Guest Blogger – “I Want More”

Hello everybody-

Last month, Sorrel visited the New York College of Osteopathic Medicine to speak to a group of medical students. It was a terrific visit, and we wanted to share a med student’s perspective on Sorrel’s visit. First year med student Syed Gillani shares some interesting thoughts. Thank you, Syed!

I want to tell you the story of a little girl named Josie King. She had a whole life ahead of her that was drastically cut short due to medical error. Today, she would have been in middle school thinking about her next soccer game, dance recital or sleepover at a friend’s house. However, on February 22, 2001, Josie King died at the Johns Hopkins Hospital at eighteen months of age.

Rolling forward to February 9, 2011. It was lunchtime and a Student Osteopathic Medical Association (SOMA) meeting was scheduled. Like all other meetings, people signed in, grabbed their food and settled down in their favorite seats. The speaker was Sorrel King, Josie’s mother, and the room was packed. I am not sure whether it was because of our gourmet food or Sorrel King, but I’ll let you figure it out on your own. I signed in and sat in the front row, waiting for the speaker to talk. Since I am a SOMA E-board member, I had heard about the speaker’s tragedy in and E-board meeting, but did not anticipate how it would play a role in my life.

Dean Scandalis introduced Sorrel King and she took the stage. This confident, professionally-dressed woman started out telling the details of her daughter’s death as a result of a medical error. Right from the very first minute of her talk, I felt that she engaged everyone in the audience. I was not an exception. The story was so emotional that my throat started to get dry. Being in the front row, I was sitting very close to all the refreshments, but I could not get up and grab a drink. My eyes were locked on Sorrel and I would not want to be distracted for anything. I felt a different energy in the room than most lunch meetings, and I am sure that I was not the only one in the room who was feeling like that. As I noticed the face of a guy sitting next to me turning red, I knew he was as emotional as I was.

I still remember Sorrel King telling us that during the last days of her life, Josie was thirsty and asking for more water. That helped me to forget about my dry throat, which was bothering me. I cannot imagine the shock and emotional trauma this entire family had to bear. I can tell that Sorrel King has not yet recovered from that loss and, not surprisingly, may never recover fully. I found her to be passionate about patient safety and uniquely aware of the factors that affect patient outcomes.

As Sorrel so insightfully stated, we all go through some sort of trauma sometime in our lives. It ranges from having a bad day at work to losing a loved one. The kind of human beings we are is defined by how we react to these events and the choices we make down the road. Sorrel King turned her adversity into an opportunity to delivery her message effectively. She has made choices that are making a difference in so many lives. She started to dig deeper into her tragedy and found out that 98,000 people die every year from medical errors, making it one of the leading causes of death in the United States. She decided to build the platform that would help to decrease the deaths from this particular cause. She formed the Josie King Foundation (JKF) with the money she received as compensation from her daughter’s death….

As we begin our professional lives in medicine, I strongly recommend that you visit www.josieking.org and read all of the information at your own convenience. This information will be very helpful in the future and gives a different perspective of what it means to be a physician. I was overwhelmed to discover how much power I will have based solely on the trust my patients will place in me. As always, power comes with accountability. Since I have a choice, I would rather create my own accountability than have someone else do it for me. I would rather facilitate medical error prevention by acquiring updated knowledge and developing effective communication skills than be externally reprimanded following an adverse event I caused out of ignorance. According to research, communication breakdowns are the most common cause of patient death due to medical error. I have learned that in my future practice, when I am not sure about something, I’ll simply ask. I will not let any factor stop me from being a patient advocate. At the end of the day, I may only be able to save one family from their lifelong grief, but that is the priceless reward.

It was after 1:00pm, but few people had gotten up to leave and the room was still silent. Due to time constraints, Sorrel had to wrap up the talk quickly, but she had effectively conveyed her message. I left the room with my dry throat and I was not even able to talk for awhile. I wanted to walk down to Alyssa Bennett, current President of SOMA who arranged this unforgettable event, and ask her (out of necessity, in the sign language my fourteen-month old nephew uses) “I Want More!” I want more awareness and education about the prevention of medical malpractice. I want children like Josie growing up to a rightful old age, having trust in our health care system and processes.

IHI On Call: Talking with Nursing and Medical Students

The first time that I ever spoke to a room full of medical students was a few years ago at Johns Hopkins. I told them Josie’s story and at the end of the talk I asked them if they had ever head of the Institute of Medicine’s report “To Err is Human”. No one raised their hand. I remember feeling shocked that these students- who were taught how to cure diseases, deliver babies and mend broken bones- were not being told about one of the leading causes of death in our country- medical errors. The more medical and nursing students to whom I talked, the more I realized that it was indeed a rarely discussed topic. I found this frustrating and confusing. Since then I have tried to talk to as many medical and nursing students as I can. These young minds are the next generation, and if I could make a tiny difference in how they would care for their patients by sharing Josie’s story then I was going to do it.

I am grateful to the Institute for Healthcare Improvement (IHI) for creating the Open School (www.ihi.org/openschool). The Open School is a great resource for medical and nursing students to round out their patient safety education. They offer free courses in patient safety and quality improvement, sponsor essay contests, and host safety conferences for students of the health professions. Each month the Open School offers an On Call teleconference lecture, in which a guest speaking talks about a topic related to patient safety. Students from all over the country listen in and learn. I don’t believe anything can take the place of a classroom with a professor, however this may be the next best thing.

On Tuesday- with the help of modern technology- I sat at my desk in my home in Baltimore and had the honor of talking to a few hundred students from around the country. The session was called “Channeling Grief into Action”. Simon Mathews, a medical student at Johns Hopkins, moderated the hour-long session. I shared Josie’s story. I explained that Josie didn’t die because of one misplaced decimal point, because of one doctor or nurse. She died because of a lack of communication. After I spoke, Simon opened the lines to take questions from callers. I loved hearing from the students and I could tell that they had been moved.

For me it had been an hour well spent. It was my chance to make an impression on these brilliant minds that will take healthcare into the future. It was my chance to remind them of the importance of good communication and the need to create a culture in which reporting errors is considered heroic; a culture where doctors and nurses work as a team to prevent medical errors; a culture where the patient is heard and when a mother says, “Something is not right…” she is listened to. I hope I succeeded in delivering that message.

Thank you to IHI for realizing the importance of getting this information to students. Thank you Deepa Ranganathan for pulling the program together, and thank you Simon Mathews for being a great moderator.

For more information, check out the links below:

-An audio recording and a transcript of the session will be available at www.ihi.org/openschool at the end of the month. This link is also the gateway to all of the information about IHI’s Open School.

-IHI’s Open School blog (www.ihiopenschool.blogspot.com) has an open conversation about the session where you can post comments/questions. I’ll be checking in on the comments and responding to them.

-Want to take IHI’s educational programming wherever you go for free? You can subscribe to their informative podcasts at the Apple iTunes Store. Just go to the iTunes Store, search for “Institute for Healthcare Improvement” and click “Subscribe” to download IHI’s podcasts.

With the Medical Students

A few nights ago I spent the evening with 27 Post-Baccalaureate students from Johns Hopkins University. I had been asked by the director to join the students for dinner and then speak to them for an hour or so. I was to be joined by Rick Kidwell, who had been the lead attorney at Hopkins when Josie died and was now at UPMC, University of Pittsburgh Medical Center.

The Hopkins Post-Baccalaureate program is a year long program that prepares students for medical school. Hundreds of students from all over the country apply to this program, with only 42 acceptances for 27 positions. These students have earned their undergraduate degrees with an average of a 3.7 or above. More impressive than their high academic standings are the things they have done after college on the humanitarian level. Each one had an amazing story to tell. Some had spent time teaching in impoverished areas overseas. One spent a year with Dr. Paul Farmer, who is known throughout the world for his work and dedication in the poor towns of Haiti. Another student worked with the world renowned Dr. Benjamin Carson, a Hopkins pediatric neurosurgeon. One student worked as a teacher in the Mississippi Delta and then went on to teach children with AIDS in Africa. These life experiences shaped their young minds and led them to discover what it was that they truly wanted to become. Doctors. It is this dedication to public service, this humility and this selflessness that set these students apart from all others and landed them in the prestigious Hopkins Post-Bac program.

I always find it invigorating to be with medical students. They are so young and eager with bright minds that can be shaped. I can see the future in their eyes, and as I sat at my computer the day before and read all that they had accomplished and all that they had contributed to society and at such a young age, I knew that it was going to be a memorable evening.

Rick and I sat on folding chairs on stage and began our presentation. I started by sharing Josie’s story. I broke it down as if it were a case study and watched them as they began to put the pieces together, realizing that a little girl had died at one of the best hospitals in the world, not because of a misdiagnosis or a medication error. It was something far simpler: communicaton, or rather, a lack of communication. I continued to talk about the importance of disclosure, and what it means to a family to be told the truth, to have questions answered and to know that the problem will be fixed. Rick shared the hospital’s side of the story. He talked about how doctors and nurses are affected by medical errors. He told the students that when they become doctors, and if they make a mistake always to tell the family. “Don’t worry about a potential lawsuit,” he said. “That is the job of the risk manager.” The discussion led to error reporting systems, family involved root-cause analysis and more. They asked interesting questions, and they shared their thoughts.

Soon these students will be in medical school. They will be inundated with Biology, Chemistry, Physiology. The importance of communication might not be woven into their curriculum. This was my chance to sink a story into their hearts and hope that when they become doctors that they will remember how to listen and communicate. These students are going places. These are the ones who are going to win Nobel prizes and find cures for our diseases. They are going to save lives. I am sure of it. I was honored to be with them I wish them all luck, and I thank them for listening.