Online with doctor Danielle Ofri. St. Louis oldest bookstore is turning 51 years this year we would like to thank all of our supporters, and everyone for the outpouring of love for our bookstore. With the Current Situation are still bring you the things you love most with terms like a pickup and delivery to anywhere in the world are series are virtual we have a way to expand your mind and bring new thoughts to make the world a better place bird we hope you enjoy this event we hopefully will purchase a copy for you and all of your friends. We went to keep our books and staff here so thank you so much for your support. We will taking questions from the audience if you type your questions in the comments and everyone on facebook be sure to like us you can see whats coming up. Can also comment on the watch party 70 here and watching. People go into the medical system they go there thinking its the best place possible. They made enormous strides for suffering but theres also no doubt that treatment can cause harm. A significant portion is preventable. We do harm when theres a medical error and Patient Safety in our National Healthcare conversation. We also want to look at administration, patients, families exploiting the diagnostic, systemic, cognitive issues of medical error to advocate for strategic groups that comes to safety improvements to the Electronic Medical record that focuses on the fullscale required to make eight meaningful dents and medical error. There are stories she is renowned for these errors not everyone argues is possible to minimize and this should be a galvanizing issue. What makes this book special is perceptive and compassionate nature. She portrays them as real people and showing their vulnerability. Its analysis of a challenging problem with a personal touch. Its an essential read for anyone involved her interested in patient care. Danielle ofri is a critical professor with the school of medicine cares for patients for more than two decades. Shes authored seven books in colluding what patients say, what doctors here. What doctors feel doctor Danielle Ofri is a regular contributor to the New York Times writing can be found on twitter shes been working in the covid19 and experience she has shared in the New York Times. Also joining us tonight is doctor damon tweedy. Im very happy he is here tonight especially now we should be looking at the root of the healthcare industry. Doctor damon tweedy is Duke University law school is at the Medical Center and has a staff position varies published articles about race and medicine and the American Medical Association in the annals of internal medicine. His comments have appeared in the New York Times, patient conduct reviews observer. And now im very happy and thankful and would love to welcome doctor Danielle Ofri and doctor damon tweedy. Everyone at home would give them a very hearty welcome round of applause. Thank you. Its great to me to it doctor Danielle Ofri as a fellow physician i have admired your work the breath the you write about i just want to say thank you its great to be with you. Thank you. Host we will start off with why this book . We are going to talk about covid19 and disparity. But we will open up the session more broadly at the beginning to talk about your book so why this book and why now . Guest the only physician in a Publishing House full of english majors you seem to get everybodys questions about medical issues. The couple views of the set mean email and had a study with headlines saying medical errors was the third leading cause of death. When i read that email i thought is this really true . And i have to say i didnt know the answer i hadnt read the study and i didnt know but. Byfield is true i would face that every single day it doesnt feel like i do. Then i wondered are the data wrong . Are they correct them are simply blind to it . In some trying to answer that question and i start began digging into the data. First of all the hard question to answer. So on a death certificate they dont write medical error. So counting the numbers of errors is very difficult. And if its an error cause of death is even higher. Like someone is dying of cirrhosis and is dying and gets an antibody is that the air in the patients death that peaked my interest. Host we see that in our setting, how does it come about that idea that theres a cause of death . Its so hard to track, how did it come up . Guest in fact it really went back to previously published data in that involves taking data from smaller sets and multiplying it out to the whole population. So if there is even a slight error in the study it gets multiplied out for people then its magnified. It was a calculated and predictive study. Seem to be taken after Heart Disease and cancer. So its probably not that high but its also not that low. But we certainly know many errors occur. And even if is not a cause of death was so important to find because its the next thing waiting to cause harm. Even if we dont know the exact number we need to dive in and theatrically make healthcare overall safe and minimize errors periods. Host its hard to keep track of it from a long time doctors certainly talk about it but your recent book talks about how 20 years ago there is a study that sort of landmark study i guess its more about the history of how hard it is for doctors to talk about and the difficult data. Sure if you think about why would doctor ever talk about an error they made . And our country open yourself up for a lawsuit. But even beyond that issue is just the emotional part. Most people in medicine healthcare they certainly see that now, so if youve done something even inadvertently to harm your patient were devastated we dont want to talk about it. And particularly the near misses or the air and affect doctors in my midst someone told me a cat scan report was fine and accepted that before looking at it myself my air was clear i did not look at the skin is a should have. The patient was fine the fact isnt near miss. Its still an error patient could have been dead were lucky nobody died. The error was still there. What interested me was my reaction patient did fine why say anything i didnt tell my resident i didnt tell my intern and i sure didnt or their family and could not imagine a more horrible thing to tell a patient i almost killed you and took me a long time to think about it. You also think about the emotional side to keep errors hidden all of these errors underwater. We dont know what they are hackley possibly fix them . Sounds like your describe it as you assume youre going to the assume certainly went to help everyone to be smart and conscientious mummy assume theres the same part and a lot of this. There is guilt and shame i didnt really understand the difference between them. And i read this cold and fun apology. It was about guilt and shame and what happens. Its you dont make the error again. Its about you not be the person you thought you were pretty when i made this error i felt bad about i swear would never do it again with the shame in one second i was not the doctor thought it was. So i thought of as good as my peers in that was light came crashing down and i thought im a danger to the patient i better quit now and i realize that was paralyzing and prevented me from talking about it and from sharing it to help doctors and the patient and correcting errors because that shame is overpowering i was sure i had made many mistakes that could have been prevented. See when you also talk about how it doesnt go the narrative of medicine medicine is involved in our physicians are heroes but another thing that leading the culture that makes it hard. I think we think about this idea how we look at impressions the history of medicine over the past 200 years is a swashbuckling adventure. Decapitating disease with the medical machetes. Flattening 19th century illnesses. Vaccines, antibiotics, from the 20th century swaggered second half of the 20th century, ordering about executing 360 degrees, chemotherapy, antipsychotics, blood transfusions, birth control, hiv treatment, slaying goliath every dragon. So maybe there be one straight trajectory over the years successes had dominant in medicine and with good reason. Its an afterthought and should not be taken for granted. So much space talk about the medical errors and the outcomes of our treatments. At best, the counseling strife. I think we have this idea that every error we have just get fixed with more research there be more medications. We dont really talk about it. Talked about in the news about mortality and often their punitive. I was a surgical student that just gotten onto the ward. The guy who ran our department he scared everyone. The residence had flatlined and they called on him. Theres a big auditorium pension he said to her, why even bother operating . Why bother operating question i remember the resident turned a ghastly shade of green. I was a medical student and i learned a couple things. One is a better not make any errors. If i do make an error im not telling anyone. I am not getting screamed at by doctor spencer. Im going out of the parking lot. Im staying clear. Its a message we got about medical errors. C1 so with the culture moving forward were going to talk about Something Else. So far we focus in the doctor side of it of course with any medical error there is a patient or a real person. Could you kind of share with her readers a little bit about the patient side of it . Guest one of the challenges is to write about the patient especially when there has been an error. One does not want to be exploited in the situation. On the other hand is what i found those patients in families were eager to have the story told the one to be there situation to be reference for others. I had most of the medical errors and what happened after words was communications. There is a 60 somethingyearold gentleman named glenn was in a rural area he was involved in a fire the controlled burn in a neighborhood. He was at the local hospital is okay entreat her he did not need to go to the burn center. And it comes in overnight the doctor comes in the next day eventually he sadly died about ten days later. And they were devastated and the daughter wanted to know what happened . How did this happen my dad was completely healthy how did he not get transported to the right place and they could not get the answers. Took them five years to try to get information because hospitals when theres a bad outcome is the hardest thing for them. So much more no matter what the reason is we want the chance to mourn and to grieve. Instead, those precious years there fighting to find out what happened because our system does not have an other compensation or something one can do. And of course it brings back the person. Number one thing was a promise and a demonstration they could do better for the next patient. It sounds like when you talk about when people end up finding out medical area think of lawyers. Can you tell us a little bit about misconceptions about that with the general public when you go to see the doctor but theres a lot of misconceptions can assure a little about what you found . Everyone and their peers. I think in theory that can be in malpractice. Experts injuring people it was expensive. So the highest chances of winning in the chance of winning a large settlement they will only take on cases in which there is a severe outcome and the costs and treatment are very high. If it isnt that the case wont ever get its day in court. To the malpractice is a very small if your air did not cause major harm would not present an element you get a legitimate error no not that your day in court. So the truth is the very few patients even the patients who did get their day in court not a day usually drags on for years and years. No matter which side because theres agony for both sides but theres the other end and we serve that many patients they never get their day in court. Quite adversarial. See say most cases the settlement than those who go to trial the majority is that how you see it . Most settle out of court and the ones that do go to court typically the patients is somewhat stacked against them or to difficult to prove. You have to prove the air was negligent. And the negligence because the bad outcome for thats very hard to approve to prove. It with a bad outcome its hard to prove. To prove the error caused the death is very difficult to do. I have a surgery and the surgery doesnt really help is hard to prove if i already had problems that was the case i calving the leg amputated something drastic. Is that how works . Very few patients get that you contrast that like a surgery in denmark. They recognize that the more important thing is patients get some sort of reputation for tha that. Very similar to workers compensation. Note if you are injured on a job you dont go to court. It becomes Administrative Court were what qualifies you get some criticism. And so in denmark they met very separate system that any patient can fire a check file against the physician used for restitutive the harm that was done. So many more patients get compensation. Some modest competenc compensation. The american sessions are which is why we need americans to cover mike if you go through childbirth and the child roundtheclock care its a very expensive theres a reason people do that. And we can do that and many more patients get served. So in the great old land of denmark, are there areas within the u. S. There adopting our their pockets where more of this happening . The vaccine to make a very small Profit Margins that does not take much to get them sued sam not in going to bother doing it. Theres a situation where many vaccine manufacturers pulled off the market is not worth the ris risk. We did not have enough vaccinations for the american public. So the idea they came together there is a vaccine compensation fund. Anyone with an injury and think about the vaccine there is and a pocketbook settlement. The Vaccine Group with the fund theres a small tax on the fox nation. Malpractice insurance is gone so high because of big losses related to injuries that made them stop practicing. Kind of a cooperative fund of course more people to benefit and they see this. I dont think its going to happen. Effectively getting your day in court. Look at the professionals is a different view this child by your peers but most dont get their day in court. I think its so important talk about the concept doing good job of showing the pitfalls in that system for lets switch a little bit now how do we get our way out of some of these problems . One thing for all doctors now with the medical record good and bad slots see that peace. Its funny, april 1 the oneyear anniversary of her hospital was such a nightmare. There were many great things through this crisis we were taking patients to the hospital sometimes 30 or 40 patients at a time. You never know it was going on in these stations. And theres help for preventing medical errors. One is when you have an infection outbreak or the common outbreaks in the hospital is an affectionate transfers on contact and causes death its very hard to eradicate this when there is an outbreak it can be tough to do. To see this outbreak they contract every patient that goes in the hospital who went to g. I g. I. , which doctors and nurses interact with each patient you have to track every single interaction for thousands of patients over many days. Theres a cat scan machine in one hand is not handled properl properly. They made the hospital find it. On the other hand and one example is it prescription. Every time i write a prescription visit interaction with this and that, there are so many i cant read them all. In some of them are ridiculous. Every female could be in your 60s pretty unlikely 55 youre going get pregnant. There are so many things on their end up ignoring it all. It makes me angry because they put everything for a liability accident doctor checks it off there not. That makes me frustrated. Theres so much you just want to make it go away is when the update had in my head recently. One morning in my clinic jose my first patient of the day and i notice theres a difference apparently theyve been something roll out of an update in the middle of the night. My fingers automatically knew that spanish is the most common language. So i had to scroll to the long list of languages somehow another relative had been added in spanish number 42. But in spanish the numbers 41 so all of a sudden it came out speaking a different language and all the sudden there were Food Allergies environmental allergies there all these allergies with anything they want with medications allergies and saying to myself stop that i think latex free environment is unimportant, but it makes it harder. After the patient left the room to the computer is not the focus of my visit. No into the process is grabbing them before they reach the elevator tying about latex gloves and pet dander and everyone was speaking serbian. I had another sheet they had the past medical history since they were 18 they summed it up with Something Else but it put it in automatically and i discovered once you put it in you couldnt take it out so all of my males that week had a ob history attached to their chart forever. [laughter] sue and i guess the question is how do we make the best where listening to talk about moving forward . Guest there are many things we can do ive had moderate success with procedural things like preoperative work making sure we have everything we need is a simple intervention but it works for that kind of thing. Doesnt work so well for things like diagnostic error, how to diagnose a patient you cant have a checklist of how you think. When it comes to that i think we have to consider the time for doctors and nurses and if we have the emr system they can actually talk with the patient, listen to the patient and think about the patient. Those i think are the three biggest things with diagnostic error. So if really, really want to minimize error is how do we do medicine . How did they have more time with their patients to think about i it. The less patient conversation these are the biggest things are Patient Safety. I cant say how many times ive heard patients complain about a doctor who spent the whole time looking at a screen and never looking at them. There are so many things to do if we dont do it we never get through. I think we need to reconfigure the system so we need to have it so we can actually talk with our patients. The second thing is the cultural shift. More making errors you not to speak about it. Its about the culture it will take to make life safe in that doctors typically, we never call in sick. That is disloyal so changing the culture thinking about what we do. We see this as a near miss or an error or see if an inadvertent patient is disloyal to not let up it really is our commitment to talk about it make it easy for people to do we want to know about the errors to change the environment we need to talk about whats going on doctors being repurposed for all sorts of things we havent done a long time we feel like its been truthful lets talk a little bit about that and i see that fitting into this conversation . Certainly now with this issue i thought very long and hard about whether to write about this at this point. What went right during covid . Ive never seen anything like it in my life. Its way out of the comfort zone and it was incredible. Not everything went as well as we liked. Was inevitable the next pandemic the next medical disaster before we get so caught up in this the same reason people get up at 7 00 p. M. To necessitate we could honestly even when its not comfortable stomach and think there be a lot of things to be uncovered as you mentioned theres so many medical things it had to be put off. Tower medical system is set up i think there is a lot see i think many deep down wasnt quite though it was during covid was not set up well under burden of things to get set up. Intentionally or set set it up that way. It is not completely Overall Society the economic structure we think about the way americans had been disproportionally harmed with covid19 you talk about that . Its a reflection of society. Our society where americans have individuals that many positive effects we have to recognize the hospital. Donnelly came from communities where they could not social distance they could not work online from home but had no choice to work. It was so clear it was not even. We have to go out there with that. Populations have been pretty striking. The sea medicine i think with nurses and collective voices think our voices have even more now the product is not seen and i think we owe it to our patients liquid our societies look at the unnecessary deaths that occurred in the community. We have this a moment with workers youve certainly done a great job with that for several years now. Before we get to the question session mentioned about the idea about how to prevent its from a future medical student its the idea can you talk about the fact that simulation programs and how they can be a big part of the next step. Can you talk more about that experience . I have trial and error. And it was terrifying. I never thought about what didnt mean for the patient how grueling it was. As an excuse for everything. The practice of medicine and so i know with simulation we have procedures nonessential line and all of these procedures. Also conversations arent giving bad news you should do that for the first time on a patient with actual cancer death of a family member. We should not be trying it out then. It simulations very critical we have a Training Ground were typical some conversations and procedures for the first time never done before and we remember the real thing there is a real person under there. And it is not a simulation. Its a moment in their life. Is that famous book about his cancer were the doctor, was talking to patients on his rounds i try to remember that phrase overlooked it in 20 hours you see 50 patients but for that one patient it is the crisis of their life and we need to remember that. Is a great lesson. You talk about the stories the trial and error and being asked to fix the face laceration. He actually said he was stuck with me and should ive been the one to do that in that particular situation . With facial laceration with other parts of your body maybe think about that also has a structure of medicine and healthcare and how things are so set up. I know asked a lot of questions but is anything unit talk about customer. Is a lot of questions there. Thematic height. Jack and betty dont see you. [laughter] [inaudible] submit first of all thank you both so much that was an incredible discussion. So the first question is from nicole. There are there more rural hospitals and if there are what is being done to help them . So thats a great question. Guest i dont think we can know there is not a National Database and one of the things they did with the compensation system as it ended up to be a way to collect data and that was the goal was to improve rural care. Theres a lot filed about and if there is one hospital with a lot of errors we could focus on that. So the answer is we just dont know. I think rural medicine has a number of challenges including not enough staff. Its very hard to attract the staff in to the rural hospitals. And so many of these hospitals are having closures because of the Financial Issues and lack of staff. Its a very critical situation there. So one big issue is a database tracking and then we could know where the problem is and how to address them. Switch it right. When you think about Florence Nightingale had the most measurables out there pretty few dont collect the data you never know. She did not endear herself to others because they thought she was crazy because she talked about data. This month was a 200th anniversary and there is a celebration of that. We should all be recognize the importance of whats going on with our patient so we know we need to fix something. Is a medical student permitting a medical error is petrifying. So how many medical students are having conversations about medical errors in clinical, how can students work towards changing the culture . Guest hopefully we can start by saying lets talk about medical errors. Heres what you do and you have your first medical error. I think the whole issue of medical error when he does start at the top and come down. When the chair or the dean of the school says heres what happens when i had an air of this is what i did this is what you do. They do occur. If we pretend we will have no medical errors we are lying to ourselves and lying to our patients at the better to be honest. If they dont have the discussion some consent really scared at making my first error can we talk about before it happens . I want to have this conversation with you. Host we do have dedicated students weve been talking about that was students exactly what you describe. That data is very useful experience to see that. Theres also we talk about the experience or procedural errors and you see that respect as wel well. They dont choose that culture. Host next questions going to be for me. As a patient, how can doctor regain the trust of patients who have been may be not, not mistreated but dont have medication with trust and not having that care from doctors. How can that doctor patient gain that respect and trust what is the stress of what happened . More than half revolves around error. So kind of air is extremely rar rare. Its what happens better when they acknowledge and think the most doesnt seem right the way to reach me they will let me know people are fallible. Need to recognize these things from happening. I dont think anyone truly expects to be perfect with they do want is that its hypothetical for patients who have a doctor or not now that i know i can trust them. So they tell me a better trust my doctor. They more seriously understand. Jackie asks how can we empower our patients to reduce their chance of becoming victims of medical error . Many patients dont know their details. Its good to keep Major Medical conditions for medications or allergies. When you go see a doctor or nurse their top you want to talk about. I want to make sure we get to these three things. And in the hospital she was going on to the best of your abilities what medications, and you may be too sick to do that. You may not be able to do that. But doctor should be able to answer your question we could also seek out advocate. And that helps navigate the system . So pederast you described like workers comp. And exclusive remedy. The system that if you try if you choose to go to about practice you can sit its free it does not cost any money. If data entry is much lower. There is. [inaudible] its an opt in but most will find it more userfriendly to navigate. Host joslin asks if theres any data on how to effectively communicate heirs to patients . Guest what you always want to start out with what is the patients understanding of whats going on. There are some things you can help clear up or give them knowledge. It affects more patients will choose not to sue if they can get the information. Most the time the patients are not getting answers. He think the hospital tells them they dont want to sue, nobody wants to see a lawsuit. That is very helpful. But the hospital or what you are doing to fix the problem. Some errors cant be fixed. We can fix the system that made the air more likely we can show concrete steps and efforts with the hospital is looking to make things safer, patients are much more satisfied. That is what they want mostly. Is a medical student whos about to enter rotation takes the time to prepare, take the time to read the charts you are not in a rush. When you are finished in whatever you do ask the patient is anything ive missed. Is there anything that got this straight and that in patients they know you got that part wrong and ask of this anything else you need to let me know. And when you asked that question its must uncheck much less likely will miss something. Before you make any further steps. So going another question for m me. With the doctor type, people will know what that is but how do you think the patient are so many universities are using these days can really help improve patient communication and reduce medical error . Guest that is ridiculous im going to ask how crazy can that be . Tell you what, you are locked in, they are great. I had one recently about medical consent. They were phenomenal they were all over the patient they were coughing theres a nurse waving even in a simulation it feels real. So if you have the chance of elder pressure of these conversations and talk with the patient after words. I dont think they ever take that away. It had a break that news how to avoid medical error how to have consent tend of end of life care, those are all things we need to practice and practice over and over and they say it safely part so if anything it can be really helpful. Guest absolutely. With theres read training you stay on top of patient care. So that is the question. Speech i think its a great idea. Especially in the conversation part with the diagnosis, learning how to make a diagnosis is very complicated. I think we are seeing more and more. And particularly when things go wrong and how to talk to patients about that. How to approach dnr orders. How to approach whether to do Cancer Treatment or not, whether to do dialysis . These are all things are more complex and how to convey that without uncertainty. I think we should presume we wont have a one 100 answer. It how to convey in different situations you can certainly see that so yes, but the problem is we need different doctors and nurses to do this. We squeeze that in between patients or after you finish work, so making time to get this sort of education. The role of how the doctor had any thoughts about that last thing we talked about have all of that that goes is a different generation. They could stay overnight and sleep but now he cant. Still had an easy answer. I think we know for sure we need to get enough sleep most of us can get the energy to whether or not we can get in the moment. There is an emotional resilienc resilience. But you couldnt angry patient or angry colleague that was much more we make it more errors like that. Doctors and nurses need to slee sleep. Problem is every time someone goes home visit transition of care. Its a transition of care is when the errors. We need to focus on how we transition care we have to find that sweet spot. We stayed too late will be overtired. We have trial and error paying attention to that a lot more for the people we only scratch the surface we only scratch the surface here today. Thank you everybody i really appreciate it. I would recommend the fantastic book. You have a lot of time on your hands or pick up some books to read. Host the book is for sale will ship them to anywhere in the country thank you so much for doing this event. It was really fantastic and for everyone watching if you enjoyed this you can share it, make sure your friends can watch it. And join us next time for another online adventure. With the Left Bank Books online. Thank you everybody so thank you guys thank you. And a discussion on the Wilson Center washington d. C. Georgetown university talks about the normalizing of cycle warfare is a geopolitical tool. Heres a portion of his talk. The way i like to phrase it and i phrase it here a lot is the United States has the nicest rocks we still live in a house. We come into it intricate beautiful cyber offense thats extraordinary its extraordinary intricate operation just because youre going to do that we cant defend well is probably no better example with effects department of justice for the basically the chinese hacked the personal information of 140 million americans, probably everyone here who has a credit card is likely in this file being maintained by echo facts. This is a case in which most americans exist theyre not Getting Company protection they are clearly not defending adequately. The attorneys are more than happy to say will take that that is the glass house. So to watch the rest of this Program Visit the website booktv. Org. And search for ben buchanan or the title of his book, the hacker and the state using the search box at the top of this page. Next on book tv, president trumps former National Security adviser, john bolton, discusses his book, the room where it happened i already consider every conversation with me highly classified. That would mean if he wrote a book and the book gets out hes broken the law and i would think that he would have criminal problems. I hope