported in the paper and complaints came in so I was let go from my employment.
I have found that patients think a doctor is “good” if they like him or her and/or feel cared for and listened to by the doctor. There’s an old story about a doctor and an old lady. A medical student is observing an interview. The doctor greets the woman, asks about her grandkids, sits down next to her, listens to her fears. After the examination, the woman says to the med student; “OH, isn’t he just such a wonderful doctor?”. The med student didn’t know what to say. She had just seen the doctor “listen” to the woman’s lungs with the ear parts of his stethoscope firmly around his neck.
Jesse, I really appreciate your post. More specifically, I appreciate that you are the parent of an ill child who is able to see the system for its limitations and not transfer what must be a powerful combination of emotions onto your son’s caregivers.
I am a physician who is currently involved in a lawsuit. I believe I am a caring and skilled physician. But a patient had a bad outcome. I listened to Brian Goldman’s TED talk after reading your post. He talks about shame and the imperfection of all people, and about the distinction between a ‘bad doctor’ vs a doctor whose patient had a bad outcome.
Your comments about the system issues, especially coming from the family member of someone who is sick, are deeply appreciated. I will say though that, even in the airline industry, there is a lot of blame. Just think about the publicity and public shaming that goes on of the pilot after an airplane crash. The same is true of the police department and individual police officers after a shooting.
People in our society like to believe in perfect…perfect information, perfect action, perfect outcome. I think it makes us all feel safer and like we can control our world. When we don’t get perfect, there is blame. Against an individual, against a system. The bad outcome is someone’s fault and they should pay.
Even the IOM ‘to err is human’ that Dr Goldman references has been used for publicity and to politicize the current healthcare system. I’m not sure that we will be able to change this particular emotion that makes up our society or that we will be able to achieve a neutral assessment of the system issues that you reference.
Dr. Goldman’s TED talk was wonderful.