TDCF Young Physicians Essays 2011-12

Award Winning Essays 2011 and 2012
The Doctors Company Foundation
Young Physicians Patient Safety Award

Conferred in partnership with the Lucian Leape Institute at the National Patient Safety Foundation
The Doctors Company Foundation Young Physicians Patient Safety Award

Conferred in partnership with the Lucian Leape Institute at the National Patient Safety Foundation
The Doctors Company Foundation is pleased to present the winners of the 2011 and 2012 Young Physicians Patient Safety Award, a prestigious essay competition recognizing young physicians for their deep personal insight into the significance of patient safety work. The Doctors Company Foundation was created in 2008 by The Doctors Company, the nations largest insurer of medical professional liability for physicians, surgeons, and other health professionals. The Foundations purpose is to advance and protect the practice of good medicine. Working to improve the practice environment for doctors and all health care providers, we award grants to support patient safety research, education, forums, and pilot programs. The Doctors Company Foundation believes it is important to make the culture of safety an integral part of the culture of medicine. We advocate reforming medical education curricula to incorporate patient safety as a fundamental component. To this end, we supported the development of the Lucian Leape Institutes white paper Unmet Needs: Teaching Physicians to Provide Safe Patient Care. The Foundation is proud to partner with the Lucian Leape Institute in sponsoring The Doctors Company Foundation Young Physicians Patient Safety Award. Six awards are presented annually to third- and fourthyear medical students or first-year residents who write a winning essay about the most instructional patient safety event they personally experienced during their clinical rotations. The essays are judged by the National Patient Safety Foundation (NPSF). Each winner receives $5,000 plus registration and travel expenses to the Annual NPSF Patient Safety Congress.
David B. Troxel, MD Chairman The Doctors Company Foundation
Leona Egeland Siadek Executive Director The Doctors Company Foundation
Winners of the Award

2011
Dan Henderson, MD, MPH candidate, University of Connecticut School of Medicine and Harvard School of Public Health Mengyao Liang, MD candidate, University of Illinois at Chicago Andrey Ostrovsky, BA, MD candidate, Boston University School of Medicine Noah Rosenberg, MSIII, University of Massachusetts Medical School Wael Salem, MPhil, Mayo Medical School Christopher Thom, MD, University of Virginia
2012
Elizabeth Butler, BA, University of Massachusetts Brian A. Freeman, MPH, CPH, University of Louisville School of Medicine Kevin Koo, MPhil, Yale University School of Medicine Lorette Johnson, MSIII, SUNY Upstate Medical University Andrew Robert Lee, BS, Washington University in St. Louis Joshua M. Liao, BA, BS, Baylor College of Medicine
The award-winning essays are reproduced on the following pages. For assurance of privacy, names of individuals and organizations have not been associated with the essays.
Award-Winning Essays 2011
distressed father, living an otherwise tranquil life as
a West African fisherman, runs into the emergency department holding his unconscious, toxic appearing child in his arms. The physician launches a resuscitation effort. The nurse grabs the resuscitation kit and takes out the equipment, less a bag mask which is unexpectedly missing. Calamity strikes. A series of unintelligible expletives voice the physicians concern. The nurses look on with expressions of bewilderment and fear. Ten minutes go by before the physician finds the mask and barks his orders again. The team dynamic is crumbling. Roles are undefined. As attention switched to the mask, the patient became decentralized. Having come from an institution where teamwork and safety measures are boiled down to a science, I was shocked that the physician had tried to run a complicated code requiring a series of tasks and steps as a solo operation. He had effectively silenced his team through his unilateral relationship with the nurses. He was frazzled, disorganized and agitated. These emotions were a strong reflection of the commitment he made to his patients, but his actions and the ensuing team dynamics compromised patient safety. The patient didnt receive prompt resuscitation and treatment, suffering negative outcomes as a result. I would not have imagined that patient safety would take center stage on my three month long rotation in Central Africa. In dissecting the situation that unfolded with the child, I identified two points that endangered the safety of the patient. First, the kit was incomplete and not properly prepared. Second, the doctor exercised a breed of medicine that silenced his team and marginalized important players that could have positively impacted this unforeseen event. I set out to take the first steps toward creating a culture of preparedness and open communication in order to improve patient safety. I talked to other students, nurses and staff at this hospital in regards to my problem. It was clear that measures to improve patient safety would be met with a great deal of resistance. At the epicenter of the problem, the traditional culture of medicine in which the physician handed down orders was incredibly restrictive. The physician was overburdened with clinical
decision making, procedures and patient care. He was on call 24/7 and quite frankly, worked to the brink of exhaustion. The rest of the staff often had some downtime, but since these were times during which they hadnt received direct orders they were content to lay low. Moreover, since the nurses had such a low level of autonomy I perceived them as taking less stake in their patients. My suspicions were confirmed when I asked them directly. Their efforts would be futile given that they were constantly micromanaged. The goal was to open the lines of communication among the team members to optimize the working environment to benefit patient safety. While the doctor was not convinced by the proposed changes, he was incredibly astute in recognizing the points at which the lines of communication had broken down, as were the nurses. The problem was not a lack of awareness of their behavior. Instead, there was a lack of an external and supervisory source authorizing each team member to have a particular predefined role. We organized a meeting and allowed a certain level of autonomy congruent with a nurses training, experience and skills. This worked mainly to empower the various team members of taking stake in their respective roles and speaking up while allowing the physicians to attend to their proper clinical role. The second goal was to improve general preparedness. As illustrated by the mask episode, resource availability is not only about ordering and receiving the medical devices, instruments and medications, it is about finding them in a timely manner to efficiently put them to use when needed. Unprepared, it was impossible to efficiently put them to use. We split up the medical equipment into various subcategories. We then assigned one nurse to be in charge of making sure items in his or her division were in their proper place and that enough of a supply existed. We created a checklist of the most important items and the stockpile. On a weekly basis, another member of the team would have to go through the checklist. In essence it was a circular reporting system where everybody on the team had to report to another at the same level. Micromanaging orders were not coming from above. While preparedness improved, there were pleasant surprises that emerged as well.
Young Physicians Patient Safety Award 2011 and 2012 4
Our simple measures improved the lines of communication and preparedness in the hospital. Moreover, there was a shift in the culture of safety that carried with it far reaching implications. As necessary decisions were shifted onto other members of the team, we found them to take much more ownership in their patient care. Over time the physician seemed less tired and burned out. The lines of communication had also opened up considerably. Team members were more attentive to mistakes. The teams enthusiasm for asking questions and increasing their medical knowledge also flourished. While the changes were subtle, the environment we worked in took major advances in building a culture of safety. As I reflected on my experience, it bewildered me to think that such cost effective and beneficial measures did not play a greater role in health care development and global health. In addition to increasing patient safety, these measures had myriad downstream effects that promote a better work environment, open the lines of communication and decrease physician burnout. Investing in patient safety promises to dramatically improve healthcare delivery in resource poor areas. Through concrete as well as intangible elements, a new culture of medicine will flourish. Patient safety improvements need to be carried out with equal fervor in the developing world as they are now here in the US. Only by addressing this pivotal area of medicine will we be able to optimize the vast commitments to global health that we have already made.
belied her years as stern matriarch of her family, came to the emergency department short of breath. She was just in time: her electrocardiogram showed torsades des pointes, a heart arrhythmia that even a medical student can spot from across a room, for its distinctive, tornado-shaped pattern and wellknown lethality. The ED team stabilized Maggies heartbeat. Another crew remedied the underlying problem a dead pacemaker battery. Quick, skillful action saved Maggie from the brink of catastrophe, but the victory was short-lived. Maggie grew anxious, her pulse quickened, and her blood pressure sagged despite bolsters of fluid. A scan found a bleed in her abdomen. We gave blood, clotting cells, to no avail. Maggies body grew bloated from the infusions, restricting her breathing; even with a ventilator, her lungs couldnt get enough oxygen. A decision was needed a tough one and we located Maggies loved ones. The family meeting was raw: Screams. Tears. Frantic phone calls. Sobs. Prayers. That Wednesday afternoon in the ICU, our boldest hope was that Maggie might be able to say goodbye. I decided to present the case to classmates and was shocked by what turned up in Maggies chart. The cause of her bleeding was identified as a rare but well-known complication of a blood thinner. Intended to prevent clots, it had precipitated an immune attack on her ability to patch small bleeds. The complication, heparin-induced thrombocytopenia (HIT), occurs in up to 1 in 20 patients with a medical history like Maggies. It was predictable was it preventable? Deep within the phonebooksized chart, I spotted a hasty note, scrawled days before Maggies death, ?Platelets consider work-up for HIT syndrome. The critical recognition never got from the chart to my team. We did not complete the work-up in time, and Maggie perished as a result. Feeling sick, I rushed out of the sub-basement records room, unsure of what to do with this information. I was shocked that our team that I had failed Maggie. Worse, I felt as if my chosen profession, a calling based on helping patients, had betrayed me. Finding meaning in Maggies case took time and another mistake, this time a benign one. I booked a flight for the wrong day and, arriving early to an empty convention, wandered into a symposium on patient safety. As we discussed sources of medical error, Maggie reappeared. Every system is perfectly designed to achieve exactly the results it gets, the lecturer, a pediatrician from Boston, explained. The hairs on my neck stood up. Maggies was a case of predictable human error a lost communication within a system that failed to catch the mistake. The answer was not to replace us with a smarter, more
he first thing I noticed about the hospital was the
silence. Were still adjusting, said my guide, an attending physician. We should probably think about Muzak. The quiet was eerie, like someone died. In fact, someone had. In 2004, a patient was killed by a mix-up during a routine procedure. Rather than conceal the error, the hospitals leadership openly discussed the patients death. You cant understand something you hide, the patient safety officer had explained. The move galvanized a campaign to become the safest hospital possible. As we waded through the stillness of a clinic strangely devoid of patients waiting, phones ringing, and pagers interrupting, my guide described the response to that patients death. We have a saying here, If you lose the patient, be sure you dont lose the lesson. I came to learn how to make health care safer. The journey was set in motion a year before, during my third year surgical clerkship. Maggie, a 76-year-old grandmother, whose kind eyes
experienced team, but to implement a system to mitigate our fallibilities. A few months after the symposium, I left medical school for a yearlong fellowship in Washington, DC, with the American Medical Student Association. I was initially drawn to the opportunity to be involved in the health care reform push, but as I began my job, I couldnt imagine ignoring patient safety. I took a risk and rewrote my entire work plan. I developed a patient safety platform to attract activist students to the cause. The WHO Surgical Safety Checklist seemed ideal, and visiting a dozen campuses and conferences, I urged students to become checklist leaders. I designed a symbolic pin for their white coats and a free checklist app for their iPhones. That September, I connected with an international team of students, and we convened in Boston to create a campaign we named Check a Box. Save a Life: The first global student sprint to improve health care. We launched the effort with live online speeches from Drs. Don Berwick and Atul Gawande, leading proponents of patient safety, particularly through the checklist. To our excitement, the broadcast drew a crowd of 1,400 students in 11 countries. This audience went on to spark change at dozens of campuses. One participant, a Chicago medical student, won checklist implementation across his entire hospital system. Check a Box. Save a Life proved students could be safety leaders, and I wanted to understand where we could apply that leadership. After seeing what improvements were possible, I became determined to focus my career on improving health care. To this end, I have taken another detour from medical school, to study public health and health care management including quality improvement with the goal of gaining the analytic and leadership skills I need to be an effective physician-improver. After medical school and residency, I intend to reinvigorate field of primary care by improving quality, safety, teamwork, and value. Maggie continually reminds me of the urgency of learning our way to better, safer health care and the stakes of failing in this pursuit. I lost the patient, but I will carry on the lesson.
was graduation day. It was a day where we stood, after four years of intensive study, fully knowing that the personal sacrifice that had been required was easily worth the experiences that we now shared. Our atmosphere that day was undoubtedly one of optimism, one that would carry through to our imminent internships and on through our medical careers. We did find, however, that internship greeted that optimism harshly. Being overworked and overextended became more common than I had prepared myself for. I often found myself placed in situations where I was not ready, had minimal related training, or was in a state of fatigue that enabled only the coordination necessary to keep myself upright. One such instance that I have reflected greatly upon occurred in the Medical ICU. It was already long into the evening when Tony and I heard that we would be getting another transfer from an outside hospital. It had felt like we were swimming upstream for most of the day and into the evening, as the constant stream of ICU patients kept coming from our ER. We had been keeping the pace up thus far, but 0200 is about the time you start to feel the pinch during the 30 hour shift. We knew this new patient was about one hour out, so Tony encouraged me to try to use the time to get some sleep in before they got there. Knowing how poorly I function at hours 24 to 30, I took him up on his offer. Unfortunately, the pages to look after our current patients kept coming steadily at about 15 minute intervals. It made trying to sleep frustrating enough wherein I gave up and just did another set of walk rounds on our patients. It was at this time when our last transfer patient arrived. She had been billed to us as respiratory distress, hypotension of unknown etiology. As she came in, we could see that her mental status was depressed, she had a thready palpable femoral pulse, and she was struggling to breathe. We ordered a salvo of basic labs, got an x-ray, and started our first fluid bolus to try to increase her blood pressure. From here, things progressed very steadily in the wrong direction and in a manner that seemed almost completely out of my control. Despite our basic resuscitative efforts, she continued to deteriorate. We had to start IV pressors to attempt to artificially increase her blood pressure. Shortly later, we realized she was going to need to be intubated because her work of breathing was continuing at such a constant and unsustainable level. As Anesthesia came for intubation, she suddenly went into an arrhythmia and coded on the table before us. At this point, it was about 0630 and our attending was just arriving in to get ready for rounding. His arrival timing was crucial. Well rested, knowledgeable, and experienced, he helped us through the code until we managed to again get a normal sinus rhythm beating from our patients heart.
he smiles of optimism seemed to glow even more in
the warmth of the sun on that cloudless and memorable day. As I looked out at the rest of my medical school class, it was clear that we were each filled with a plethora of vibrant and diverse emotions. Chief amongst my own was simply being proud of what we, as a collective group, had accomplished. It
As we started getting data back and went through information, our attending realized that our patients clinical picture and lab work fit best with a prolonged, untreated asthma attack. At the moment she said that, I distinctly remember how all the blocks finally fell into place. It made the most sense, and it would have potentially been easily treated by a continuous nebulizer treatment. We hadnt picked up wheezing on physical exam, but this was simply because she had progressed so far along that she was not moving enough air back and forth for the wheezing to be produced. We knew about that caveat to prolonged asthma attacks, we had learned about it in medical school, and had circled the correct answer on countless multiple choice tests. However, in the fog of our sleep deprivation, it had not yet made it into our consciousness. At the end of this event, it was abundantly clear that our interpretation of results and clinical findings, our development of differential diagnoses, and our application of treatments were all greatly slowed and affected by our fatigue. Reflecting upon this incident is impossible to do without again acknowledging that atmosphere that we had on graduation day. I remember, during the long hours of that night, not only wondering how much patient care was suffering, but also how it was causing that initial optimism I had carried through medical school to invariably fade. Being overworked and underprepared is one thing, but being put in a difficult situation while simultaneously being forced to take the massive handicap of being awake for close to 30 continuous hours was an incredibly disheartening experience. I knew I could do better, and I knew we were not doing everything we should, or could, for this patient. Like all others, this was a patient who had a unique life, a unique story to tell. Doing her the disservice of having someone awake for so long directly responsible for her life seemed nearly impossible to accept. I kept wondering if we would ever have an airline pilot working 30 continuous hours, or a bus driver, or a ships captain. I do know that medicine is costing increasingly too much, and that there is no foreseeable money in the Medicare budget to expand residency programs to a point where this situation would not be mandatory. However, it does seem impossible to internally justify having our physicians work for 30 hours at a time without the opportunity for sleep. Having experienced it, I am forced to submit that the quality of care necessarily plummets as the second morning approaches and passes. The mistakes made during those hours are some of the most frustrating, as they are largely needless and avoidable. Being helpless at the hands of fatigue and being forced to face the complexities of modern clinical care at that time represented the most consequential detriment to patient safety that I have experienced in my medical training thus far.
It is with stories like these that I hope it becomes easier to understand and to justify the necessity of official limitations on work hours, and their honest enforcement, for physicians in training. The changes set to begin in July 2011 will help, as the maximum hours go from 30 to 28 for upper level residents. It does not seem like much, but it certainly brings us one step closer to being capable of providing safe and effective clinical care at all hours of a hospitals operation. It goes without saying that stories like this one are abundant in academic centers around the country. And it is necessary for us as a medical community to begin to acknowledge them openly and accept that they do occur. It is with this acknowledgement that we can move forward with changes that put patients less at risk of sleep deprived errors, but still maintain the rigor we know is necessary in residency training.
reating Heroes: A surgeon, army veteran, and personal mentor once said
to me, Lots of people call doctors heroes, but patients are the real heroes because they undergo anesthesia, they let someone open them upthey take the risk. For surgical patients, risk is clear and present. For medical patients as well, however, lingering in a hospital opens the door to nosocomial infections. My mentors words remain with me as a tool to empathize with patients, to appreciate the risks they take in pursuit of healing. Not two months after he said them, my mentors words were made even more poignant when he inadvertently removed a patients kidney while performing another operation. Despite the best intentions of health care professionals, patients often take real risks at the same time as they seek treatment. In this case, a middle-aged woman planned to have the lower part of her colon removed because of recurrent sigmoid diverticulitis, a condition in which weakening of the colons walls causes infection. At the outset of the procedure, the surgeon called a timeout, during which he repeated the patients full name as well as the procedure and side it was to be completed on. Everyone present in the room, including the surgeon, surgical resident, nurse anesthetist, surgical technician, circulating nurse, and two medical students, had to agree that they were about to perform the correct procedure on the correct patient. Some said, I agree, while others nodded their assent. With that, the surgeon made the first incision. The procedure proceeded as planned until the surgical resident noticed something unusual in the patients pelvisa mass of tissue that bore an alarming resemblance to a tumor. A
flurry of questions filled the room: What was the mass? Cancer? If so, what should they do? Take the mass out now, or make the patient undergo another operation and round of anesthesia? Together, the surgeon and surgical resident agreed that the mass was worrisome enough to warrant biopsying and likely removing it. They would explain their choice to the patient after the procedure. As is the approach to many types of cancer, they decided to biopsy a small part of the mass and send it to the pathology lab for identification before removing it. After the biopsy, they had little to do but wait. As the time allotted for the procedure elapsed, pressure to do something began to mount; the operating room was needed for another surgery, while the surgeon and resident were needed for other cases. Under these conditions, they decided to act. While surgeons train for years to make decisions under pressure, enough pressure has been shown to make anyone a poorer decision maker. Before the biopsy results came back, the surgical team decided to move forward and remove the unidentified mass. It was a surprisingly easy procedure. For one, the mass appeared to possess a stunted blood supply, meaning it could be removed without much blood loss. In addition, the mass was encapsulated, as many cancers are, leaving it free to separate from the healthy tissue around it. When the mass was fully excised, the resident placed it on a table and cut into it, revealing glistening glomeruli: the unmistakable architecture of a kidney. The first thing the surgeon did was explain to the patients family what had transpired. He described, as he later would in his operative note, how kidneys are rarely found so low in the pelvis, how atrophied the kidney appeared, and how these and other factors contributed to the mistake. In the midst of feeling grief for the patient and her family, I contemplated how to approach this case and others like it to ensure that they did not occur. After doing some research, I concluded that wrong-site/wrong-surgery cases provided an instructive background for root cause analysis of this situation. For example, the Joint Commissions Sentinel Event reviewers have identified factors that contribute to an increased risk of wrong-site surgery, many of which apply to this case. For instance, emergency cases have an increased risk for mistakes. While this case may not truly have been an emergency, the surgeon felt that the presumed pelvic mass was life-threatening and warranted immediate removal. The risk is further increased when multiple procedures are conducted on the same patient during a single trip to the operating room. This point is particularly salient in this case because not only were
multiple procedures performed on the patient, but the mistaken procedure was unplanned. In addition, unusual time pressures increase risk. Perhaps most importantly, poor communication among members of the surgical team increases risk. This was definitely a factor because the surgeon proceeded to remove the presumed mass before pathology reported the results of the biopsy, which ultimately showed distinctly renal structures. After performing this research, I felt duty-bound to write up my findings and submit them to the hospital administration along with an idea for how to avoid such tragic events. I encouraged the hospital to codify and adhere to a policy regarding the performance of unforeseen procedures on a patient under anesthesia who has not consented to the new procedure. Especially in situations that are not immediately life-threatening, I suggested that a second, intra-operative timeout could be performed related to the new procedure. In addition, improving communication and requiring that surgeons wait for pathology reports before proceeding with procedures that depend on them could have avoided this tragic event. Later this year, I will undertake a quality improvement project inspired by this patient. While a physician seeks to recommend a treatment in which the benefits outweigh the risks, those risks are ever-present. Patients are heroes because they take those risks and, more often than not, are simply grateful to be healed. The event that changed this patients life activated me to work so that that heroism will never be taken for granted.
ow much is a word worth? In the landmark malpractice case of a young Latino boy who was paralyzed due to lack of interpreter services, one word was worth $71 million.[1] When non-Spanish speaking providers misinterpreted the word intoxicado as intoxicated instead of the intended meaning of nauseous, the young mans brain aneurysm was misdiagnosed as drug abuse. Besides the $71 million dollar settlement, the error resulted in permanent quadriplegia.
Although the case of the paralyzed young man occurred over two decades ago, patient safety continues to be compromised due to poor language access. As a third year medical student, I have personally witnessed several breakdowns in patient safety due to language barriers. One nearly tragic event occurred during my pediatrics rotation. I was assigned to a community hospital in the suburbs. A
Spanish-speaking two-year old girl was admitted to our service with severe cellulitis. The infection continued to worsen despite initiation of antibiotics in the ER three days prior. Fortunately, the attending physician on service with me was proficient in Spanish and was able to figure out that no interpreter was used when the pain-stricken child first presented in the ER. Consequently, the childs mom misunderstood the ER physicians directions and was giving the little girl an inadequate dose of antibiotics. Once we carefully counseled the mother in Spanish, she was able to administer the correct antibiotic dose and the childs skin infection and pain improved substantially over the next few days. Had the little girl not been lucky enough to come across my Spanish-speaking attending, she may have gone undertreated and had severe complications. The near-miss with the cellulitis frightened me into taking medical Spanish classes. But I quickly discovered that even clinicians with language training often overestimate their linguistic abilities, especially as they pertain to cultural competence.[2] Consequently, I instead focused on becoming fluent in navigating interpreter services. At the onset of any rotation at a new hospital or clinic, I immediately familiarized myself with the interpreter options available at that venue. On several occasions, I was the only member of the medical team that knew the phone number to access remote interpreter services for limited English proficient (LEP) patients. While I may not have saved anyone from becoming quadriplegic, I probably did make a few patients lives easier by providing a clear line of communication through a translator. And even when I felt comfortable speaking with patients in a non-English language, such as my first language, Russian, I still used an interpreter as back up in order to prevent missing any critical pieces of information. The diverse patient populations at my teaching hospitals helped me become proficient in working with LEP patients. These patients also taught me that poor patient safety due to inadequate language access was just the tip of the iceberg when it comes to the negative repercussions of health disparities. To gain a more in-depth understanding of the antecedents of poor health in disenfranchised populations, I took a year off after 3rd year of medical school to move to the West coast and develop a web-based tool to evaluate and improve health disparities (http://bit.ly/eMohMD). The San Francisco Community Vital Signs tool laid the groundwork for neighborhood and hospital-level data that will hopefully inform efforts to improve patient safety and overall care for underserved populations.
Having worked on disparities in patient safety and language access at the city level, I wanted to learn about what was being done on the national level. Through various personal and professional connections, I secured a volunteer internship to write ten speeches on health disparities for a national leader in health policy, U.S. Senator Benjamin Cardin from Maryland. Motivated by the little girl with cellulitis and by several other instances of compromised patient safety due to language barriers, I was approved to dedicate an entire speech to health disparities among LEP patients. In the speech, I reference several studies that demonstrate how LEP patients are predisposed to receive incorrect or unnecessary medications and to suffer from more severe and more frequent medical complications compared to English-speaking patients.[3] I also site a study in which 32 of 35 language access-related malpractice cases involved failure to use a professional interpreter.[4] The cases resulted in many patients suffering death and irreparable harm including one patient who was rendered comatose, one who underwent a leg amputation, and a child who suffered major organ damage. Senator Cardin is scheduled to deliver the language access speech in the Spring of 2011 as the fourth speech in his series of ten. The first health disparity speech that I wrote has already been delivered and can be seen here (http://www.c-spanvideo. org/program/id/237988 ) at time mark 1:45:15. My work at the city and national levels has given me a broader perspective on the implications of compromised patient safety due to language barriers. Recognizing the language access gap in my home state of Maryland, I decided to take advantage of my experience on the hill to improve health for LEP patients where I grew up. Leveraging the relationship with the Senator, I have partnered with a grass-roots coalition of students to advocate for a specific aspect of reducing the language barrier in Maryland health care. In particular, we are trying to convince the Governor of Maryland to take advantage of a federal funding match program whereby the state and the federal government share the fiscal burden of reimbursing interpreters through Medicaid and SCHIP. Thats basically a 50% discount on the cost of saving lives! Twelve states in the country have already leveraged this valuable policy instrument including the nearby state of Virginia and Washington, DC.[5] The $5,000 from The Doctors Company Foundation and the Lucian Leape Institute would be instrumental in funding the remainder of our effort to educate policy makers about this fantastic match program. In particular, the money would be used for printing brochures, developing a professional video for dissemination via YouTube, and viral marketing via other social
media such as Facebook, LinkedIn, and Twitter. I really appreciate your consideration. Thank you, gracias, and spacibo. References 1. Harsham P. Intoxicado: a misinterpreted word worth $71 million. Med Econ. 1984;61:p289(3). (Malpractice case due to language barrier). http://find.galegroup.com/gtx/infomark. do?&contentSet=IAC-Documents&type=retrieve&tabID=T002 &prodId=AONE&docId=A3305584&source=gale&srcprod=AO NE&userGroupName=mlin_b_bumml&version=1.0. 2. Diamond LC, Reuland DS. Describing physician language fluency. JAMA. 2009;301(4):426-428. http://jama.ama-assn.org/ content/301/4/426.short. 3. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press, 2003. 4. Quan K , Lynch J. The High Cost of Language Barriers in Medical Malpractice. University of California, Berkeley: School of Public Health, 2010. 5. Chen A, Youdelman M, Brooks J. The legal framework for language access in healthcare settings: Title VI and beyond. Journal of General Internal Medicine. 2007;22(0):362-367; 367. http://dx.doi.org/10.1007/s11606-007-0366-2.10.1007/ s11606-007-0366-2.
Previously the IV bags were arranged by drug, the decision was made to reorganize them by size. This lead to the one-liter bag of Pitocin being placed right next to the one-liter bag of magnesium. Changes to hospital policies and procedures are common, and should not provide difficulties to patient care, except in this instance; the change was never communicated to the staff. None of the doctors or nurses that evening knew a change in medication lay out was occurring. A single misstep usually does not lead to patient harm; the system should have many fail-safes built in, but they were not evident that day. For easy distinction, the Pitocin bag was to have an additional bright green sticker while the magnesium back was to have a bright pink sticker. On the day of the incident, the only labeling the doctors and nurses saw was the black text on white background of the Pitocin and white text on black background of the magnesium. Despite all of these failures, had any member of the staff checked the label before administering the drug, the adverse event could still have been prevented. The nurse administering the drug later recounted how routine it was she has done this a million times before, so she just grabbed an IV bag from the same old spot and hung it and went about her remaining duties. While the patient was coding, the team had tremendous tunnel vision. Protocol was yet again not followed, not a single person looked at the IV pole to double check what was hanging. The attending thought it was an amniotic fluid embolism, the team followed his direction. It was not until the patient was in the ICU and blood tests came back, that we even realized the patient had magnesium toxicity. After the event, the hospital played the shame and blame game, and tried to brush all of it under the carpet. The only open and honest discussions were whether to even tell the patient about the events surrounding the incident and whether to fire the nurse that administered the medication or not. There was no debriefing of the staff. None of the attendings, residents or medical students were queried regarding the events of that evening by hospital administrators. The only quality improvements measures were done internally within the Ob/Gyn silo, with no contribution from nursing or pharmacy. The nurse who administered the medication has been working in the unit for many years and is very well liked. She broke down in front of the attending that evening, sobbing, asking how she could have been so careless. Those present did their best to comfort her, but there was no other care for the providers. She heard people openly discussing whether or not she would be fired from her job.
he team had just brought another life into this world
kicking and screaming. The infant boy was delivered vaginally at term with no complications. As the room was cleaned up, the IV was hung and the team basked in the joy of the ecstatic family. As things were wrapping up, the new mother began to complain about feeling warm and she appeared a little flushed. The doctors and nurses didnt think it was too concerning, so they decided only to monitor her. Within minutes, she complained of nausea and minutes after that difficulty breathing. Less than ten minutes after her initial complaint of feeling warm, a resident was performing CPR on the patient while a code team was called. When the patient was transferred to the intensive care unit, she had a serum magnesium level of 22 mEq/L. The series of events that lead up to the patients cardiac arrest began in a boardroom. A decision was made to reorganize the layout of premixed IV medications in the Ob/Gyn ward.
I will always carry the pain that the patients family and the nurse who administered the medication for the rest of my life. I believe it all starts with open and honest communication, not only between the patient and providers, but also between the different silos within the hospital. To that end I have been working with other health professional students to create an interdisplinary leadership series. The goal is to break down the silo early in the careers of health care providers. Medical, nursing, public health, applied health and pharmacy students mingle and participate in joint activities with hopes that the cooperation will be carried into their practices. Open disclosure after an adverse event is my true passion, though it is not enough. The information we gain not only needs to be disclosed to patients, but also used for quality improvement purposes. I am currently working with the Institute of Patient Safety Excellence at UIC on the 7 pillars grant. The institute is taking the combined full disclosure and quality improvement model from UIC and implementing it at multiple hospitals in the Chicago area. This event has instilled in me a passion and a drive to always be open and honest, whether it is with my patients or with my fellow providers. I believe it is only a first step, but it is a giant step if everyone in the healthcare profession can take it to heart. I hope to be part of a generation of health care providers who will work together to instill a patient safety culture across the field of medicine.
Award-Winning Essays 2012
ull----, Mr. A swore at us after we suggested obtaining
yet another imaging study for him. Oddly enough, he didnt say it with spite, anger, or even disrespect. He had simply had enough. Seven months into my third year of medical school, I had seen plenty of patients declining treatment which we, the medical team, had suggested. What made this case different, however, was that it was Mr. A. Mr. A was practically an establishment on my monthlong rotation at this hospitalhe had been there on my first day, and he was there 24 days later on my final week. He suffered from a complex host of medical problems including pulmonary fibrosis, severe hypertension, and renal failure, but I always looked forward to seeing him on morning rounds. Without exception, he was friendly, courteous, and cooperative. He had patiently endured numerous uncomfortable diagnostic procedures as we gradually brought his illnesses under control. Late one evening, Mr. A began to vomit uncontrollably and felt excruciating chest pain. A troponin level revealed that he had suffered a non-ST elevation myocardial infarction. The next morning, Dr. X, the resident taking care of Mr. A, was entering a note on the computer when he noted only three or four medications on the automatically generated medication list, where there had been dozens just one morning before. As it turns out, the electronic medical orders system used at this hospital required all medication orders to include an expiration date. At admission, the resident on duty overnight had selected a date which, at the time, seemed to be far into the distant future. Nobody had considered that Mr. A might actually stay past that date. And so as the expiration date arrived, the computer system automatically discontinued Mr. As anti-hypertensives, and as a result, he suffered a myocardial infarction. The medication change had gone unnoticed by his human caretakers, who entered notes which contained automatically-generated medication lists. And with that, Mr. As heart was damaged, physically and emotionally. His medications were restarted, but his onceoptimistic spirit could not be recovered. Though still courteous,
he denied any further treatment or diagnostics and insisted that he be transferred to a nearby rehabilitation center. The mistake had not only harmed Mr. A physiologically; it had eroded his trust in our team. It was impossible for us to care for him effectively anymore. A number of small holes in the delivery of care had come together in an unfortunate storm: our system required an expiration date, our computers deleted medications without notification, our medication lists were generated without being checked by his human providers, and a nurse delivered medications without noting that only a quarter of Mr. As usual pills were being given. It all came back to one crucial failure of imaginationthe inability to imagine that Mr. A might be much sicker than thought, and might stay at the hospital much longer than originally envisioned. The most startling thing about Mr. As story is that I had previously considered our computerized medication lists to be a marvelous invention. Tedious handwritten medication lists were the bane of residents and students alike when I rotated at other hospitals, and the electronic, automatic medication lists were one small blessing when dealing with complex patients who invariably presented with dozens of medications. Reviewing them and writing a list by hand always seemed frustrating and tediousa waste of time before we could do genuine, intellectually engaging medical analysis.To us, checking patient safety was something we did before we could practice real medicine. While Mr. As story undoubtedly suggests many improvements that must be made across many levels in this example, this is the one that stands out most clearly to me: we made the mistake of confusing computing power and convenience for intelligent and careful attention. While electronic orders bring many conveniences, they also increase the risk for mistakes such as this without proper attention and diligence. Since seeing Mr. A go to rehabilitation, changed for the worse, I have made it a point to personally review each patients medication lists and administration schedules daily. While patient safety does not always feel like new and adventurous intellectual ground, Mr. A taught me a painful lesson about its importance. I hope to never take it for granted again. *Please note that all possible pieces of identifying information (names, dates, locations, etc) have been changed for purposes of privacy.
ometimes a patient experience is so moving that it changes the way we practice as medical professionals. I had the fortune of meeting such a patient during my junior surgery rotation in 2011. The patient was a 60 year old woman originally from the East Coast who moved to be near her daughter and son-in-law. She had been recently diagnosed with Non Alcoholic Steatohepatitis (NASH) and presented to the hospitalist service midway through my rotation with hypotension and ascites. After 4 paracenteses and fluid boluses to control her blood pressure, she was referred to the transplant surgery service on hospital day 6 for liver transplant workup. During the workup a CT scan of her abdomen showed a lesion in the pancreatic head that was suspicious for malignancy. Carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA) were both elevated, and thus the surgical residents recommended that surgery be performed to remove the lesion before further evaluation of her liver transplant. She reluctantly agreed and a Whipple procedure was performed. She was immediately moved to the ICU after the procedure, as the surgery had several complications. In the ICU her condition stabilized for a short time, but shortly thereafter she started to bleed from her incision sites and developed bacteremia. By post operation day 4 her creatinine rose from a baseline of 1 to 4.2. Despite fluids and aggressive resuscitation measures she developed shock and died on post operation day9.
I followed the patient the day she was transferred to the surgery service as part of my transplant surgery subspecialty rotation. She was outgoing, personable, and despite her illness had a positive outlook about her future. She would tell me I cant control the fact I have this disease. All I can do is thank God for everything He has done for me in my life. As a third year medical student I have the luxury to spend significant time with my patients and hear their stories. We would talk about the activities she enjoyed, which included making fudge every month. She sounded disappointed, because weakness prevented her from making fudge that month for her friends and was a source of significant morbidity. Her spirits improved greatly when the transplant team started evaluating her for a liver transplant. Her daughter just welcomed their first child and the patients first granddaughter. She was fighting to stay alive so her granddaughter would know who she was. The transplant is my only chance at being a part of my granddaughters life she would say. The morning we informed her of a possible pancreatic malignancy was the only time I saw her frustrated. She asked out loud, What have I done to deserve this? We did not have an answer for her.
I identified with the patients frustration and uncertainty on a personal level. I was diagnosed with Focal Segmental Glomerulosclerosis (FSGS), an autoimmune renal disease, just before I was about to apply to medical school. It was a shock to me, then a 22 year old person about to graduate from college and in the prime of my life. I looked up research that showed that a majority of people with this disease end up needing renal transplants or dialysis. The prospect scared me, but gave me greater resolve to live my life to the fullest. This was the same sentiment I observed from the patientthat despite her endorgan disease she was determined to enjoy the remaining years of her life. The transplant would allow her to do that. When she would talk about her granddaughter I inevitably would think about my own life and its prospects. I had just proposed to my fianc a couple of weeks before I began following the patient so thoughts drifted into my head about my future family. Would I be around to watch my children grow up? What would my wife do if I died and left her alone? After surgery the excised specimen was sent to pathology for analysis. The day after she died I overheard the residents discussing the results: benign pancreatic adenoma. I was visibly upsetI thought to myself that she went through all of the surgery and post operation morbidity for a benign adenoma. The residents did not seem too upset however, as they mentioned At least we got to practice a Whipple. The next Friday during the surgery departments weekly Mortality and Morbidity (M&M) conference the PGY4 who performed the surgery presented this case to the department. As the resident presented the case, the Chairman of surgery promptly noted that the laboratory tests our team had used to decide that the tumor was probably malignant were not reliable indicators of malignancy. Elevated CA 19-9 and CEA dont mean anything he said. Ive got a patient dead on my service because the resident operated on a benign lesion. Pancreatic cancer is difficult to diagnose and there are no reliable diagnostic tests other than biopsy. I looked up the laboratory tests after the M&M conference and found that CA 19-9 can be elevated in patients with bilary/hepatic disease, and CEA is not sensitive or specific as a pancreatic adenocarcinoma tumor marker. Looking back, we did not perform a percutaneous biopsy of the lesion before surgery and the decision to operate was made on the two lab tests only. The patients liver disease and resulting poor coagulation studies were not taken into account before undertaking such a complicated operation. Considering the patients overall health condition when deciding on a plan to diagnose or treat disease is paramount.
As residents and medical students, we have a finite time to hone our skills before we will be expected to practice independently. However while we are trainees, we also have an obligation to ensure our patients are receiving appropriate medical care. I believe the resident saw this pancreatic lesion as an opportunity to practice a difficult surgical procedure instead of thoughtfully concluding that the procedure was the appropriate one for this patient. In essence, the resident treated himself, which resulted in shifting the goal of her care from liver transplant to operating on an interesting pancreatic lesion. The consequence in this case was death. Though this case resulted in a bad outcome, I find personal solace in this experience. Living with disease is a daunting task. As a medical student I try to distance myself from my patients emotions, while at the same time I am often having thoughts about my own disease. She showed me how to maintain a positive outlook despite living with disease and displayed a courage I hope to one day attain. I am grateful for my opportunity to get to know her, as the lessons she and her hospital course taught me will remain with me throughout my professional and personal life.
t was five in the morning and I was on my first day of the labor and delivery service during my third year rotation. I convened with my new intern and a fellow medical student in the resident room where the intern quickly told us what we were expected to do and gave us a copy of the list of patients. Our job was to remove the staples from the post-Caesarean patients four days after their surgery. I had just learned how to remove staples the week before and had an idea of how to do the procedure, but was by no means a professional. I tried to explain this to the intern, but she said to page her if we had any problems and to get moving on the list because sign-out was soon. Then she scurried out of the room, leaving the other medical student and I to look at each other in mild panic and then get down to the business of trying to decipher the list. We scooted to the room of the first patient on the list that was four days postCaesarean section and woke her up before we realized that we had forgotten the staple removal kit and both ran out to find it. We probably should have realized at this time we were over our heads and asked for help or guidance before starting our task, but both of us being eager to please did not want to disappoint the team so we carried on.
We found the kits after asking several nurses and hurried back to the patients room, where she had understandably fallen back asleep. We dutifully woke her back up and told her we were medical students who were going to remove her staples. She seemed confused but obligingly showed us her belly and we started the task of removing her staples. As neither of us had ever taken staples out ourselves before we were hesitant and slow and did not know exactly how the process should go or how the wounds should look. The new mother was patient with us, even though we could tell that we were causing her discomfort. We removed the staples and applied the steri-strips and left her to go back to sleep. After this first patient we felt more confident and moved through the list without any problems, other than the discomfort we felt at waking the patient up at such an early hour. We removed the staples from four more patients and then went to the resident room to meet with the rest of the team. The residents started sign-out and we listened until our intern started talking about her patients. She read them by room number and I was confused as to why some of the room numbers had changed but did not question anyone. It was not until she read our first patients name and indicated that she was two days postpartum that I realized that I had made a colossal mistake. I quickly spoke up and verified that she was only two days postpartum and then declared that Katherine and I had mistakenly removed her staples. After a few moments of confusion and accusations, the team realized that the list Katherine received had not been updated and still had yesterdays room numbers on it. Katherine and I had performed a procedure on a patient without verifying her name or medical identification number, and regrettably it was the wrong woman. Unfortunately the team chose not to inform our attending physician or the patient of our mistake which I deeply regret, even more so than making the initial mistake. Our resident told us to go to clinic after rounds in the morning, so we gratefully left the floor for a few hours. When we returned it was time for attending rounds and Katherine and I took our place in the back of pack. When it came time to talk about our patient, the intern graciously attempted to take the blame for the mistake, but Katherine and I knew it was time to speak up and admit to our error. The attendings response was not calm, nor particularly productive, but the patient was informed of the error and made sure to be healing appropriately. She took the news with grace and I was lucky to be able to follow up with her on an outpatient basis and appreciate that she was recovering normally. After tempers had calmed we were able to discuss what had gone
wrong and came up with the following rules to prevent this from occurring again: (1) always identify the patient and the procedure and obtain consent, (2) update any form of communication about patients so that every member of the team is always up to date on each patient (3) identify the capabilities of your team members and do not assign tasks of which they are incapable or uncomfortable performing (4) if a mistake is made, report it immediately. This event sparked a personal transformation because it demonstrated that patients will trust me on the basis of my white coat and that I must always be extremely conscientious regarding patient care. I learned to never forget the basic tenets of performing a procedure: making sure that I have the correct patient and am performing the correct procedure. Although this incident might have been avoided had the list been updated correctly it does not excuse the fact that I did not follow basic safety rules, and as a result, a patient suffered the consequences. I feel exceptionally lucky that this patient was understanding and that this was a relatively minor error, however this rule has been seared in my brain and I always reinforce this guideline when working with other students in the hope that we can all avoid future errors similar to this one.
he patient was thirty-five weeks into an uneventful
pregnancy when I met her in clinic. She smiled warmly through silver-rimmed glasses as I introduced myself and answered my questions with quiet patience. As I examined her, I learned about her life and family, and we shared thirty minutes of enjoyable conversation. A month later, I was pleasantly surprised to see her name on the Labor-and-Delivery board. Shed done well since clinic but came in after developing strong cramps that morning. In the hospital, her contractions crescendoed appropriately, and her cervix dilated. Her pain remained well controlled. Even as my resident and I gowned in preparation, she sat comfortably with husband and daughter at her side. We counted out her contractions together in preparation for smooth delivery. As we waited for her final pushes, however, the attending obstetrician stalked in, visibly upset. There was risk for shoulder injury given the babys size, she snapped, and she shouldve been notified. She shook her head briskly, mumbled under her breath, and stepped in front of the resident, who then turned towards me sternly and ordered me aside.
Thankfully, the baby was delivered without complication, and the patient only suffered a minor laceration. With the parents huddled contently around their newborn, the attending ungloved and left. My resident prepared the supplies to close her wound and assigned me the placenta. Id never delivered one before, I told her, only observed. So? she said without looking up. See one, do one, teach one. I hesitated, and she released an impatient, staccato sigh. Look, I dont have time for this. Give traction, but not too much. Just get it done before [the attending] gets more pissed! Part of me was afraid and wanted further guidance. But another part sensed how upset she was at being scolded by the attending and embarrassed in front of everyone. I feared her response to my further hesitation more than procedural uncertainty, so I pushed the heaviness into my chest with a long breath and pulled the cord. It came smoothly at first, coiling easily around my clamp. My resident glanced over without speaking, a quiet affirmation I was doing it correctly. I continued, gaining confidence as I went, until suddenly, without warning, the cord went slack. Jets of blood sprayed across my gown. Oh my God, the resident said from behind me. She looked into my eyes, to emphasize her point. You tore the cord. The next few minutes were a blur of voices and passing shapes. The resident reached into the uterus, to manually free the placenta. Nurses shuffled across the room with supplies. As I retreated to a corner, the space suddenly felt small and suffocating. My heart pounded into my throat, like a fish on dry land. Pulsing heat swelled behind my ears. I scanned the room, and my gaze caught the patient, disarmingly still amid the chaos. She was staring into my eyes intently, as if studying something behind them, weighing its integrity. Her gaze felt clear, but afraid, and I glanced away to escape the uneasiness rising within my chest. Soon the attending arrived, barking orders. She dismissed me from the room and took me off the case. I heard later that the patient had done well, but never saw her again. This memory has stayed with me ever since. Before this experience, Id been involved in patient safety/quality improvement. Id met leaders, participated in projects, earned certifications, and founded the Baylor interest group. Id been an American College of Medical Quality (ACMQ) Scholar and served on national leadership for ACMQ and Institute for Healthcare Improvement (IHI). Id successfully conceptualized and implemented a required safety course for students. But despite all of
that, I was unprepared for this patient, whose case hinged not on error or inefficiency, but communication and culture. The culture surrounding this incident discouraged safety: the relationships were rigidly hierarchical, the opportunities for communication sparse. After that experience, I studied these issues and realized that little had been done on safety culture and error disclosure from student perspectives. Existing work focused mostly on student knowledge definitions and statistics that while helpful, werent functional. They wouldnt help students identify/prevent errors in clinical care, wouldnt teach them how/where to report errors, or when, if ever, to speak up in team settings. What students seemed uniquely suited to contribute, by virtue of perspective and time with patients, would likely come through communication and culture. But with this patient, these were the very things threatening her safety. Driven by her memory, I committed myself to championing these issues. I sought mentorship from a safety culture leader and crafted a medical student study addressing culture, disclosure, and behavioral intent. I dedicated three months to studying error disclosure with Thomas Gallagher, a nationally-renown expert. Ive worked with Baylor leadership to incorporate safety culture into required coursework, clinical rotations, and independent programming like the recent statewide IHI convention I spearheaded. And Ive built connections with hospital leadership to safety culture awareness within departments and clinical teams. In all of this, Ive often thought of this patient. I wish I could apologize for lacking the courage to hold her gaze that day after chaos ensued, sorry she couldnt sense my humanity pressed against hers afraid of the moment, but present. I wish I could share the exciting things Ive learned since, emphasizing how powerfully theyve shaped local medical education and my own professional goals. Mostly, I wish I could thank her: for not only demanding measures of my mind and heart, but examinations of the systems within which I practice; for reminding me that beyond diagnosis and management, doctoring is a lesson in journeying well with people through uncertainty, and into the joy or grief waiting beyond it; for teaching me that communication and culture are integral to that charge, and that at its best, the endeavor of medicine must irrevocably change me, so that as I try to affirm the highest goals in my patients lives, they also affirm and develop mine.
watched the obstetrical forceps fall to the floor, their
Shes crashing! came the attendings booming voice. The OR doors flew open and an anesthesiologist raced into action. Gown up! the attending said firmly to me. My reaction was automatic: left arm, right arm, gloves, and spin. But as I stepped up to the operating table and saw the marking pen drawing the line of incision, the husbands words echoed in my mind: The knife is forbidden. Forbidden, I thought. He hadnt said, I dont prefer that you do a C-section, or Try to avoid going to the OR. The word was forbidden. Wait, I blurted suddenly. They said no surgery! The ceiling lamps felt hotter than usual. The husband said no, it was forbidden, and they talked on the phone, and she agreed with him! The words came tumbling out of my mouth. She gave us consent for care, and this is the standard of care, the attending said flatly. But she said no, I replied, the courage having drained from my voice like the blood from my face. My attending threw down the marking pen. Our duty is to the patient! she roared. I steadied myself on the rail of the table. Yes, I pleaded, but isnt what she wants as important as what we think she needs? Get the husband on the phone. A nurse connected the husband on speaker phone, and he and his wife conversed briefly. They remained adamantly against surgery. Do you understand, asked the attending sharply, that her life is at stake? And your babys life? Yes, doctor, came the reply. But she cannot have the knife. THEN SHE WILL DIE! A whisper escaped from the patients lips: Then let it be the will of God. The OR halted as if a still-life portrait: the attending, negotiating a choice that might crumble into disaster; the patient, steadfast in her belief, surrendering to her faith; and I, the medical student, wondering whether I had said too much, yet perhaps not enough. Even if surgery was the medically necessary choice, was it the right thing to do? And in our quest to protect our patients health, had I done enough to defend the patient herself? Get me the forceps, came the attendings answer, as the scalpel was taken off the field and the obstetrical forceps
handles striking the linoleum tile and emitting a dull, hollow sound soon drowned out by the newborns first cry and his mothers sighs of relief. But the forceps remained, each half bearing traces of blood and amniotic fluid, spattered across the shank, and the leather tops of my shoes. Two days earlier, the patient had arrived clutching a large purse in one hand and her belly in the other. Now six weeks into my obstetrics rotation, I greeted the patient, who remained silent, her gaze to the ground. The unit doors slid open and a harried-looking man ran in. She is my wife, he stated. I introduced myself as the medical student on the unit, part of a team of physicians that would care for his wife. He nodded, unimpressed. I stepped behind the wheelchair and invited him to follow me. You go, I stay in waiting room, he said. It is not allowed for the husband to see when the baby is coming. I assured him that the team would do our best to accommodate the patients needs. The patient, a slender, 30-year-old woman with flowing black hair, was over forty weeks pregnant with her first child and indeed in labor. I had never encountered a request like this, but I respected the patients cultural traditions and expected little interference with the normal course of care. Except that the clinical course turned abnormal overnight, as her labor arrested with no cervical change and cessation of fetal descent. The team proceeded with the standard administration of oxytocin and careful monitoring. But 24 hours later, when we recorded erratic contractions and fetal distress, the attending quickly booked an operating suite. Go tell the husband, she said to me decisively, that were going to section her. I had developed a good relationship with the patients husband. Since he could not see his wife on the unit, I had brought in a telephone connected to her room and visited him frequently with updates. This morning, however, the news of the Caesarian section was met with a scowl. No surgery! he stated resolutely. In our culture, the knife is forbidden. I reiterated my concern over the phone for his wifes safety and that of the baby, but their beliefs were immutable. Feeling a burden of failure, I returned to the unit to find the mood had shifted from concern to emergency.
unwrapped. The delivery was risky and difficult but in the end successful, as the patient gave birth to a healthy boy, whose first cry was met over the phone by his fathers shouts of praise. Exhausted, my attending stepped back from the operating table. The forceps slipped from her fingers and tumbled to the floor. Gazing at the forceps, I pondered what they represented: a high-stakes, life-and-death situation that challenged our notions of the patients best interests; an unconscious systemic failure to consider the impact of her social and cultural identity on her care; and an understanding that the foundation of an unwavering dedication to patient safety was found not simply in checklists or consent forms, but also in our appreciation of the patient herself as richly enmeshed in the narrative of health and illness. As I complete medical school and become a young physician, my experience with this patient defines my commitment to stand up to threats to patient safety, to speak out on behalf of those whose lives we protect, and to act with courage to eliminate the systemic barriers to better care. In my life and my career, I accept this challenge in service of our profession, our patients, and our common good.
nephrologist by phone who advised that the patient should be admitted to the hospital for treatment of dehydration. When the intern and I entered the room to gather a history and examine the patient, the small infant lay quietly on the disproportionately large hospital bed. She hardly made an effort to open her eyes. Even during more invasive exams such as using the tongue blade to get a better look at her mouth and throat, she did not cry. I remember getting concerned at this point. Although new to the pediatrics team, I had a gut feeling that something wasnt quite right. Then she threw up a profuse bright green vomit and I began to feel even more uneasy. The intern remained calm and cleaned the mess after a couple more episodes of bright green vomit. Her calmness did reassure me. Perhaps I was overreacting. Once we left the room, I tried to discuss my assessment of the patient with the intern. I told her that I was worried the baby might have a bowel obstruction. She didnt dismiss the idea, but she kept her attention to filling out paperwork. Without looking away from her work, she reasoned that the bilious vomit was most likely due to our examination and less likely due to any obstruction. Besides, her nephrologist had already been consulted and provided a diagnosis of dehydration. I pressed on. I expressed my concern that if the patient did have a bowel obstruction, it could lead to ischemia or death of the affected bowel if left untreated. We could order a bedside abdominal x-ray to quickly and easily evaluate the possibility of an obstruction. She did not agree. A chest x-ray had been ordered by the ED physician and the intern argued that enough of the abdomen could be visualized to see that an obstruction was unlikely. I pulled up the chest x-ray on a nearby computer to find that, at most, one-third of the abdomen could be visualized. I attempted to share this finding with her. She merely said, Ive already seen it. I urged the intern to consider that if the patients bowel did become ischemic, a surgical emergency, that our small community hospital lacked any pediatric surgeons and she would have to be transferred. The nearest hospital equipped to care for her was one and a half hours away, a significant time delay in treatment. She remained unconcerned and so I went back to the patients room to ask her parents additional questions. My questions focused on further evaluating the possibility of a bowel obstruction. I learned that the childs last bowel movement was the day before with no bowel movements since. Even more worrisome, when asked if the baby had passed any gas since her last bowel movement, her mother responded, Now that you mention it, no she hasnt. I asked if she could normally hear her baby pass gas and she continued, Yeah. It usually
arrived at the emergency department of a small community hospital late Sunday night. As a part of my pediatrics rotation in my third year of medical school, I was on call every 4th to 6th night to help the interns with new admissions. On this particular night, the importance of effective communication, working collectively as a team, and trusting gut instinct conflicted with my ability to manage the delicate balance that exists between acting in ones own best interest versus that of the patient.
I met with the intern in the emergency department (ED) and we discussed the patient with the ED staff. Our patient, a two month old female, had the unfortunate history of spending the first seven and a half weeks of her life in the neonatal intensive care unit at a hospital one and a half hours away from home. She was born with a kidney tumor that was removed when she was four weeks of age. Shortly after, she developed pneumonia and wasnt able to return home until 7 and a half weeks of age. At home, her parents paid close attention to her health. They became concerned when she did not drink her formula, seemed constipated, and had only a few moist diapers since returning home. After a full workup, the ED physician consulted with her
sounds wet or as though she is having a bowel movement but when I go to check her diaper, its clean. I went on to ask if the babys belly looked larger than usual and the mother confirmed that it did. This new information greatly supported the possibility of a bowel obstruction. I left to rejoin the intern and found her on the phone waiting to get a hold of the attending. While on hold, I explained that the baby had not passed any flatus and had a distended abdomen, supporting an obstruction. She nodded but did not respond. Shortly after, her demeanor changed from guarded to overly pleasant as she greeted the attending and explained the patients presentation. She neither mentioned the distended abdomen nor absence of gas. Later that night, within hours after being admitted to the pediatric floor, the babys condition rapidly worsened. Her belly blew up and she had unremitting vomiting that progressed to include fecal matter. She was transferred to a hospital with a higher level of care by life flight and sent directly to the operating room. She had a small bowel obstruction and lost the majority of her bowel. This case elucidates several ethical issues including that of nonmaleficence and beneficence. Nonmaleficence, or do no harm, is an ethical guideline that forbids physicians from providing ineffective therapies or from acting selfishly or maliciously (1). In this case, ego played a substantial role in the care of this patient. The intern failed to mention key information to the attending that would have changed patient management. If she had included bowel obstruction in her differential, theres no doubt the attending would have been made aware of the distended abdomen and lack of gas. Overlaping with nonmaleficience is beneficence, a guideline in which the physician has the duty to act in the best interest of the patient(1). The patient was admitted to the pediatric floor instead of being transferred to a different hospital for a higher level of care. The lack of pediatric surgeons in our local area needed to be considered when admitting this patient. Although one may argue that the patients diagnosis was uncertain and thus transfer to a higher level of care was not warranted, it was also in the patients best interest to further explore the possible differential diagnoses, something that we failed to do as a team. Instead, we submitted to the nephrologist who labeled the infant as dehydrated. The differential diagnosis of bowel obstruction could have been further explored with an abdominal xray. Its cost effective, easy to do at the bedside, and fast. The diagnosis would have been made sooner so that the patients best interest to be directly transferred to a higher level of care would have been fulfilled.
One of the most important issues encountered in this experience involves the ethics of speaking up. The hierarchical system of attending, then resident, intern, and last medical student is such that the concerns of the medical student are often overlooked or dismissed, as in this case. Although speaking up to improve patient outcome was morally the right thing to do, doing so is often at the expense of fostering working relationships with those higher up in the hierarchical system. During a meeting to discuss the importance of recognizing a sick patient as a consequence of this case, the intern shared that she believed I was too pushy. This could be a dire mistake, because a medical students grades depend on subjective evaluations by the interns, residents, and attendings. Making matters worse, the babys outcome did not change as a result of my brashness. On the other hand, I may not have spoken up enough or in the right manner. Often medical students play dumb to hint towards the diagnosis or management of a patient so that the intern or resident does not feel challenged. This way concerns and/or ideas can be voiced without jeopardizing working relationships.(2) Perhaps I was too pushy and threatened the interns ego. However, playing dumb can have its own unfavorable consequences. The subservient medical student who does not speak up or plays dumb will not learn how to manage conflict or how to argue for better patient care. It may also lead to an alteration of attitude towards subservience that can be carried into practice later on. Too often, as in this case, medical practitioners go along with the conclusions of other medical practitioners even if incorrect or inadequate. Although it is helpful to consult a specialist, in this case the specialists diagnosis undermined the patients actual diagnosis. Neither the intern nor ED physician explored the patients presentation beyond the diagnosis of dehydration as they acquiesced to the expertise of the nephrologist. Thus the medical student who remains quiet risks developing a habit of continuing to do so, putting that medical student at risk of emulating the same behavior as the intern and ED physician in this case. Ultimately, it is the role of the medical student to learn. This includes learning when and how to speak up. This is an art in which the student should consider the nature and certainty of their judgment, their specific role in the situation, the potential harm to patients, the probable effectiveness of speaking up, and the likely cost to themselves if they do speak up.(1) Although I had a high index of suspicion that our patient had a medical emergency that warranted better care than what could be provided in our hospital, I was still uncertain of my clinical knowledge. I had never seen bilious vomiting before and questioned if thats what I truly saw, especially when the intern
and ED physician were not similarly concerned. Furthermore, in this case the interns expectations of a medical students role in patient management was made perfectly clear. The medical students role was to stand aside, watch, and keep quiet, making the effectiveness of speaking up unlikely with this specific intern. While I could have gone higher up in hierarchy until my concerns were addressed, the medical system is set up such that medical students have very little direct interaction with the chief resident or attending. Ive actually never met either and wouldnt know how to contact either if I needed to. This elucidates a major flaw in the medical team. It is set up such that it is difficult to find someone who will listen, because alternative avenues of communication are limited and/or prevented completely. Thus, while it is the obligation of the student or medical practitioner to speak up for better patient care, those with more power and authority have a greater obligation to confront the problem to change the conditions that make it so difficult for those below them to speak up.(2) If the attending had been available directly in person rather than by telephone, I may have been able to share the information I believed to be so important in changing the patients management and ultimately her outcome.
Although I was unable to alter this childs outcome, I will strive to prevent similar consequences of poor patient care. As I progress up the hierarchical ladder towards the attending, I will always remember the important lesson learned from this experience as a medical student. I will retain my inquisitive nature with the humility to understand that the best patient care is achieved through effective communication, teamwork, and personal sacrifice. References 1. Lo, Bernard. Overview of Ethical Guidelines. In Ethical Dilemmas: A Guide for Clinicians (pp. 1117). Lippincott Wiliams & Wilkins, 2009. 2. Dwyer, James. Primum non tacere: An ethics of speaking up. The Hastings Center Report; Jan 1994;24(1); Platinum Periodical.

TDCF Young Physicians Essays 2011-12

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David B. Troxel, MD Chairman The Doctors Company Foundation

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distressed father, living an otherwise tranquil life as

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he first thing I noticed about the hospital was the

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he smiles of optimism seemed to glow even more in

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he team had just brought another life into this world

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ull----, Mr. A swore at us after we suggested obtaining

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he patient was thirty-five weeks into an uneventful

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watched the obstetrical forceps fall to the floor, their

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