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TED Talks - Medicine

TED Talks - Medicine

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Published by: jykl91 on Jul 23, 2012
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10/21/2013

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Search Talks | TEDxBrian Goldman: Doctors make mistakes. Can we talk about that?Click on any phrase to play the video from that point.I think we have to do something about a piece of the culture of medicine that hasto change. And I think it starts with one physician, and that's me. And maybe I'vebeen around long enough that I can afford to give away some of my false prestigeto be able to do that.Before I actually begin the meat of my talk, let's begin with a bit of baseball. Hey,why not? We're near the end, we're getting close to the World Series. We all lovebaseball, don't we? (Laughter) Baseball is filled with some amazing statistics. Andthere's hundreds of them. "Moneyball" is about to come out, and it's all aboutstatistics and using statistics to build a great baseball team.I'm going to focus on one stat that I hope a lot of you have heard of. It's calledbatting average. So we talk about a 300, a batter who bats 300. That means thatballplayer batted safely, hit safely three times out of 10 at bats. That means hitthe ball into the outfield, it dropped, it didn't get caught, and whoever tried tothrow it to first base didn't get there in time and the runner was safe. Three timesout of 10. Do you know what they call a 300 hitter in Major League Baseball? Good,really good, maybe an all-star. Do you know what they call a 400 baseball hitter? That's somebody who hit, by the way, four times safely out of every 10. Legendary-- as in Ted Williams legendary -- the last Major League Baseball player to hit over400 during a regular season.Now let's take this back into my world of medicine where I'm a lot morecomfortable, or perhaps a bit less comfortable after what I'm going to talk to youabout. Suppose you have appendicitis and you're referred to a surgeon who'sbatting 400 on appendectomies. (Laughter) Somehow this isn't working out, is it?Now suppose you live in a certain part of a certain remote place and you have aloved one who has blockages in two coronary arteries and your family doctorrefers that loved one to a cardiologist who's batting 200 on angioplasties. But, but,you know what? She's doing a lot better this year. She's on the comeback trail.And she's hitting a 257. Somehow this isn't working.But I'm going to ask you a question. What do you think a batting average for acardiac surgeon or a nurse practitioner or an orthopedic surgeon, an OBGYN, aparamedic is supposed to be? 1,000, very good. Now truth of the matter is, nobodyknows in all of medicine what a good surgeon or physician or paramedic issupposed to bat. What we do though is we send each one of them, includingmyself, out into the world with the admonition, be perfect. Never ever, ever makea mistake, but you worry about the details, about how that's going to happen.And that was the message that I absorbed when I was in med school. I was anobsessive compulsive student. In high school, a classmate once said that BrianGoldman would study for a blood test. (Laughter) And so I did. And I studied in mylittle garret at the nurses' residence at Toronto General Hospital, not far from here.And I memorized everything. I memorized in my anatomy class the origins andexertions of every muscle, every branch of every artery that came off the aorta,differential diagnoses obscure and common. I even knew the differential diagnosis
 
in how to classify renal tubular acidosis. And all the while, I was amassing moreand more knowledge.And I did well, I graduated with honors, cum laude. And I came out of medicalschool with the impression that if I memorized everything and knew everything, oras much as possible, as close to everything as possible, that it would immunize meagainst making mistakes. And it worked for a while, until I met Mrs. Drucker.I was a resident at a teaching hospital here in Toronto when Mrs. Drucker wasbrought to the emergency department of the hospital where I was working. At thetime I was assigned to the cardiology service on a cardiology rotation. And it wasmy job, when the emergency staff called for a cardiology consult, to see thatpatient in emerg. and to report back to my attending. And I saw Mrs. Drucker, andshe was breathless. And when I listened to her, she was making a wheezy sound.And when I listened to her chest with a stethoscope, I could hear crackly sounds onboth sides that told me that she was in congestive heart failure. This is a conditionin which the heart fails, and instead of being able to pump all the blood forward,some of the blood backs up into the lung, the lungs fill up with blood, and that'swhy you have shortness of breath.And that wasn't a difficult diagnosis to make. I made it and I set to work treatingher. I gave her aspirin. I gave her medications to relieve the strain on her heart. Igave her medications that we call diuretics, water pills, to get her to pee out theaccess fluid. And over the course of the next hour and a half or two, she started tofeel better. And I felt really good. And that's when I made my first mistake; I senther home.Actually, I made two more mistakes. I sent her home without speaking to myattending. I didn't pick up the phone and do what I was supposed to do, which wascall my attending and run the story by him so he would have a chance to see herfor himself. And he knew her, he would have been able to furnish additionalinformation about her. Maybe I did it for a good reason. Maybe I didn't want to be ahigh-maintenance resident. Maybe I wanted to be so successful and so able totake responsibility that I would do so and I would be able to take care of myattending's patients without even having to contact him. The second mistake that I made was worse. In sending her home, I disregarded alittle voice deep down inside that was trying to tell me, "Goldman, not a good idea.Don't do this." In fact, so lacking in confidence was I that I actually asked the nursewho was looking after Mrs. Drucker, "Do you think it's okay if she goes home?" Andthe nurse thought about it and said very matter-of-factly, "Yeah, I think she'll dookay." I can remember that like it was yesterday.So I signed the discharge papers, and an ambulance came, paramedics came totake her home. And I went back to my work on the wards. All the rest of that day,that afternoon, I had this kind of gnawing feeling inside my stomach. But I carriedon with my work. And at the end of the day, I packed up to leave the hospital andwalked to the parking lot to take my car and drive home when I did something thatI don't usually do. I walked through the emergency department on my way home.And it was there that another nurse, not the nurse who was looking after Mrs.Drucker before, but another nurse, said three words to me that are the threewords that most emergency physicians I know dread. Others in medicine dreadthem as well, but there's something particular about emergency medicine because
 
we see patients so fleetingly. The three words are: Do you remember? "Do youremember that patient you sent home?" the other nurse asked matter-of-factly."Well she's back," in just that tone of voice.Well she was back all right. She was back and near death. About an hour after shehad arrived home, after I'd sent her home, she collapsed and her family called 911and the paramedics brought her back to the emergency department where shehad a blood pressure of 50, which is in severe shock. And she was barely breathingand she was blue. And the emerg. staff pulled out all the stops. They gave hermedications to raise her blood pressure. They put her on a ventilator.And I was shocked and shaken to the core. And I went through this roller coaster,because after they stabilized her, she went to the intensive care unit, and I hopedagainst hope that she would recover. And over the next two or three days, it wasclear that she was never going to wake up. She had irreversible brain damage.And the family gathered. And over the course of the next eight or nine days, theyresigned themselves to what was happening. And at about the nine day mark,they let her go -- Mrs. Drucker, a wife, a mother and a grandmother. They say you never forget the names of those who die. And that was my first timeto be acquainted with that. Over the next few weeks, I beat myself up and Iexperienced for the first time the unhealthy shame that exists in our culture of medicine -- where I felt alone, isolated, not feeling the healthy kind of shame thatyou feel, because you can't talk about it with your colleagues. You know thathealthy kind, when you betray a secret that a best friend made you promise neverto reveal and then you get busted and then your best friend confronts you and youhave terrible discussions, but at the end of it all that sick feeling guides you andyou say, I'll never make that mistake again. And you make amends and you nevermake that mistake again. That's the kind of shame that is a teacher. The unhealthy shame I'm talking about is the one that makes you so sick inside.It's the one that says, not that what you did was bad, but that you are bad. And itwas what I was feeling. And it wasn't because of my attending; he was a doll. Hetalked to the family, and I'm quite sure that he smoothed things over and madesure that I didn't get sued. And I kept asking myself these questions. Why didn't Iask my attending? Why did I send her home? And then at my worst moments: Whydid I make such a stupid mistake? Why did I go into medicine?Slowly but surely, it lifted. I began to feel a bit better. And on a cloudy day, therewas a crack in the clouds and the sun started to come out and I wondered, maybeI could feel better again. And I made myself a bargain that if only I redouble myefforts to be perfect and never make another mistake again, please make thevoices stop. And they did. And I went back to work. And then it happened again. Two years later I was an attending in the emergency department at a communityhospital just north of Toronto, and I saw a 25 year-old man with a sore throat. Itwas busy, I was in a bit of a hurry. He kept pointing here. I looked at his throat, itwas a little bit pink. And I gave him a prescription for penicillin and sent him on hisway. And even as he was walking out the door, he was still sort of pointing to histhroat.And two days later I came to do my next emergency shift, and that's when mychief asked to speak to me quietly in her office. And she said the three words: Doyou remember? "Do you remember that patient you saw with the sore throat?"

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