‪TEDxToronto – Dr. Brian Goldman – Redefining the Practice of Medicine 
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that may be the only round of applause I get this is the moment when I feel very very antsy because I have no idea what you're gonna think of me at the end of it which I guess makes it a bit giddy and exhilarating but here goes anyway you know I think we have to do something about a culture a piece of the culture of Medicine that has to change and I think it starts with one physician and that's me and maybe I've been around long enough that I can afford to give away some of my false prestige to be able to to do that before I actually begin the meet of my talk let's begin with a bit of baseball hey why not you know we're near the end we're getting close to two to the World Series right we all love baseball don't we baseball is filled with some amazing statistics and there's hundreds of them Moneyball is about to come out and it's all about statistics 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 its called a batting average so we talked about a 300 a batter who passed 300 that means that that ballplayer batted safely hit safely three times out of 10 at-bats that means you know hit the ball into the outfield it drops it didn't get caught and whoever tried to throw to first base didn't get there in time and the runner was safe three times out of ten do you know what they call a 300 hitter in Major League Baseball good really good you know maybe an all-star you know what they call a 400 baseball hitter that's somebody who hit by the way four times safely out of every ten legendary as in Ted Williams legendary the last major league baseball player to hit over 400 during a regular season now let's take this back into my world of Medicine where I'm a lot more comfortable or perhaps a bit less comfortable after what I'm going to talk to you about suppose you have appendicitis and you're referred to a surgeon who's batting 400 on appendectomy somehow this isn't working out is it now suppose you live in a certain part of a certain remote place and you have a loved one who has blockages in two coronary arteries and your family doctor refers that loved one to a cardiologist who is batting two hundred but you know what she's doing a lot better this year she's on the comeback trail and she's hitting 257 somehow this isn't working but I'm going to ask you a question what do you think a batting average for a cardiac surgeon or a nurse practitioner or an orthopedic surgeon an OB GYN a paramedic is supposed to be 1,000 very good okay now the truth of the matter is nobody knows in all of Medicine what a good surgeon or physician or paramedic is supposed to that what we do though is we send each one of them including myself out into the world with the admonition be perfect never ever ever make a 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 an obsessive-compulsive student in high school classmate once said that Brian Goldman would study for a blood test and so I did and I studied in my little 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 and insertions of every muscle every branch of every artery that came off the aorta differential diagnosis obscure and common I even knew the differential diagnosis and how to classify renal tubular acidosis and all the while I was amassing more and more knowledge and and I did well I graduated with honors laude and I came out of medical school with the impression that if I memorized everything and knew everything or as much as possible as close to everything as possible that it would immunize me against making mistakes and it worked for a while until I met mrs. Drucker I was sort of resident at a teaching hospital here in Toronto and mrs. Drucker was brought to the emergency department at the hospital where I was working at the time I was assigned to the cardiology service on cardiology rotation and it was my job when the emergency staff called for a cardiology consult to see that patient in emerge and to report back to my attending and I saw mrs. Drucker and she was breathless and when I listened to her she was making a wheezy sound and when I listened to to her chest with a stethoscope I could hear crackly sounds on both sides that told me that she was in congestive heart failure this is a condition in which the heart fails and instead of being able to pump all the blood forward some of the blood backs up into the lungs the lungs fill up with blood and that's why you have shortness of breath and that wasn't a difficult diagnosis to make I made it and I set to work treating her I gave her aspirin I gave her medications to relieve the strain on her heart I gave her medications that we call diuretics water pills to get her to pee out the excess fluid and over the course of the next hour and a half or two she started to feel better and I felt really good and that's when I made my first mistake I sent her home actually I made two more mistakes I sent her home without speaking to my attending I didn't pick up the phone and do what I was supposed to do which is to call my attending and run the story by him so he would have a chance to see her mind for himself and he knew her he would have been able to furnish additional information about her maybe I did it for a good reason you know maybe I didn't want to be a high maintenance resident maybe I wanted to be so successful and so able to take responsibility that that that I would do so and I would be able to take care of my attendings patients without even having to contact him the second mistake that I made was worse in sending her home i disregarded a little 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 nurse who was looking after mrs. Drucker do you think it's it's okay if she goes home and the nurse thought about it and said very matter-of-factly yeah I think she'll do okay I can remember that like it was yesterday and so I signed the discharge papers and an ambulance came paramedics came to take 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 carried on with my work and at the end of the day I packed up to leave the hospital and walk to the parking lot to take my car and drive home when I did something that I 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 three words that most emergency physicians I know dread others in medicine dread them as well but there's something particular about emergency medicine because we see patients so fleetingly the three words are do you remember do you remember that patient you've sent home the other nurse asked matter-of-factly well she's back in just that tone of voice oh she was back all right she was back in near death about an hour after she had arrived home after I'd sent her home she collapsed and her family called 9-1-1 and the paramedics brought her back to the emergency department where she had a blood pressure of 50 which is in severe shock and she was barely breathing and she was blue and the emerg staff pulled out all the stops they gave her medications to raise her blood pressure they put her on a ventilator and you know i-i-i was shocked and shaken to the core and and I went through this rollercoaster because after they stabilized her she went to the intensive care unit and I hoped against hope that she would recover and over the next two or three days it was clear 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 they resigned themselves to what was happening at about the nine day mark they let her go mrs. Drecker a wife a mother and a grandmother they say you never forget the names of those who died and that was my first time to be acquainted with that over the next few weeks I beat myself up and I experienced 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 that you feel because you can't talk about it with your colleagues you know that healthy kind when you betray a secret that a best friend made your promise never to reveal and you get busted and then your your your your best friend confronts you and you have terrible discussions but at the end of it all that sick feeling guides you and you say you know I'll never make that mistake again and you make amends and you never make 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 were bad and and it was what I was feeling and you know it wasn't because of my attending he was a doll he talked to the family and I'm quite sure he smooth things over and made sure that I didn't get sued and and I kept asking myself these why didn't I ask my attending why did I send her home and then at my worst moments why why did I make such a stupid mistake and why did I go into medicine slowly but surely it lifted I began to feel a bit better and and you know on a cloudy day there was a crack in the clouds and the Sun started to come out and I wondered you know maybe I could feel better again and I made myself a bargain you know that if only I redoubled my efforts to be perfect and never make another mistake again please make the voices 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 community hospital just north of Toronto and I saw a 25 year old man with a sore throat it was busy I was in a bit of a hurry he kept pointing here I looked at his throat it was a little bit pink and I gave him a prescription for penicillin and sent him on his way and even as he was walking out the door he was still sort of pointing to his throat and two days later I came to do my next emergency shift and that's when my chief asked to speak to me quietly in her office and and she said the three words do you remember remember that patient you saw with the sore throat well it turns out he didn't have a strep throat he had a potentially life-threatening condition called epiglottitis you can google it but it's an infection not of a throat but of the upper airway and it can actually cause the airway to close and you know fortunately he didn't die he was placed on intravenous antibiotics and he recovered after a few days and I went through the same period of shame and recriminations and felt cleansed and went back to work until it happened again and again and again twice in one emergency shift I missed appendicitis now that takes some doing especially when you work in a hospital that at the time saw about 14 people at night now in both cases you know I didn't send them home and I don't think there was any gap in their care one I thought had a kidney stone I ordered a kidney x-ray when it turned out to be normal my colleague who who was doing a reassessment of the patient noticed some tenderness in the right lower quadrant and called the surgeons the other one had a lot of diarrhea I ordered some fluids to rehydrate him and asked my colleague to reassess him and he did and when he noticed some tenderness in the right lower quadrant called the surgeon so in both cases they had their operations and they did okay but each time they were not at me eating at me and I'd like to be able to say to you that my worst mistakes only happened in the first five years of practice as many of my colleagues say which is total BS some of my doozies have been in the last five years alone ashamed and unsupported here's the problem if I can't come clean and and and talk about my mistakes if I can't find the still small voice that tells me what really happened how can I share it with my colleagues how can I teach them about what I did so that they don't do the same thing if I were to walk into a room like right now I'm telling I have no idea what you think of me when was the last time you heard about somebody talk about failure after failure after failure oh yeah you go to a cocktail party and you might hear about some other doctor but you're not trying to hear somebody talking about their own mistakes if I were to walk into a room filled with my colleagues and ask for their support right now and start to tell what I've just told you right now I probably wouldn't get through two of those stories before they would start to get really uncomfortable somebody would crack a joke they'd change the subject and we would move on and in fact if I knew and my colleagues knew that one of my orthopedic colleagues took off the wrong leg in my hospital believe me I'd have trouble making eye contact with that person that's the system that we have it's a complete denial of mistakes it's a system in which there are two kinds of physicians those who make mistakes and those who don't those who can't handle sleep deprivation and those who can those who have lousy outcomes and those who have great outcomes and it's almost like an immunological reaction like the antibodies begin to attack that person and and we have this idea that if we drive the people who make mistakes out of medicine what will we be left with but a safe system but there are two problems with that in my 20 years or so of medical broadcasting and journalism I've made a personal study of medical malpractice and medical errors and to learn everything I can from one of the first articles I wrote for the Toronto Star to to my show white coat black art and what I've learned is that errors are absolutely ubiquitous we live in a we work in a system where errors happen every day where one in ten medications are either the wrong medication given in hospital or at the wrong dosage where hospital-acquired infections are getting more and more numerous causing havoc and death in this country as many as twenty four thousand Canadians die of preventable medical errors in the United States the Institute of Medicine pegged it at a hundred thousand in both cases these are gross underestimates because we really aren't ferreting out the problem as we should and here's the thing in a hospital system where medical knowledge is doubling every two or three years we can't keep up with it sleep deprivation is absolutely pervasive we can't get rid of it we have our cognitive biases so that I can take a perfect history on a patient with with chest pain now take the same patient with chest pain make them moist and garrulous and put a little bit of alcohol on their breath and suddenly my history is laced with contempt I don't take the same history I'm not a robot I don't do things the same way each time and my patients aren't cars they don't tell me their symptoms in the same way each time given all of that mistakes are inevitable so if you take the system as I was taught and weed out all the error-prone health professionals well there won't be anybody left and you know that business about people not wanting to talk about their their worst cases on my show on white coat black guard I made it a habit of saying here's my worst mistake I would say to everybody from paramedics to the to the chief of cardiac surgery here's my worst mistake bla bla bla bla bla what about yours and I would point the microphone towards them and their pupils would dilate and they would recoil then they would look down and swallow hard and start to tell me their stories they want to tell their stories they want to share their stories they want to be able to say look don't make the same mistake I did what they need is an environment to be able to do that what they need is a redefined medical culture and it starts with one physician at a time the redefined physician is human no she's human exception isn't proud of making mistakes but strives to learn one thing from what happened that she can teach to somebody else she shares her experience with others she's supportive when other people talk about their mistakes and she points out other people's mistakes not in a gotcha way but in a loving supportive way so that everybody can benefit and she works in a culture of medicine that acknowledges that human beings run the system and when human beings run the system they will make mistakes from time to time so the system is evolving to create backups that make it easier to detect those mistakes that humans inevitably make and also fosters in a loving supportive way places where everybody who is observing in the healthcare system can actually point out things that could be potential mistakes and is rewarded for doing so and especially people like me when we do make mistakes were rewarded for coming clean my name is Brian Goldman I am a redefined physician I'm human I make mistakes I'm sorry about that but I strive to learn one thing that I can pass on to other people I still don't know what you think of me but I can live with that and let me close with three words of my own I do remember

23 comments

  1. Amazing honesty and from this a culture of improvement can take place if hand on heart every doctor thought like you.

  2. Thanks so much for your honesty, Dr. Goldman. Your point is that docs aren't gods, so why do we expect them to be? I haven't finished watching but I bet you'll share how you believe we need to change the system so that docs aren't so isolated in their work and that they have the support in the system needed to do better.

  3. OMG it is all so true. It makes me work to be a better nurse. What it should really be is that the nurses who are there to support the patient should not point out mistakes after the fact and take credit- but say "hey I think I have something to contribute" often I saw something relevant it made a difference.

  4. Somebody decided to make people watch this video in our Patient Safety class. It was recommended the video be less than 10 minutes. Thanks TEDx.

  5. Dr. Brian Goldman, you can go to the head of the class. I hope you can help the medical culture to improve. Mistakes happen. They should not be covered up. Measures should be sought that prevent errors from happening. BTW: doctors in Canada cannot be sued, contrary to what doctors believe. The CMA and the CMPA crush victims of medical errors and abuse. This helps no one. Medicine needs quality control not coverups and gag orders.

  6. @1bigbucknut You know, you are the very essence of what he was talking about. You can't face your own mistakes, so you go on the attack. I don't believe that NOBODY in your team has make a serious mistake. Maybe you need to speak to them in a bit more compassionate manner than what your post suggests.

  7. I do agree strongly that it is a cultural change that medicine, and to come extent America , needs if we wish to achieve goals of better health and wellness while spending fewer dollars . The rest of the political and bureaucratic mumbo jumbo is wasteful crap…it spends more money and worsens delivery of care.

  8. As a physician I would say that was interesting and perhaps refreshing and timely for lay persons to hear. On the other hand , while we all make mistakes, some of us make them more regularly than others. I am not aware of any of my team who have suffered such numerous and grave errors. I have found in medicine those physicians that struggle often migrate to administrative, consultative or in this case Radio, journalism or the internet. Good for him to go where his strengths lie.

  9. Great talk. Patients need to remember this too. We are all human and the whole system would work better if we all.remembered our fallability. Thanks Dr Goldman.

  10. All healthcare professionals (medical, paramedical, and mental health care) need to watch this. If only the culture of shame would be lifted in these fields, I can't even begin to imagine the immense benefits to patients, physicians, and communities. Accountability and the admission of errors/uncertainties are not weaknesses; they are the cornerstones upon which a healthy community must be based. Dr. Goldman, thank you. This is exactly what is needed to re-inspire trust in our healthcare system.

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