Brian Goldman: Doctors make mistakes. Can we talk about that?

Summary

El Dr. Brian Goldman reflexiona sobre la cultura de la medicina y cómo el error humano es inevitable, a pesar de las altas expectativas de perfección en el campo. A través de historias personales de fallos médicos, comparte la vergüenza, aislamiento y el miedo que experimentó al cometer errores como médico. Goldman aboga por una nueva cultura médica que acepte la humanidad de los profesionales de la salud, fomente el aprendizaje a partir de errores y promueva un entorno de apoyo y transparencia. Su discurso es una llamada a redefinir la medicina para un sistema más seguro y compasivo.

Takeaways

• 🏥 La cultura médica necesita cambiar para reconocer y aprender de los errores.
• ⚾ En béisbol, un bateador con un promedio de 300 es considerado bueno, pero en medicina, no hay un estándar claro de qué tan bueno debe ser un cirujano o médico.
• 👨‍⚕️ El médico narrador comparte experiencias personales de errores para destacar la necesidad de transparencia y aprendizaje.
• 📚 Durante su formación, se inculca a los médicos que deben ser perfectos y nunca cometen errores, lo que lleva a un estigma围绕 los errores.
• 👵 La historia de Mrs. Drucker, una paciente con insuficiencia cardíaca, ilustra cómo los errores médicos pueden tener consecuencias fatales.
• 🤔 El médico reflexiona sobre por qué cometió errores y la importancia de escuchar la voz interna que sugiere que algo no está bien.
• 😔 El sentimiento de vergüenza y aislamiento que siente el médico tras cometer errores puede ser dañino y obstaculizar el aprendizaje y la mejora continua.
• 🔍 La narración explora la omnipresencia de los errores en la práctica médica y cómo son inevitables dados los límites humanos y la complejidad del sistema de atención médica.
• 👥 Se hace un llamado a la necesidad de un cambio cultural en el que los médicos sean humanos, acepten sus errores y los compartan para el beneficio colectivo.
• 🌟 El médico redefine su papel y se presenta a sí mismo como un ser humano que comete errores, pero que se esfuerza por aprender de ellos y enseñar a otros.
• 💡 El reconocimiento de que los errores son comunes y la creación de un sistema que los detecte y minimiza sus efectos es fundamental para la mejora de la atención médica.

Q & A

¿Qué es lo que el doctor Brian Goldman quiere cambiar en la cultura de la medicina?

Brian Goldman quiere cambiar la cultura que exige la perfección absoluta de los médicos y que no permite hablar abiertamente sobre los errores. Busca una cultura donde los errores se compartan para aprender de ellos y mejorar el sistema médico.

¿Por qué compara el orador la tasa de bateo de los jugadores de béisbol con el rendimiento de los médicos?

El orador utiliza la tasa de bateo en el béisbol para resaltar que, en otras profesiones, se considera aceptable fallar parte del tiempo. Sin embargo, en medicina, se espera que los profesionales sean perfectos en todo momento, lo cual es poco realista y genera presión innecesaria.

¿Qué error cometió el doctor Goldman con la paciente Mrs. Drucker?

El doctor Goldman diagnosticó a Mrs. Drucker con insuficiencia cardíaca congestiva y la trató, pero cometió el error de enviarla a casa sin consultar a su superior y sin seguir su intuición de que algo no estaba bien. La paciente volvió al hospital en estado crítico y falleció unos días después.

¿Cómo afectó emocionalmente al doctor Goldman la muerte de Mrs. Drucker?

La muerte de Mrs. Drucker impactó profundamente a Goldman. Se sintió solo, aislado y consumido por la vergüenza, llegando a cuestionarse por qué había entrado en la medicina. Este sentimiento de vergüenza fue debilitante y lo llevó a prometerse a sí mismo que nunca volvería a cometer un error.

¿Qué tipo de vergüenza distingue Goldman en la medicina?

Goldman distingue entre dos tipos de vergüenza: la vergüenza saludable, que enseña y guía a las personas a mejorar, y la vergüenza no saludable, que provoca aislamiento y hace que la persona se sienta inherentemente mala por haber cometido un error.

¿Por qué es difícil para los médicos compartir sus errores con sus colegas?

Es difícil para los médicos compartir sus errores porque la cultura de la medicina los lleva a sentirse juzgados, aislados y avergonzados. Los colegas tienden a sentirse incómodos y cambiar de tema en lugar de abordar los errores de manera abierta y constructiva.

¿Qué lección aprendió Goldman de sus errores médicos?

Goldman aprendió que los errores son inevitables en la medicina y que es crucial hablar de ellos abiertamente para poder aprender de ellos y evitar que otros cometan los mismos errores.

¿Qué problema ve Goldman en la estructura actual del sistema médico en relación con los errores?

Goldman señala que el sistema médico actual no está diseñado para admitir errores, lo que dificulta aprender de ellos. Los profesionales de la salud que cometen errores son estigmatizados, y el sistema no fomenta un entorno de apoyo y aprendizaje.

¿Qué propone Goldman para cambiar la cultura de la medicina?

Goldman propone una redefinición de la cultura médica donde los profesionales acepten que son humanos y que cometerán errores. Esta nueva cultura fomentaría el apoyo mutuo, el aprendizaje de los errores y la creación de sistemas que minimicen las posibilidades de errores graves.

¿Cómo se define a sí mismo Brian Goldman al final de su discurso?

Al final de su discurso, Brian Goldman se define como un 'médico redefinido', reconociendo que es humano, que comete errores, pero que está comprometido a aprender de ellos y a compartir sus experiencias para mejorar la atención médica.

Outlines

00:00

⚾ Reflexiones sobre estadísticas y el cambio en la medicina

El orador comienza hablando sobre la importancia de cambiar ciertos aspectos de la cultura médica. Relaciona el concepto de promedio de bateo en el béisbol con la práctica médica, destacando que mientras un bateador con un promedio de .300 es considerado excelente, en la medicina se espera la perfección. Esto pone de relieve la presión a la que los médicos están sometidos, ya que se les exige no cometer errores, algo que es irreal en la práctica clínica.

05:01

🏥 El primer error: El caso de la Sra. Drucker

El orador relata el caso de la Sra. Drucker, a quien diagnosticó con insuficiencia cardíaca congestiva y, tras mejorar su condición, cometió el error de enviarla a casa sin consultar a su supervisor. Más tarde, la Sra. Drucker regresó al hospital en estado crítico y finalmente falleció. El orador reflexiona sobre las emociones y dudas que enfrentó, además del impacto psicológico que le dejó este error.

10:03

🤒 Nuevos errores y la creciente frustración

El orador comparte una serie de errores que siguieron ocurriendo durante su carrera médica, como el mal diagnóstico de epiglotitis en un joven o la falta de diagnóstico de apendicitis en otros pacientes. Expresa su frustración al continuar cometiendo errores y reflexiona sobre la naturaleza inevitable de los mismos, independientemente de su experiencia o tiempo en la profesión.

15:07

💊 La cultura del error en la medicina

El orador describe cómo los errores médicos son comunes y cómo el sistema de salud falla al abordarlos adecuadamente. Se mencionan estadísticas preocupantes sobre errores en la administración de medicamentos y la prevalencia de infecciones hospitalarias. A pesar de estos errores, la cultura médica tiende a negar su existencia, lo que lleva a una falta de apoyo y a una peligrosa expectativa de perfección entre los profesionales de la salud.

🔄 La necesidad de una cultura médica redefinida

El orador concluye proponiendo un cambio en la cultura médica, abogando por una aceptación más humana de los errores. Cree que los médicos deben reconocer sus fallos y compartir sus experiencias para prevenir que otros los repitan. Describe cómo la creación de un ambiente de apoyo, donde se puedan discutir los errores de manera constructiva, beneficiaría a todos los profesionales de la salud y mejoraría el sistema en general.

Keywords

💡Cultura médica

Se refiere al conjunto de valores, creencias y comportamientos que predominan en la profesión médica. En el video, el autor critica una cultura que exige la perfección y oculta los errores, lo que genera vergüenza y aislamiento en los médicos cuando cometen equivocaciones. Propone una 'cultura médica redefinida' en la que los errores se reconozcan y se compartan para aprender de ellos y mejorar la práctica médica.

💡Errores médicos

Son los fallos o equivocaciones que ocurren en la atención médica y que pueden tener consecuencias graves, incluso fatales. El orador menciona varios ejemplos personales de errores, como el caso de la paciente que regresó al hospital tras ser dada de alta de forma prematura. El tema central del video es cómo lidiar con los errores médicos y la necesidad de un sistema que permita aprender de ellos en lugar de ocultarlos.

💡Vergüenza insana

Es el sentimiento de culpa destructivo que hace que una persona no solo se sienta mal por un error cometido, sino que también se perciba a sí misma como una mala persona. En el video, el autor describe cómo esta vergüenza insana lo afectó después de sus errores médicos, impidiéndole hablar sobre ellos y aprender de ellos de manera saludable.

💡Redefinición del médico

Se refiere a la propuesta del autor de cambiar la forma en que los médicos ven su rol y sus errores. Un médico redefinido es consciente de su humanidad, reconoce que cometerá errores y se compromete a aprender de ellos para mejorar. Esta idea contrasta con la visión tradicional que exige perfección de los médicos.

💡Sistemas de respaldo

Son mecanismos o protocolos que se implementan en los sistemas de salud para detectar y corregir los errores humanos antes de que tengan consecuencias graves. El autor sugiere que en lugar de intentar eliminar a los médicos que cometen errores, el sistema debería diseñarse para identificar y corregir esos errores de manera más eficaz.

💡Error cognitivo

Son los sesgos o errores de juicio que ocurren en el proceso de toma de decisiones. En el video, el orador habla de cómo los prejuicios pueden influir en la manera en que los médicos interpretan los síntomas de un paciente, afectando la calidad de la atención médica.

💡Perfección

En el contexto de la medicina, la perfección se refiere a la expectativa irreal de que los médicos nunca cometan errores. El autor critica esta expectativa, explicando que genera una presión indebida sobre los profesionales de la salud y crea una cultura de ocultamiento de errores en lugar de aprendizaje.

💡Sistemas hospitalarios

Hace referencia al conjunto de normas, procedimientos y personas que operan en los hospitales. El autor menciona cómo estos sistemas son complejos y están llenos de errores potenciales, lo que subraya la importancia de tener sistemas de respaldo para minimizar el impacto de esos errores.

💡Epiglotitis

Es una inflamación grave de la epiglotis, que puede bloquear las vías respiratorias y resultar en una emergencia médica. El orador usa este término para describir un error médico que cometió al diagnosticar incorrectamente a un paciente con una simple infección de garganta, cuando en realidad tenía esta condición mucho más peligrosa.

💡Batting average

Es un término del béisbol que indica la proporción de veces que un jugador batea exitosamente. El autor utiliza esta analogía para destacar la diferencia entre el mundo del deporte, donde el fracaso es aceptable hasta cierto punto, y la medicina, donde se espera una perfección imposible. Esta comparación sirve para resaltar la presión poco realista que enfrentan los médicos.

Highlights

Brian Goldman emphasizes the need for a cultural change in medicine starting with individual physicians.

Goldman uses baseball statistics to illustrate the unacceptability of errors in medical practice.

He highlights the unrealistic expectation for medical professionals to be perfect and never make mistakes.

Goldman shares a personal story of misdiagnosis and the consequences of sending a patient home prematurely.

He describes the unhealthy shame that medical professionals feel when they make mistakes and the isolation it causes.

Goldman criticizes the medical culture that denies mistakes and fails to support those who make them.

He discusses the inevitability of errors in a complex medical system where knowledge is rapidly expanding.

Goldman argues that a culture of openness and support is needed to learn from mistakes and improve patient care.

He suggests that physicians need to accept their humanity and share their experiences to foster a safer medical environment.

Goldman calls for a redefined medical culture that acknowledges human errors and creates systems to detect and learn from them.

He advocates for a supportive environment where medical professionals can openly discuss and learn from their mistakes.

Goldman highlights the importance of communication and collaboration in preventing and addressing medical errors.

He shares his experience in medical broadcasting and journalism, emphasizing the ubiquity of medical errors.

Goldman stresses the need for systemic changes to reduce preventable medical errors and improve patient safety.

He concludes by identifying himself as a redefined physician who acknowledges his mistakes and strives to learn and teach from them.

Transcripts

I think we have to do something

about a piece of the culture of medicine that has to change.

And I think it starts with one physician, and that's me.

And maybe I've been around long enough

that I can afford to give away some of my false prestige

to be able to do that.

Before I actually begin the meat of my talk,

let's begin with a bit of baseball.

Hey, why not?

We're near the end, we're getting close to the World Series.

We all love baseball, don't we?

(Laughter)

Baseball is filled with some amazing statistics.

And there's hundreds of them.

"Moneyball" is about to come out, and it's all about statistics

and using statistics to build a great baseball team.

I'm going to focus on one stat

that I hope a lot of you have heard of.

It's called batting average.

So we talk about a 300, a batter who bats 300.

That means that ballplayer batted safely, hit safely

three times out of 10 at bats.

That means hit the ball into the outfield,

it dropped, it didn't get caught,

and whoever tried to throw it to first base didn't get there in time

and the runner was safe.

Three times out of 10.

Do you know what they call a 300 hitter

in Major League Baseball?

Good, really good,

maybe an all-star.

Do you know what they call

a 400 baseball hitter?

That's somebody who hit, by the way,

four times safely out of every 10.

Legendary --

as in Ted Williams legendary --

the last Major League Baseball player

to hit over 400 during a regular season.

Now let's take this back into my world of medicine

where I'm a lot more comfortable,

or perhaps a bit less comfortable

after what I'm going to talk to you about.

Suppose you have appendicitis

and you're referred to a surgeon

who's batting 400 on appendectomies.

(Laughter)

Somehow this isn't working out, is it?

Now suppose you live

in a certain part of a certain remote place

and you have a loved one

who has blockages in two coronary arteries

and your family doctor refers that loved one to a cardiologist

who's batting 200 on angioplasties.

But, but, you know what?

She's doing a lot better this year. She's on the comeback trail.

And she's hitting a 257.

Somehow this isn't working.

But I'm going to ask you a question.

What do you think a batting average

for a cardiac surgeon or a nurse practitioner

or an orthopedic surgeon,

an OBGYN, a paramedic

is supposed to be?

1,000, very good.

Now truth of the matter is,

nobody knows in all of medicine

what a good surgeon

or physician or paramedic

is supposed to bat.

What we do though is we send each one of them, including myself,

out into the world

with the admonition, be perfect.

Never ever, ever make a mistake,

but you worry about the details, about how that's going to happen.

And that was the message that I absorbed

when I was in med school.

I was an obsessive compulsive student.

In high school, a classmate once said

that Brian Goldman would study for a blood test.

(Laughter)

And so I did.

And I studied in my little garret

at the nurses' residence at Toronto General Hospital,

not far from here.

And I memorized everything.

I memorized in my anatomy class

the origins and exertions of every muscle,

every branch of every artery that came off the aorta,

differential diagnoses obscure and common.

I even knew the differential diagnosis

in how to classify renal tubular acidosis.

And all the while,

I was amassing more and more knowledge.

And I did well, I graduated with honors,

cum laude.

And I came out of medical school

with the impression

that if I memorized everything and knew everything,

or as much as possible,

as close to everything as possible,

that it would immunize me against making mistakes.

And it worked

for a while,

until I met Mrs. Drucker.

I was a resident at a teaching hospital here in Toronto

when Mrs. Drucker was brought to the emergency department

of the hospital where I was working.

At the time I was assigned to the cardiology service

on a cardiology rotation.

And it was my job,

when the emergency staff called for a cardiology consult,

to see that patient in emerg.

and to report back to my attending.

And I saw Mrs. Drucker, and she was breathless.

And when I listened to her, she was making a wheezy sound.

And when I listened to her chest with a stethoscope,

I could hear crackly sounds on both sides

that told me that she was in congestive heart failure.

This is a condition in which the heart fails,

and instead of being able to pump all the blood forward,

some of the blood backs up into the lung, the lungs fill up with blood,

and that's why you have shortness of breath.

And that wasn't a difficult diagnosis to make.

I made it and I set to work treating her.

I gave her aspirin. I gave her medications to relieve the strain on her heart.

I gave her medications that we call diuretics, water pills,

to get her to pee out the access fluid.

And over the course of the next hour and a half or two,

she started to feel better.

And I felt really good.

And that's when I made my first mistake;

I sent her home.

Actually, I made two more mistakes.

I sent her home

without speaking to my attending.

I didn't pick up the phone and do what I was supposed to do,

which was call my attending and run the story by him

so he would have a chance to see her for himself.

And he knew her,

he would have been able to furnish additional information about her.

Maybe I did it for a good reason.

Maybe I didn't want to be a high-maintenance resident.

Maybe I wanted to be so successful

and so able to take responsibility

that I would do so

and I would be able to take care of my attending's patients

without even having to contact him.

The second mistake that I made was worse.

In sending her home,

I disregarded a little voice deep down inside

that was trying to tell me,

"Goldman, not a good idea. Don't do this."

In fact, so lacking in confidence was I

that I actually asked the nurse

who was looking after Mrs. Drucker,

"Do you think it's okay if she goes home?"

And the nurse thought about it

and said very matter-of-factly, "Yeah, I think she'll do okay."

I can remember that like it was yesterday.

So I signed the discharge papers,

and an ambulance came, paramedics came to take her home.

And I went back to my work on the wards.

All the rest of that day,

that afternoon,

I had this kind of gnawing feeling inside my stomach.

But I carried on with my work.

And at the end of the day, I packed up to leave the hospital

and walked to the parking lot

to take my car and drive home

when I did something that I don't usually do.

I walked through the emergency department on my way home.

And it was there that another nurse,

not the nurse who was looking after Mrs. Drucker before, but another nurse,

said three words to me

that are the three words

that most emergency physicians I know dread.

Others in medicine dread them as well,

but there's something particular about emergency medicine

because we see patients so fleetingly.

The three words are:

Do you remember?

"Do you remember that patient you sent home?"

the other nurse asked matter-of-factly.

"Well she's back,"

in just that tone of voice.

Well she was back all right.

She was back and near death.

About an hour after she had arrived home,

after I'd sent her home,

she collapsed and her family called 911

and the paramedics brought her back to the emergency department

where she had a blood pressure of 50,

which is in severe shock.

And she was barely breathing and she was blue.

And the emerg. staff pulled out all the stops.

They gave her medications to raise her blood pressure.

They put her on a ventilator.

And I was shocked

and shaken to the core.

And I went through this roller coaster,

because after they stabilized her,

she went to the intensive care unit,

and I hoped against hope that she would recover.

And over the next two or three days,

it was clear that she was never going to wake up.

She had irreversible brain damage.

And the family gathered.

And over the course of the next eight or nine days,

they resigned themselves to what was happening.

And at about the nine day mark, they let her go --

Mrs. Drucker,

a wife, a mother

and a grandmother.

They say you never forget the names

of those who die.

And that was my first time to be acquainted with that.

Over the next few weeks,

I beat myself up

and I experienced for the first time

the unhealthy shame that exists

in our culture of medicine --

where I felt alone, isolated,

not feeling the healthy kind of shame that you feel,

because you can't talk about it with your colleagues.

You know that healthy kind,

when you betray a secret that a best friend made you promise never to reveal

and then you get busted

and then your best friend confronts you

and you have terrible discussions,

but at the end of it all that sick feeling guides you

and you say, I'll never make that mistake again.

And you make amends and you never make that mistake again.

That's the kind of shame that is a teacher.

The unhealthy shame I'm talking about

is the one that makes you so sick inside.

It's the one that says,

not that what you did was bad,

but that you are bad.

And it was what I was feeling.

And it wasn't because of my attending; he was a doll.

He talked to the family, and I'm quite sure that he smoothed things over

and made sure that I didn't get sued.

And I kept asking myself these questions.

Why didn't I ask my attending? Why did I send her home?

And then at my worst moments:

Why did I make such a stupid mistake?

Why did I go into medicine?

Slowly but surely,

it lifted.

I began to feel a bit better.

And on a cloudy day,

there was a crack in the clouds and the sun started to come out

and I wondered,

maybe I could feel better again.

And I made myself a bargain

that if only I redouble my efforts to be perfect

and never make another mistake again,

please make the voices stop.

And they did.

And I went back to work.

And then it happened again.

Two years later I was an attending in the emergency department

at a community hospital just north of Toronto,

and I saw a 25 year-old man with a sore throat.

It was busy, I was in a bit of a hurry.

He kept pointing here.

I looked at his throat, it was a little bit pink.

And I gave him a prescription for penicillin

and sent him on his way.

And even as he was walking out the door,

he was still sort of pointing to his throat.

And two days later I came to do my next emergency shift,

and that's when my chief asked to speak to me quietly in her office.

And she said the three words:

Do you remember?

"Do you remember that patient you saw with the sore throat?"

Well it turns out, he didn't have a strep throat.

He had a potentially life-threatening condition

called epiglottitis.

You can Google it,

but it's an infection, not of the throat, but of the upper airway,

and it can actually cause the airway to close.

And fortunately he didn't die.

He was placed on intravenous antibiotics

and he recovered after a few days.

And I went through the same period of shame and recriminations

and felt cleansed and went back to work,

until it happened again and again and again.

Twice in one emergency shift, I missed appendicitis.

Now that takes some doing,

especially when you work in a hospital

that at the time saw but 14 people a night.

Now in both cases, I didn't send them home

and I don't think there was any gap in their care.

One I thought had a kidney stone.

I ordered a kidney X-ray. When it turned out to be normal,

my colleague who was doing a reassessment of the patient

noticed some tenderness in the right lower quadrant and called the surgeons.

The other one had a lot of diarrhea.

I ordered some fluids to rehydrate him

and asked my colleague to reassess him.

And he did

and when he noticed some tenderness in the right lower quadrant, called the surgeons.

In both cases,

they had their operations and they did okay.

But each time,

they were gnawing at me, eating at me.

And I'd like to be able to say to you

that my worst mistakes only happened in the first five years of practice

as many of my colleagues say, which is total B.S.

(Laughter)

Some of my doozies have been in the last five years.

Alone, ashamed and unsupported.

Here's the problem:

If I can't come clean

and talk about my mistakes,

if I can't find the still-small voice

that tells me what really happened,

how can I share it with my colleagues?

How can I teach them about what I did

so that they don't do the same thing?

If I were to walk into a room --

like right now, I have no idea what you think of me.

When was the last time you heard somebody talk

about failure after failure after failure?

Oh yeah, you go to a cocktail party

and you might hear about some other doctor,

but you're not going to hear somebody

talking about their own mistakes.

If I were to walk into a room filled with my colleages

and ask for their support right now

and start to tell what I've just told you right now,

I probably wouldn't get through two of those stories

before they would start to get really uncomfortable,

somebody would crack a joke,

they'd change the subject and we would move on.

And in fact, if I knew and my colleagues knew

that one of my orthopedic colleagues took off the wrong leg in my hospital,

believe me, I'd have trouble

making eye contact with that person.

That's the system that we have.

It's a complete denial of mistakes.

It's a system

in which there are two kinds of physicians --

those who make mistakes

and those who don't,

those who can't handle sleep deprivation and those who can,

those who have lousy outcomes

and those who have great outcomes.

And it's almost like an ideological reaction,

like the antibodies begin to attack that person.

And we have this idea

that if we drive the people who make mistakes

out of medicine,

what will we be left with, but a safe system.

But there are two problems with that.

In my 20 years or so

of medical broadcasting and journalism,

I've made a personal study of medical malpractice and medical errors

to learn everything I can,

from one of the first articles I wrote for the Toronto Star

to my show "White Coat, Black Art."

And what I've learned

is that errors are absolutely ubiquitous.

We work in a system

where errors happen every day,

where one in 10 medications

are either the wrong medication given in hospital

or at the wrong dosage,

where hospital-acquired infections are getting more and more numerous,

causing havoc and death.

In this country,

as many as 24,000 Canadians die

of preventable medical errors.

In the United States, the Institute of Medicine pegged it at 100,000.

In both cases, these are gross underestimates,

because we really aren't ferreting out the problem

as we should.

And here's the thing.

In a hospital system

where medical knowledge is doubling

every two or three years, we can't keep up with it.

Sleep deprivation is absolutely pervasive.

We can't get rid of it.

We have our cognitive biases,

so that I can take a perfect history on a patient with chest pain.

Now take the same patient with chest pain,

make them moist and garrulous

and put a little bit of alcohol on their breath,

and suddenly my history is laced with contempt.

I don't take the same history.

I'm not a robot;

I don't do things the same way each time.

And my patients aren't cars;

they don't tell me their symptoms in the same way each time.

Given all of that, mistakes are inevitable.

So if you take the system, as I was taught,

and weed out all the error-prone health professionals,

well there won't be anybody left.

And you know that business

about people not wanting

to talk about their worst cases?

On my show, on "White Coat, Black Art,"

I made it a habit of saying, "Here's my worst mistake,"

I would say to everybody

from paramedics to the chief of cardiac surgery,

"Here's my worst mistake," blah, blah, blah, blah, blah,

"What about yours?" and I would point the microphone towards them.

And their pupils would dilate,

they would recoil,

then they would look down and swallow hard

and start to tell me their stories.

They want to tell their stories. They want to share their stories.

They want to be able to say,

"Look, don't make the same mistake I did."

What they need is an environment to be able to do that.

What they need is a redefined medical culture.

And it starts with one physician at a time.

The redefined physician is human,

knows she's human,

accepts it, isn't proud of making mistakes,

but strives to learn one thing

from what happened

that she can teach to somebody else.

She shares her experience with others.

She's supportive when other people talk about their mistakes.

And she points out other people's mistakes,

not in a gotcha way,

but in a loving, supportive way

so that everybody can benefit.

And she works in a culture of medicine

that acknowledges

that human beings run the system,

and when human beings run the system, they will make mistakes from time to time.

So the system is evolving

to create backups

that make it easier to detect those mistakes

that humans inevitably make

and also fosters in a loving, supportive way

places where everybody who is observing

in the health care system

can actually point out things that could be potential mistakes

and is rewarded for doing so,

and especially people like me, when we do make mistakes,

we're rewarded for coming clean.

My name is Brian Goldman.

I am a redefined physician.

I'm human. I make mistakes.

I'm sorry about that,

but I strive to learn one thing

that I can pass on to other people.

I still don't know what you think of me,

but I can live with that.

And let me close with three words of my own:

I do remember.

(Applause)