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2012 YP Award Essay 4
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2012 Winner - Essay 4

The Doctors Company Foundation Young Physicians Patient Safety Award


The 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. She’d 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 baby’s size, she snapped, and she should’ve 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. I’d 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 don’t 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, I’d been involved in patient safety/quality improvement. I’d met leaders, participated in projects, earned certifications, and founded the Baylor interest group. I’d been an American College of Medical Quality (ACMQ) Scholar and served on national leadership for ACMQ and Institute for Healthcare Improvement (IHI). I’d 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, weren’t functional. They wouldn’t help students identify/prevent errors in clinical care, wouldn’t 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. I’ve 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 I’ve built connections with hospital leadership to safety culture awareness within departments and clinical teams.


In all of this, I’ve 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 couldn’t sense my humanity pressed against hers—afraid of the moment, but present. I wish I could share the exciting things I’ve learned since, emphasizing how powerfully they’ve 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.


*Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.


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