I was relaxed and would soon arrive at the meeting point for our weekly Wednesday hike up Spencer Butte in Eugene, 6 miles, 1000 feet vertical.  It’s a good weekly workout, and I like the other hikers.  I came to a 4-way stop, looked left then right, focusing on the car to my right.  I let him turn; he was there first, and he was to my right.  I started to go, but for some reason, looked left.

I had NOT seen the bicycle just to my left.  I hit the brakes and stopped immediately, quickly enough that I didn’t get a dirty look, but still shaken.  Where did SHE come from? It was possible when I looked the first time, the cyclist wasn’t visible, but I doubt it.  I think I looked for a car, not a bike, didn’t see a car, so I then looked right. There’s a term for that, and it’s called inattentional blindness*.  We see what we expect to see.  If you are watching a video of a basketball game, asked to count the number of times people in white shirts pass a basketball, you might not notice the person in a gorilla suit that comes out, thumps her chest, and walks away.  Half the people viewing the video didn’t. Yes, really:

We operate on faulty assumptions, too.  Last year, I was driving east, when a cyclist on a cross street to my left made a right turn, heading west.  I didn’t give it another thought.  Slowing to make a right hand turn in heavy traffic, I eased over, fortunately not quickly, as I suddenly had this “where the hell did he come from?” moment.  The cyclist had made a U-turn behind me and came up faster than I was driving.  I almost hit him, and it would have been my fault.  On the other hand, had the cyclist, who gave me a very dirty look, realized how I interpreted his move, he might not be so quick to do that again.  Or he might, since he wasn’t wearing a helmet, and that to me is a strong sign of ignorance.  Helmets save lives, and they are a “go to the mat” issue for me, one upon which I will not compromise.

I bring this up because of a TED video about Dr. Brian Goldman’s experience with medical errors.  His video is nearly five years old, a decade after I proposed a system for dealing with doctor imperfections and system design failures, wanting what Dr. Goldman wanted—ability of doctors to come clean.  I approached it from the standpoint of reporting anonymously, he from the standpoint of allowing doctors to stop hiding what shouldn’t be hidden and admit what is normal:  people aren’t perfect.  Both of us agree that better system design is the answer, so that when errors are made—for they will be—there are backups in place to make it impossible or at least highly unlikely that the errors will propagate or concatenate into worsening problems.  Dr. Goldman is a young man, compared to me, so he doesn’t know that three decades ago, I knew that sleep deprivation, hurry, and interruptions were rampant in medicine and were wrong.  I was told by my colleagues to put up:  good doctors didn’t make mistakes.

Yes they did, but back then I believed the contrapositive—if you made a mistake you weren’t a good doctor.  Being sued for missing an acoustic neuroma was the first step that ultimately would lead to my leaving medicine.

I’ve mostly gotten beyond the bitterness of the lawsuit, but my wife tells me I take insults personally too long.  She’s right.  I do, although the lawsuit was personal.  It took me years to realize my not being a successful consultant in medical statistics was not entirely my fault.  Or that my medical safety reporting system, introduced 14 years ago, had no chance of passing in the state in which I was living. Dr. Goldman is personable, has a radio show, and is a somebody.  I was an average doc who hadn’t the personality, the drive or ability to convince people something is a good idea. I swore I’d never deal with medical quality again.

Moving to Oregon changed that.  Or maybe I grew up a little.

Oregon has a patient safety commission here that deals with doing root cause analyses on voluntarily reported errors.  I did a little reading, emailed them with my experience, and was invited to talk to them up in Portland.  It helps, if one is a volunteer.  Yes, you may get what you pay for, but you may get wisdom for free.  Or not.  It was interesting to talk about things I haven’t talked about in a long time.  I’m a bit rusty about how medicine is practiced today.  In some ways, there has been great progress.  In the matter of errors and patient safety, I haven’t missed a lot in the past decade since I left.  The head of the commission and I were both a little discouraged.  I had expected more progress, frankly.

I doubt I will do much for them, because I can’t make doctors and nurses report errors and investigate them.  Everybody is busy.  Too busy.  Too busy doing things to get by, too busy to fix systems that rob their lives of time to do other things.  I could tell the woman was in a hurry, although she was polite.  I recognize all the signs.  I kept a cautious eye on the clock.  Time is important.  Most people are important.  I’m not.

Twenty years ago, I made a list of things to do “if there is only a little time left.”  That’s the bad cancer diagnosis list of things to do, like take my wife to Hawaii or England, as promised.  There are also things to do while I can still do them, like one more time in the Refuge.  That’s ANWR.  That’s the “you aren’t going to be healthy forever,” list.  There are also things to do because I like them.  That’s the, “you are alive, and you have an opportunity. Do them” list.

If my  latest ventures don’t work, well, I can keep providing answers on  Look me up, under “Boreal”.  I’ve taught English, reading, and math.   I know English well, I taught myself to read when I was 2.  Math is just natural.  And fun.

*For inattentional blindness, the observer must (1) fail to notice a visual object or event, (2) the object or event must be fully visible, (3) observers must be able to readily identify the object if they are consciously perceiving it, and (4) the event must be unexpected and the failure to see the object or event must be due to the engagement of attention on other aspects of the visual scene and not due to aspects the visual stimulus itself. Individuals who experience inattentional blindness are usually unaware of this effect, which can play a subsequent role in behavior.

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