Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: And now, your host, Dr. Sergio Zanotti.
Speaker: In 1999, the Institute of Medicine released a landmark report entitled To Err as Human, Building a Safer Health System.
Speaker: The report stated that errors caused between 44,000 and 98,000 deaths every year in American hospitals and over 1 million injuries.
Speaker: This report was a catalyst for all the efforts we see today in patient safety.
Speaker: The topic for critical matters today is medical errors.
Speaker: It's a pleasure to have as our guest Dr. Nitin Puri, who's Associate Professor of Medicine, Program Director of Critical Care Medicine at Cooper Medical School of Rowan University and Cooper University Healthcare.
Speaker: Dr. Puri is an accomplished clinician and medical educator.
Speaker: He's board certified in internal medicine, pulmonary disease,
Speaker: critical care and neurocritical care.
Speaker: Dr. Puri runs a nationally recognized fellowship program in critical care medicine and works clinically in the medical surgical intensive care unit at Cooper Healthcare System.
Speaker: He has a special interest in medical education, point of care ultrasound, and mechanically circulatory support.
Speaker: Nathan, welcome to Critical Matters.
Speaker: Sergio, thank you for having me.
Speaker: A true pleasure.
Speaker: So today our topic is medical errors, and I wanted to know
Speaker: as a beginning question, how did you get interested in this topic, Nitin?
Speaker: Well, um, I think because I make a lot of errors, so I had to figure out a way to forgive myself.
Speaker: And I figured that you would be an empiric expert as opposed to a theoretical expert.
Speaker: But what else is important about this as you, as it, for you as an educator?
Speaker: You know, um, in reality and also in all seriousness, um,
Speaker: I found myself as a person who has extreme attention to detail when caring for patients and taking care of other people's loved ones, that occasionally errors would be made.
Speaker: And I found myself very frustrated and I realized that I needed to learn more about the topic because
Speaker: I was very interested in improving the quality of care that I provide for patients.
Speaker: And then as I evolved as an educator, I found my trainees on the receiving end of either caring for patients where errors were made or errors they made themselves and seeing their own personal struggle with it made me realize that there was a tremendous opportunity to be able to help both the patients and my trainees.
Speaker: And I think that I trained before the report from the Institute of Medicine came out.
Speaker: I was in training when it came out.
Speaker: And it's very interesting, two decades later, how much has changed and how much has improved, but yet there's still a lot for us to do in this respect.
Speaker: And I hope that we can tackle some of those issues today.
Speaker: So my first question, Nitin, is how would you define a medical error and how is that different from an adverse event?
Speaker: I think that's an important question.
Speaker: I think the best way to define it is to give an example.
Speaker: An adverse event would be, let's say, a blood transfusion that's given to a patient and the patient has a reaction to the blood transfusion but everything was done correctly.
Speaker: That is a non-preventable adverse event, at least with the knowledge that we have currently.
Speaker: Medical error, if I was to again use another example, would be somebody placing a central line, perhaps giving a patient a pneumothorax, you know, was there opportunity around technique, was there opportunity around the site chosen, and that would be a medical error.
Speaker: So a medical error is a preventable complication
Speaker: or mistake that occurred while enacting patient care while an adverse event is a deleterious event that occurred to patients but perhaps not preventable.
Speaker: So in terms of errors and adverse events, clearly both are associated with poor outcomes for our patients in terms of
Speaker: an unexpected outcome, but the real question resides in was there a process error or was it something that could have been differently to prevent that or mitigate that outcome.
Speaker: And I think this is important because it's something that we know is very common in our practices, especially in critical care.
Speaker: Errors are committed either by commission or omission, and I think that it's something that we have to deal with and we have not probably dealt in the best way.
Speaker: Since we've defined medical errors, let's move a little bit forward in terms of how frequent are these really in practice?
Speaker: I recently read a report that cited that medical errors or preventable medical errors are the third cause of death in the U.S. Can you expand on that, Nitin?
Speaker: Yeah, that report has caused a significant amount of controversy in the medical literature and
Speaker: you know, the reason that it's so controversial is that, you know, methodology for obtaining that number, it wasn't that, you know, a large number of medical records were reviewed, medical errors were found, and then that number was extrapolated from.
Speaker: It was taken after analysis of a certain amount of
Speaker: medical literature studies examining errors that were done.
Speaker: And even from the previous to Error is Human, again, that was extrapolation of previous medical literature that was done that, you know, medical errors were a frequent cause of death.
Speaker: The problem is that even with the original report to Error is Human that the Institute of Medicine published, it was picked up by the popular press.
Speaker: And once it was picked up by the popular press, the physicians felt under siege.
Speaker: So the interface of retrospective literature being extrapolated as the cause to show that there's a large number of deaths in the United States caused by medical error then being picked up by the popular press obscured
Speaker: something which is a very important fact going on in America is that many medical errors are made every day in the United States and patient harm is caused and it's very important to address these errors and see what we can do about them.
Speaker: So if you had to throw a number out, what would be the number that people cite?
Speaker: For the amount of deaths caused by medical errors in the United States?
Speaker: Yes.
Speaker: You know,
Speaker: That's difficult to say.
Speaker: I will tell you that the physician safety study that was part of a work-over study that was done at Harvard with a couple of physicians reviewing medical records, that is probably the best literature, I think, about medical errors and that was prior to the institution of electronic medical records.
Speaker: You know, I think percentage-wise, it's tough to define, but, you know, people talk about 200,000 people perhaps having harm or losing their life second to medical errors.
Speaker: I'm not sure if that number is higher or lower because we have the inability to quantify it.
Speaker: And I think that a good point that a lot of people have made, Nitin, is that even though that number of 200,000 comes with some potential risk
Speaker: problems and methodology, it's also likely that medical errors, as we all know, are grossly underreported.
Speaker: I could not agree with you more.
Speaker: But I think that it's fair to say that we all have seen them in our practice.
Speaker: that some people think that it's a leading cause of death in the United States.
Speaker: It's a real problem.
Speaker: And like you pointed out, the real number we don't have right now, but a number that's frequently recorded in the literature is 200,000 deaths from medical errors annually in the United States.
Speaker: So,
Speaker: Let's move to what we can do to improve this from a system level.
Speaker: I think that, Nathan, that we have been trained in medicine, especially in critical care, to be heroes.
Speaker: And I think that medical errors or dealing with medical errors really does not require heroes, but requires a lot of humility.
Speaker: And I think that's been a big...
Speaker: switch in our chip that has been very difficult.
Speaker: Talk a little bit about what you think hospitals should be doing or ICUs at a system level to deal with these medical errors.
Speaker: Yeah, you know, one thing that's happened in hospitals has been the institution of patient safety officers and actually taking a critical analysis of medical errors.
Speaker: You know, the Agency for Quality and Healthcare Research, there has been a significant amount of funding to look at medical errors that started since 1999.
Speaker: And what's fascinating is if you look from 1999 to now to 2018, if you believe the medical literature and the methodology used, there's significantly more errors today than occurred in 1999.
Speaker: I don't think that that's what's occurred, I think we're just more aware of them.
Speaker: And so the institution, again, a patient safety officer, anonymous reporting system, support systems for those when medical errors are made, and honest interactions and reporting to both the medical staff and the patient after an error has occurred, and education about medical errors for the house staff, and attending physicians who may have trained in error prior to
Speaker: acknowledging that you made an error was the correct thing to do is very important.
Speaker: What are considered like the top causes of medical errors according to the literature?
Speaker: So there are two primary things that I think are very important is that one is the failure to implement a plan.
Speaker: I think in the intensive care unit there's much more time spent
Speaker: talking about a plan as opposed to implementing a plan.
Speaker: And I think that clinicians need to be aware of that and actually in a teaching institution now, I think it's important to define the definition of work rounds versus educational rounds.
Speaker: So when I round after making myself more aware of this literature and examining it more closely,
Speaker: I try to use closed-loop communication, a repeat after what I've talked about, that the plan is going to be enacted, that the nurse understands what the plan is, the intern has put in the orders, and that we're all aware what the plan should look like for the day.
Speaker: large cause of medical errors is medication safety events.
Speaker: That has improved significantly over the past 20 years.
Speaker: I think the role of clinical pharmacists on rounds in the intensive care unit, there's pretty good literature to support clinical pharmacists being involved in the delivery of critical care and patient safety mechanisms that exist that made a significant improvement
Speaker: But then you get into the gray area, right, of, you know, somebody's critically ill and the team believes that the family of this critically ill patient should progress to comfort care or withdrawal support and they, you know, are trying to be empathetic.
Speaker: but the patient needs a new IV access and central lines placed and again gives a pneumothorax to a patient.
Speaker: Now, a physician may say, often you hear a physician saying, well, the patient was going to pass anyways and this complication was a part of their course.
Speaker: Don't be upset about it.
Speaker: That's what older physicians may say to younger physicians.
Speaker: But is that the right thing?
Speaker: Is that correct?
Speaker: So again, like you were talking about earlier, and I acknowledged too, perhaps the number of errors are significantly larger than we even recognize.
Speaker: And I think that you touched on a couple of things that I want to dig in a little bit more or reemphasize that are very important.
Speaker: So first, I think that in terms of broad categories, we talked earlier and you mentioned errors of omission versus errors of commission, right?
Speaker: And you mentioned both.
Speaker: So in terms of omission, it seems like, I mean, not implementing a plan as we have outlined or the appropriate plan based on standards of care is something that probably occurs more frequently than
Speaker: Then we report, and I suspect, Nathan, that, for example, if a patient has a cardiac arrest and we say, let's start hypothermia or target temperature management, and they come from the ED, go to the ICU, and there's a four-hour delay in initiating that therapy.
Speaker: We start it late.
Speaker: It's hard to measure the impact of that on patients, but that would be an error, right?
Speaker: That is correct.
Speaker: That is correct.
Speaker: And I think that what's interesting is that my question would be, what is the main cause of that type of error in your opinion?
Speaker: Yeah, you know, um, that's also a very important cause of errors.
Speaker: Um, and, uh, it's, uh, a cause that's gotten quite a bit of, um, uh, press recognition and, uh, you know, the, the implementation of I-PASS, uh,
Speaker: basically a standardized communication tool for handoff.
Speaker: I believe handoff between clinicians also is a major cause of errors.
Speaker: And what it is is that, and this falls in terms of under the failure to implement, is that a decision is made in the emergency room that the patient needs to get targeted temperature management, but
Speaker: the plan has a failure to implement because the clinicians changed from the emergency room up to the intensive care unit and the handoff that occurred was poor or was incorrect.
Speaker: And that occurs daily in intensive care units and hospitals around the world.
Speaker: And trying to create a system of appropriate handoff and closed loop communication
Speaker: is the best way to be able to try to prevent that.
Speaker: And there's good medical literature about using standardized handoff tools to improve communication.
Speaker: And I think that communication seems to be, at the essence, the problem here.
Speaker: And it's interesting with all the advances in technology, we seem to be falling behind in communicating effectively and consistently with our fellow colleagues.
Speaker: But can you talk a little bit about...
Speaker: The closed loop or things that you might implement in the ICU that would help with improving communication between physicians or between physicians and other members of the ICU team, like the respiratory therapist, the nurses, clinical pharmacists, et cetera?
Speaker: Yeah.
Speaker: Yeah.
Speaker: One of the things that seems to make a big difference is at the end of rounds is the, depending on your setting, so I practice in the academic medical center with the multidisciplinary team.
Speaker: At the end of the rounds, we often emphasize our nursing staff repeating the plan for the day for the patient, what was discussed, we summarized.
Speaker: what went on and what needs to be done for the day and then also give our colleagues, our nursing colleagues, the authorization to hold us to test that the plan is enacted and occurs during the day.
Speaker: One of our colleagues came up with a tool called Faster Flag, which is a form of a checklist and I think that that has been
Speaker: an effective tool for us at Cooper to make sure that we hit many of the central elements of care.
Speaker: F stands for feeding, A is for analgesia, S for sedation.
Speaker: That's for both our CAM ICU and RAS scores.
Speaker: T for DVT prophylaxis, E for extubate, talking about the plan of ventilator, R for restraints.
Speaker: are they needed, what are you doing with them?
Speaker: F for Foley, is it needed or not needed?
Speaker: L for lines, number of days of having a line, do you need the line?
Speaker: A for activity, working on a progressive mobility protocol, and G for blood sugar.
Speaker: And so, at least those core elements are reviewed at the end of every patient, and then we talk about the plan for the day, and that's made a big difference.
Speaker: And that's what I mean about close communication is that
Speaker: It's the simple elements that are repeated over and over again on rounds to make sure that we're all on the same page.
Speaker: And I think that it's really about producing reproducible elements
Speaker: systems that recognize that the fallibility of human beings in terms of our behavior, I think that we all agree that none of us want to harm patients, yet on a regular basis, like you said, patients are being harmed.
Speaker: And I think this is something that we have learned from other industries and really trying to be more process-oriented in terms of providing safety.
Speaker: So let's move on to a little bit of another topic within this discussion, Nitin.
Speaker: And once an error has occurred,
Speaker: How do systems or hospitals or ICUs, how should they be handling that?
Speaker: Yeah, that's a great question.
Speaker: I found myself totally unprepared to deal with medical errors when I went out into the workforce in 2011.
Speaker: I...
Speaker: And the reason was is that I perceive myself as an empathetic person, as a caring person.
Speaker: And I also try to treat patients like I would treat my own family members.
Speaker: And when I was
Speaker: When I saw I was part of a medical error, I was unduly harsh on myself and sought to, went through a whole range of motions.
Speaker: First, like, should I speak to the family, should I not speak to the family?
Speaker: How should it be documented in the medical chart?
Speaker: Should it be documented in the medical chart?
Speaker: You know, I'm embarrassed in front of my colleagues.
Speaker: Should I acknowledge this in front of my colleagues?
Speaker: And what I did was, is actually in a large community hospital where I started my practice initially, I initiated and created a morbidity and mortality program.
Speaker: And I think like a lot of physicians who are caring, I would routinely bring up my own cases while my other colleagues would not bring up their cases.
Speaker: I'd discuss them.
Speaker: But what I found is it was making me a better physician.
Speaker: And I would understand errors that I had made.
Speaker: and that I may not realize it had even made at the time.
Speaker: Then, over a period of time, I recognized that when errors were made and I did recognize them, that I need to be able to discuss with patients' families, make sure that they're aware that errors had occurred.
Speaker: And actually, it was a sense of liberation and freedom.
Speaker: I realized that teaching that in education, educating my fellows and how staff about that process today is very, very important.
Speaker: And I think that that's a very important point, Nitin.
Speaker: And I think that most of us were not trained to handle medical errors.
Speaker: We actually were led to believe that it's best not sometimes to disclose or to avoid discussing or bringing them up.
Speaker: But I do believe that, like you said, that the ideal situation is when people are self-reporting with the intention of really improving.
Speaker: And I think that that's the goal at the end of the day that we should all have.
Speaker: And I think that really requires us from taking off our hero caps as ICU physicians and being very humble and recognizing that there's a lot more than we don't know than we do know.
Speaker: And that is likely that we will make a lot more errors in the future.
Speaker: But the goal is to keep improving.
Speaker: Yeah, and there was a, there's some literature from JAMA about speaking to outpatient internists, and I can't remember how old the paper is, maybe 10 years, and the internists were very clear that a majority of the time they would not report their medical error or they would, because they weren't sure that the public wanted to hear the medical error.
Speaker: and that they weren't sure the public would understand the medical error or the patient would understand the medical error.
Speaker: But there's also literature that patients want to know that if an error has been made, they want it to be acknowledged and they want to have trust and confidence in their physicians.
Speaker: The most trusted profession in the United States are nurses.
Speaker: And the reason nurses are most trusted in the position is that
Speaker: Patients and patients' families feel that nurses are advocating for their patients.
Speaker: Physicians are, I think, in the top five, I think number four, but families want to feel that they can trust their position, and an important part of trust in that trusting relationship is acknowledging when mistakes have been made.
Speaker: I think that's a very important point.
Speaker: And like you said, in my read of the literature, what matters to patients are four things.
Speaker: That there's disclosure of all harmful errors they want to know.
Speaker: Number two, that there's an explanation as to why the error occurred with facts.
Speaker: they are told how the effects of the error will be mitigated or will be done by the doctors to minimize the effects of the error.
Speaker: And I think something that's very important, even when outcomes are very, very poor, is they want to know what steps the physician and the institution will take to prevent a recurrence of the same error.
Speaker: And I think that that's something that we sometimes underestimate how important it is for patients.
Speaker: Any comments from your standpoint on that, Nitin?
Speaker: You know, my only comment about that is that I would acknowledge another piece of literature that exists about the moral distress that providers feel about medical errors.
Speaker: And unless they understand these basic facts that you just brought up,
Speaker: they will not have the tools to be able to deal with medical errors going forward.
Speaker: I think it's a vital part of medical education, both for trainees and physicians who are practicing.
Speaker: Because what are we all worried about at the end of the day?
Speaker: We're all worried, well not all worried, but I can tell you it's in the back of my mind.
Speaker: I worry about getting sued, right?
Speaker: Acknowledging to a family, I made a mistake, I'm gonna get sued.
Speaker: My trainees are worried about that all the time too.
Speaker: that gets in the way of the delivery of care.
Speaker: And I think that that's a very complex topic, the interaction of medical legal liability and having a therapeutic and trusting relationship with patients' families.
Speaker: And I think it's pretty clear that acknowledge medical errors are made, families are going to have more trust and more belief in you that you're going to do the right thing for
Speaker: And I think that my interpretation of the literature is regarding the risk of litigation.
Speaker: Obviously, it's a real concern.
Speaker: When you disclose an error, it's a real possibility.
Speaker: But in hospitals or in systems like the University of Michigan, where they really have an open disclosure, a very aggressive way of telling patients about all the errors that occur,
Speaker: What they found is that litigation goes down and the cost for litigation goes down when people are very open and very clear and very honest with patients.
Speaker: And I think that in general, what has been shown to decrease the likelihood of litigation is communication with families and being straightforward of what's going on with them.
Speaker: Any comments on that aspect?
Speaker: No, no, I couldn't agree with you more.
Speaker: I think that the literature does support that having an honest, open, therapeutic relationship with families decreases the incidence and likelihood of litigation.
Speaker: And also, you know, remembering why you became a physician, having empathy for the patients and their families when errors are committed.
Speaker: and being able to communicate that with family is very important.
Speaker: Absolutely.
Speaker: I think another aspect that I wanted to ask you about disclosure has to do with, do you think that we should apologize to patients for what has happened when we disclose an error?
Speaker: I apologize to patients.
Speaker: You know, it matters on the...
Speaker: significance of the error.
Speaker: I think errors have different categories.
Speaker: there was the study at Hadassah again I can't I apologize I can't remember the years but I think now it's probably 15 to 20 years old looking at medical errors in the intensive care unit and using human factors as a role for preventing medical errors and you know the categories errors is you know different types is less serious to more serious and causing patient harm or not causing patient harm I think if you know you missed to replace a potassium
Speaker: and there's no medical error, no harm caused, it's probably not a lot to talk about with the family as opposed to you didn't replace potassium and they had a cardiac arrest.
Speaker: Then I think you need to acknowledge that the mistake was made and you need to make an apology and you have to rely on the basic human instinct of forgiveness.
Speaker: Because the person who's going to be hardest on you is yourself, right?
Speaker: Not the family's at the end of the day.
Speaker: Absolutely.
Speaker: What about documenting the chart?
Speaker: What are your thoughts on that?
Speaker: That's a good question.
Speaker: I know everyone's instinct is to not document in the chart or not acknowledge an error was made or use purposely vague language.
Speaker: I don't think that's right.
Speaker: I think that if an error is made, you need to acknowledge you made an error.
Speaker: And then those going forward need to recognize that an error was made
Speaker: and be able to treat the patient going forward because critical care is a team sport.
Speaker: It's a 24-7 process.
Speaker: And so everyone needs to understand what occurred, why it occurred, and how it was dealt with to be able to move forward.
Speaker: Otherwise, those problems could linger.
Speaker: Yeah.
Speaker: And I think that if one does a good job disclosing to the patient or the family the chart documentation to just reflect that conversation.
Speaker: And I think it should be factual and relay what was told to the family and the patient.
Speaker: And I agree that we have an obligation to the patients to disclose the errors.
Speaker: But also, I think we have an obligation to our colleagues to document in the chart what has happened so that they can take that into account when treating the patient.
Speaker: I think, Nitin, that we covered a lot of very important topics.
Speaker: Clearly, we talked about the prevalence of medical errors.
Speaker: We talked about how we define them, some of the causes, how we should be disclosing them to patients, what's important for patients, and some of the things that systems should be looking at.
Speaker: But there's one thing that you mentioned that I would like to dive in a little bit more, which is the topic of moral distress for the provider.
Speaker: And often providers are considered second victims in these errors.
Speaker: And if you review this in the lay public,
Speaker: literature, there are very extreme cases of nurses who have committed suicide, doctors who have committed suicide after significant errors and after being publicly denounced for their errors.
Speaker: So clearly those are extreme cases, but I think that there's many more of our colleagues who are suffering in silence.
Speaker: Can you talk a little bit about this moral distress and the provider as a second victim?
Speaker: Yeah, this is very, very powerful when you're speaking about Sergio, especially I'm in the process of our, I currently, you know, are training critical care and public critical care fellows at Cooper.
Speaker: Providers, and we're humans, we make mistakes.
Speaker: That is the title of the 1999 report.
Speaker: To err is human.
Speaker: Errors don't occur secondary to
Speaker: medical providers, errors occur secondary to faulty systems.
Speaker: That was the point of the report.
Speaker: And weaknesses in the systems need to be analyzed, need to be improved.
Speaker: You need to do root cause analysis.
Speaker: You need to really understand why the error occurred and how you can improve the system.
Speaker: And providers will make individual mechanical mistakes if I'm placing a line.
Speaker: To suffer in silence is very dangerous and it's important that critical care providers have somebody to talk to.
Speaker: That's also part of the reason we try to work with them, to be able to speak with families and be able to be honest with them.
Speaker: Because, I'll be honest with you, even if, let's say, you were to suffer litigation because of a medical error you made,
Speaker: or because you were involved in medical error where the system failed you.
Speaker: At the end of the day, you have the ability to say, I was honest and I did my best.
Speaker: And I think that being able to be free of the burden of not feeling that you lied to anyone, not feeling that you deliberately covered a medical error is a tremendous relief on everyone's shoulders.
Speaker: And again, the literature supports this.
Speaker: Trainees, when they make errors, suffer significant moral distress and they need an outlet to be able to talk about it.
Speaker: And that doesn't change when you go into practice.
Speaker: Actually, in reality, it likely becomes worse because your outlets to be able to communicate becomes significantly less and less.
Speaker: And clearly, there's a great correlation with this type of moral distress and burnout, which is a topic that's very prevalent in critical care and in medicine in general.
Speaker: what do you recommend as outlets or, or things that we could implement outside of the context of a training program?
Speaker: Uh, you talked a little bit about what you did in your first job, but can you comment on that a little bit more Nitin?
Speaker: Yeah.
Speaker: Um, you mean outside of medicine or specifically within medicine?
Speaker: No, within the ICU, within medicine to deal with, um, providers, uh, and their, their, their relationship to medical errors.
Speaker: Yeah.
Speaker: I will tell you, um,
Speaker: There are a few things that I think are pretty important.
Speaker: I believe the culture you have in your intensive care unit is very important.
Speaker: I was trained by some very good physicians, Dr. Dellinger, you, Sergio, and a couple of other providers who created an environment of understanding and empathy.
Speaker: So when errors were made,
Speaker: They were not viewed, I was not viewed as an outlier or as a bad physician.
Speaker: I was viewed as somebody who was a trainee who made a mistake.
Speaker: And I think that that's very important.
Speaker: The culture that people are trained in or the culture which you practice in cannot be a vindictive culture.
Speaker: It has to be a supportive culture.
Speaker: So I think that's number one.
Speaker: Number two, there has to be the ability to exist for anonymous reporting systems, which I think many hospitals in the United States have today, where you can acknowledge an error was made.
Speaker: You don't necessarily have to say that you're the person who's acknowledging it and that people have the ability to go back and review the error by a third party.
Speaker: Number three is there has to be a support system for both the physicians, the nurses, or any clinical provider once errors have been made to be able to talk about it in a non-threatening environment.
Speaker: That goes back to number one, the supportive culture.
Speaker: But then there actually has to be the mechanisms in place besides
Speaker: physician who supports you, but whether it's the ability for employee assistance program, access to psychologists.
Speaker: But mental well-being is very, very important and it's the key to us being able to deliver good care because psychologically you've got to be in good place to be able to deliver good care to the critically ill.
Speaker: I think that we've touched on some very important topics.
Speaker: There's obviously a lot more to talk about, and we might do that in future episodes.
Speaker: But I think this is a good place to close, Nitin.
Speaker: And on critical matters, we usually like to finish with some questions that are not directly clinical but related to the practice of critical care.
Speaker: Would that be okay for you?
Speaker: That would be part of the question.
Speaker: So the first question, Ethan, is what book or books have influenced you the most or what book have you gifted most often to others?
Speaker: So currently, most of the books I give to others are storybooks for my little kids.
Speaker: So I'm
Speaker: I would assume these would be gifts that I'd give to adults.
Speaker: Often I found myself giving, in this current era, Harun and the Sea of Stories, a book by Salman Rushdie, where Rushdie wrote that book when he was under fatwa from the late Ayatollah Khomeini, and he wrote about the power of story.
Speaker: and There's a real famous quote from that book.
Speaker: What's the use of stories that aren't even true?
Speaker: And that's always stuck with me because in that book Rushdie who's made his life as a storyteller Defends the story and how important it is to life my favorite my favorite book is
Speaker: though is the book that opened my mind the most or still had the most impact on me was Invisible Man, which I read as a teenager and then reread about a decade later and it kept with me at all times because much like medical errors, it's when you don't acknowledge
Speaker: that there's a problem, it can erupt into a much larger problem.
Speaker: And so Ralph Ellison, I think, is one of the great writers of the 20th century.
Speaker: Absolutely.
Speaker: I think two excellent books.
Speaker: And I think that it also illustrates that there is much to be learned from fiction and that at the end of the day, we learn through stories both in life and in medicine.
Speaker: So we'll add links to these two books in the show notes.
Speaker: Nitin, second question.
Speaker: What do you believe to be true in medicine or life that most other people don't believe?
Speaker: I think doctors know this.
Speaker: It's a famous quote from my mother to me in my own mind when I was struggling through medical school.
Speaker: She said to me, Nithin, I know many physicians who are much less intelligent than you.
Speaker: When I was saying that, I wasn't sure if I could make it.
Speaker: And I think to be a good physician, you need to be detail-oriented and you need to be able to focus.
Speaker: But it's not necessarily about your potential or your IQ.
Speaker: It's about following through on tasks and
Speaker: And again, like I'm saying, just be detail-oriented.
Speaker: So my point about that is I think the lay public sees intelligent physicians as very, very intelligent people or physicians as sort of stalwarts of society and what I view them as is people who are disciplined and are able to provide care for members of society because they have attention to detail.
Speaker: And I think to some extent, attention to detail for patient care is really caring about that human being and the dignity that they bring to the table, making sure that you're treating them like you said earlier, you would treat somebody who you love.
Speaker: I think that's very powerful and very important.
Speaker: So my last question, Ethan, what would you want every intensivist to listen to this podcast to know?
Speaker: To me,
Speaker: The most important part about this topic is as trust sort of erodes in institutions that historically have sort of been the pillars of Western society whether it's the news media, whether it's elements of the American military,
Speaker: I think medicine is not invulnerable to those concerns and it's happened already.
Speaker: The more money is spent on homeopathic medicine than I think allopathic medicine.
Speaker: And I believe that if we're not honest with our patients about mistakes we make or about our own failings,
Speaker: then they will lose trust in the medical system.
Speaker: And I think that would be a tragedy for modern humanity.
Speaker: And I think that's a great place to stop, Nitin.
Speaker: I think that we as a society would not accept the level of errors in other fields that are occurring in medicine.
Speaker: And when we're dealing with people's life, that is something that I think that we should really ponder and correct.
Speaker: I agree.
Speaker: Well, it's been a great pleasure, even though the topic obviously is a tough one.
Speaker: But I think that the message, Nathan, is that we should be aware that this is real, that we should own it, and that we should find ways to make it better for the providers, the patients, and make sure that we are very straightforward and honest.
Speaker: And at the end of the day, that the real goal is to provide the best patient care and for us to keep improving as physicians.
Speaker: Any other parting thoughts?
Speaker: I think a moral from the aviation industry, I don't want medicine to exactly replicate the aviation industry because it's sort of painful to fly, but this past month was the first death in nine years in a domestic aviation
Speaker: industry or accident and the domesticated ammunition industry that how amazing would it be if we could get medicine to go down that route and what what do we need to do to get there that's that's that's the challenge for your listeners what do we need to do to get there and I think that challenge accept it and we'll
Speaker: touch base soon again to talk more about more topics related to critical care.
Speaker: Nitin, it's been a pleasure.
Speaker: Thank you so much for your time and look forward to talking with you again.
Speaker: Hey, thanks, Sergio.
Speaker: You take care of yourself.
Speaker: Thanks again for listening to Critical Matters.
Speaker: Make sure to subscribe to this podcast on iTunes or Google Play.
