Coming Out as Human

How could anyone succeed under these circumstances? How could this woman’s life depend on my ability to achieve impossible things?

We’ve gotten really good at making the impossible look easy. We all know that it’s not, but no one else does unless we tell our stories.

It is madness that our patients’ lives depend on us accomplishing impossible things every day. It is madness that we sacrifice ourselves in the process. We can and we must do better. It’s time to shift the paradigm. Our humanity is our strength, not our weakness.

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Telling stories to FIX things.

Yesterday I walked onto the FIX18 stage and gave the talk of my life. After riding the creative writing rollercoaster for the last year and getting by with a lot of support from my raft of otters, I did it! I was buoyed by the kindness of the room and then walked right out to Central Park with a full on vulnerability hangover, where I sat on a rock a sobbed. My soul was exhausted and fulfilled. It was transformative and indescribable to share my truth, and to be seen and heard and affirmed in that space. It was even more amazing to hear that my story reached many others in a meaningful way. That brings me so much joy!

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I am rooted in gratitude for the many, many, many people who held me up and helped me tell that story yesterday. It was a labor of great love, requiring many tears, many tissues, a lot of chocolate and a very wonderful team on both the family and professional fronts. I’m grateful for everyone’s patience and kindness with me as I struggled through the creative process.

I look forward to continuing to share this talk with you through the video that was recorded and through a blog post to come. For now, please read Audre Lorde’s words from the Transformation of Silence into Language and Action. When I first read it, I was struggling with how to put my talk about “Coming out as Human” into words – to take all my big feelings and my lofty ideas and put them into a story that made sense. I read that essay and I thought “Ah-ha! She did it! She already wrote my talk!” And then I wrote my talk. Thank you to Audre Lorde for writing her big feeling and her lofty ideas down so that I could read them today.

The whole FIX18 conference was wonderful. My soul feels rekindled. I connected with colleagues near and far. It was delightful to spend time with folks that I see frequently online but so rarely in real life, and to enjoy the time in their presence. I am also exhausted. I have been trying to drink from the firehose for the last 2 days and it was overwhelming.

I am still very angry.

Different people have different feelings on rage: some think it’s dangerous and to be suppressed, some embrace it. Rage is complex. I am a proponent of productive rage. My rage comes from a good place. My rage is nonviolent. My rage is loving. My rage comes from a place of knowing that we have the tools to do better than we are doing. Of wanting more from us. My rage is impatient. My rage doesn’t understand why there is preventable suffering in the world when we have so many tools that we could use to fix it.

I spend a lot of time alone, raging into the void. I spend a lot of time raging about lofty ideas about changing the culture of power in medicine. One of my favorite parts of FIX18 was meeting real live humans who said they appreciated what I write and that it is meaningful to them. That brought me so much joy. Ego aside (it’s always lovely when people say nice things!), writing is quite lonely. Twitter is fun but can get a bit intense. To know that something I wrote brought joy or meaning to someone makes it all worth it. Thank you for sharing that moment with me.

Back to the void - I do love talking about lofty ideas, like how we need to shift from focusing primarily on knowledge translation in medical education towards sharing collective wisdom. How we need to break down our professional silos and be more interprofessional to truly work as a team and serve all patients. About how we need to fight the systemic societal and economic injustices and biases that keep medicine as an ivory tower instead of a profession that reflects our communities. About how gender bias is exhausting and how we need men to speak up, too, and do some of the heavy lifting around here. I believe that we can create professional spaces that focus on wisdom and knowledge, that reflect diversity and inclusion, that advocate for justice and equity, that encourage authentic and transformative leadership.

So why don’t we have those spaces? I raged on Twitter recently in response to some thoughts about how ACEP is an EM conference that I don’t participate in because it doesn’t fit any of those criteria. Some responses fit into the model of excuses about why that’s so hard.

Well, FIX did it. Last year was great. This year was amazing. Next year, lessons will be learned and things will continue to grow.

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Fix Speaker Eva Niyibizi said “If you need something and it doesn’t exist, create it.”

We needed this space. We created it. The organizers literally created the space, and everyone who spoke, attended, and participated created the space. We made this.

Pik Mukherji wrote: “#FIX18 is like Lilith Fair. At first they said it was good for female groups. Within a few yrs. they said it was good for music. We'll look back and notice that #FIX18 was good for EM.”

FIX shows us all what is possible in our profession, and then also serves as a call to action. We can do this. We need to do this.

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We’re all hungry for this. I’m exhausted because I was so hungry for this, I got overwhelmed in my rush to take it all in. I want this to be my every day. I want the ideals of justice, equity, collaboration, curiosity, respect, diversity, authenticity, and shared humanity to be the ideals valued in my workplace, and in my profession at large.

Not every professional conference needs to be exactly like this one. But we need to create spaces where we can belong. Where we can tell our stories. Where we can safely break our silences. Where we can share the collective wisdom of the tools and resources that worked for us so that others can use them, too. Where we can both support and challenge one another to grow. Emergency physicians of all genders are hungry for this. I imagine all physicians are. I imagine our interprofessional teams of nurses, physician assistants, nurse practitioners, pharmacists, paramedics and social workers are hungry, too.

We need more spaces like this one to tell our stories. We need more of our existing spaces to become like this one. We’ve seen what’s possible. The bar has been raised. Now it’s time to fix things.

Doubt.

"Jesus came and stood among them and said, “Peace be with you!” Then he said to Thomas, “Put your finger here; see my hands. Reach out your hand and put it into my side. Stop doubting and believe.” John 20:26-27 New International Version (NIV)

Content warning: sexual assault, death

I’ve been deeply troubled this week by the evolving allegations of sexual assault facing Judge Brett Kavanaugh, and by the response of the U.S. Senate in response to those allegations. As a woman, a physician, and a Christian, I’ve been thinking about wounds and doubt. Dr. Jessi Gold wrote about how we shouldn’t have to be opening our wounds to prove that things happen. Dr. Esther Choo wrote that "The onus for changing male behavior and societal norms should not be placed on women.”

And yet. I watched a nurse from Boston stand in the Russell Senate Building and tearfully recount what it felt like to be choked and raped. “For God’s sakes, for all the boys, girls, who have been assaulted over the years, for God’s sakes, when will you stand up for the American people? For democracy?” In posting the video, Helen Brosnan noted that "We are at a moment in history where women have to repeat their trauma to the masses to literally beg Senators to vote with moral clarity.”

I am reminded of the “Bring the Dead” protest during the AIDS epidemic, when families brought the ashes of their loved ones that died from AIDS and poured them on the White House lawn in a desperate attempt to get more funding for research into treatments. I cannot watch that scene without my heart breaking, over and over again. “How to Survive a Plague” documents the work of Act Up during the early HIV/AIDS epidemic. Their activism helped expedite the discovery of AZT as a drug to fight the HIV virus and helped bring that drug to the patients who needed it. They bared their wounds to save their lives, and to some extent, it worked.

Everyone telling their #metoo stories and #whyididntreport stories are baring their wounds, too. We tell our stories in order to live.

Reach out your hand. Stop doubting and believe.

As an Emergency physician, I treat wounds of all kinds. I have repaired hundreds of lacerations, splinted broken limbs, put salve on burns, and put ice packs on bumps and bruises. But I also see many less visible wounds that need just as much care. When survivors of sexual, emotional, or physical abuse tell me their stories, I do my best listen and provide psychological first aid. I say, “I hear you.” I say, “I believe you.” I do my best to connect them to the acute and long term therapeutic resources needed to heal those deep and painful wounds.

Wounds need to be recognized in order to heal. Wounds need to be cared for. As we care for physical wounds, we know that any time we change a dressing to clean and nurse a wound, it may be very painful. We do our best to prepare by minimizing unnecessary exposures and exams, treating pain, and doing only what is necessary to help the wound heal.

The same is true for psychological wounds. When a patient comes in to the Emergency Department after a sexual assault, we do our best to avoid having that person tell the story of what happened multiple times to avoid worsening the trauma they’ve already been through. When we have to deliver bad news about a new cancer diagnosis or a family member’s death, we prepare just as we would for a complicated procedure. We know that people may remember what we say for the rest of their lives, and we do our best to honor that gravity of that moment.

Some wounds heal with barely a scar, and we may never think of them again. Some wounds - physical or emotional - never fully heal. Those wounds become a part of who we are. It’s essential to acknowledge their presence, soothe them, and care for them, regardless of how they got there. The process of justice is distinct from the process of healing, but not completely separate. Justice is about accountability. Accountability starts with acknowledging the truth and believing in those wounds.

As I watch Dr. Christine Blasey Ford, Deborah Ramirez, and Julie Swetnick come forward with credible, substantiated allegations of sexual assault against Brett Kavanaugh, I also watch those in power do their best to shame, blame, and discredit those women. I am particularly appalled by the hypocrisy of those who purport to be faithful Christians in order to gain political power, but then use that power in a markedly unchristian way. As the Catholic church that Judge Kavanaugh is a member of, and the faith community I grew up in during my childhood in Washington, D.C., experiences a sexual abuse crisis of it’s own, it is all the more imperative to create systems of mutual respect, transparency, and accountability.

Sadly, the stories of these women are embroiled in a very high-stakes political challenge timed closely with the mid-term elections, so much of the rhetoric surrounding these cases that is so deeply about them is also not at all about them. It’s about the fear of losing political momentum and power. All the more reason that these allegations should be investigated by a more neutral party like the FBI to determine what happened in the 1980s and to add clarity on what justice and accountability look like today.

Beyond what happens in the Senate this week, survivors cannot be expected to bear their wounds in order to change a culture that shirks accountability for those who inflicted them.

Stop doubting and believe.

You are not alone. Confidential help is available for free from RAINN.

Call 1-800-656-4673 or go to National Sexual Assault Hotline

Free. Confidential. 24/7.

Systems thinking

I'm continually surprised by how much of our safety culture in health care is one-dimensional. How can we expand our minds to incorporate systems thinking?

Freshman year in high school math, we read Flatland, an 1884 novella about Victorian culture and geometry. The narrator lived in a two dimensional world. The story revolved around his experiences meeting people from the one dimensional world of Lineland and the three dimensional world of Spaceland. The memory that sticks with me almost twenty years later is the perspective of the characters when confronted with evidence of the other dimensions. Just as the inhabitants of Lineland struggled to comprehend how something could move in two dimensions, the inhabitants of Flatland had trouble understanding how a third dimension worked. 

 The two dimensional square looks down upon Lineland.   

The two dimensional square looks down upon Lineland.

 

After reading this story, the idea of a fourth dimension made more sense to my teenage brain. By putting myself in the perspective of the square, I could imagine more clearly the limits of my awareness and ponder what else could be out there.

 The three dimensional sphere moving through space: a mind blowing concept for the inhabitants of a two dimensional world.

The three dimensional sphere moving through space: a mind blowing concept for the inhabitants of a two dimensional world.

In medicine,  systems thinking is our fourth dimension. In medical school we learn to do a history and physical exam with one patient. As residents, we learn to manage a team of patients. We start to realize the limits of our individual abilities - medicine happens in a complex system with many factors outside our immediate control. As attendings, we learn how to see the systems behind our care and work to improve them.

Yet when something goes wrong, we fall back to the one dimensional patient-provider interaction. Mortality and morbidity conferences or malpractice cases usually focus on the actions of individuals instead of on the complex interworkings of the systems of care. The Root Cause Analysis process often falls short of finding systematic root causes. Ultimately, this approach limits our ability to improve care. Until we recognize and analyze the strengths and weaknesses of our systems, we can't improve them to provide better and safer care.  

Watch this 3 min Animation on Systems Thinking in health care incident investigation from the Systems Thinking Lab for an overview.

 Systems Thinking: the fourth dimension of health care. 

Systems Thinking: the fourth dimension of health care. 

Many folks in medical education and patient safety are expanding on our mindset to incorporate systems thinking. Bon Ku runs the Health Design Lab at Jefferson University. Martin Bromiley runs the Clinical Human Factors Group, a charity inspired after his wife died from a medical error. Steven Shorrock blogs at Humanistic Systems about "views on human factors, systems and safety from the perspectives of humanistic thinking, systems thinking and design thinking."

It is imperative that we push the limits of our awareness to incorporate systems thinking. Once we do, we can create meaningful improvements that cause lasting change, bringing joy to our work and justice to our patients. 

Onward. 

Injustice in the U.K.

I started this blog to talk about finding joy through justice in medicine. This week, news from the U.K. about the case against Dr. Bawa-Garba highlights to great challenges we face as a global society in seeking that justice. The outcomes in the case should be troubling to physicians and patients everywhere.

Many folks working in the NHS have written eloquently about this story: 

Don't Forget the Bubbles: "Can we blame individual doctors for an outcome that has occurred in a working environment that no sane person would find acceptable? "

New Statesman: "I know of no colleague who hasn’t reacted with the thought: 'There but for the grace of God go I.' "

 54000 doctors: "As a father and a doctor I have no choice but to accept that I too could find myself being on either side of a terrible NHS mistake. We have to face facts that as a society we are making choices that will make such mistakes more likely to occur."

Patients and healers alike should be outraged that a child died and outraged that another child's mother was scapegoated and punished for it.

Unfortunately this is not an isolated example. Broken systems and a culture of blame are problems in health care worldwide. We need to do the work to build a learning culture in medicine, where we can confront our failures head on and fix the broken systems we all struggle with. A culture and a society that blame and punish individual actors doing their best will only prop up those broken systems, break those working there, and fail the patients we are meant to serve.

Failure

Healers hate failure. It feels awful - physically, emotionally, and intellectually. When we fail, people get hurt. We hate hurting people! Sometimes we hide from our failures because the knowledge that we hurt someone is too much to bear. But if we don't figure out WHY we failed, we'll fail again. How can we shine a light on failure in a productive way?

I love this video from Sidney Dekker on failure.

Reactions to failure get in the way of understanding failure.
You can either learn or blame. You can’t do both.

In simulation, we often talk about the Advocacy Inquiry debriefing method as a way to learn instead of blame. I find this communication tool tremendously helpful for discussing failure in a psychologically safe and productive way. This helps me get from blame to learning. 

Confronting our failures helps us restore joy through justice.

We are human.

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People make mistakes. That's an inescapable reality. Choosing how we react to our mistakes is another matter entirely. 

What did you do the last time you made an error? How did you feel? How did your organization react?

In 2013, UCSF Children's Hospital gave Pablo Garcia a massive overdose of an antibiotic. This is a world renowned institution. Their staff represent the best and the brightest in health care. How could this happen? After the incident, Bob Watchter published the details of this error and wrote about the many root causes identified. That story illustrates many aspects of how just culture applies in medicine. 

As you read Watcher's story, think about whether the reaction shows retributive or restorative just culture.

A retributive just culture asks: Which rule is broken? Who did it? How bad was the breach, and what should the consequences be? Who gets to decide this?

A restorative just culture asks: Who is hurt? What do they need? Whose obligation is it to meet that need? How do you involve the community in this conversation?

-Sidney Dekker

In this article, we see several victims. There are the first victims - Pablo Garcia and his family, who were harmed by this error. They were hurt and their needs must be addressed.

There are also the second victims - the resident who ordered the medication, the pharmacist who filled it, the nurse who administered it. None of those second victims came to work and said "I'm going to hurt someone today." They were all doing their best in a broken system. They were also hurt. 

Retributive justice serves neither first nor second victims. Restorative justice seeks to heal both. A restorative just culture shines a light on suffering, takes responsibility, and makes amends.

We can restore our joy through justice. The journey is long, the path is murky, but if we continue to hold up the light and keep moving, we'll get there. 

Onward.