Dr. Brian Goldman On Blame Culture - Highlights

TK: All right, so I’m here at the Royal Canadian Military Institute in downtown Toronto with Dr. Brian Goldman, who amongst other things, is a radio talk show host of CBCs White Coat Black Art. Prominent author of at least four books if I’m correct. 

Dr Goldman: Four books. 

TK: Four books, including one that we’re gonna talk about today, ‘The Power of Teamwork’. And also ‘The Night Shift’, which I don’t have with me, but which we will talk about. And on top of that, if it wasn’t enough, you’re also a practicing medical doctor. 

Dr Goldman: Emergency physician.

TK: Emergency physician.

Dr Goldman: Right up the street at Sinai Health System.

TK: Right on. So I’ve got you here today, there’s some some really interesting perspectives on the power of teamwork that have an aviation nexus, which is my background. So that’s part of the reason why why I reached out, and hope we could have a discussion on looking at what we can do in healthcare to implement some of the valuable lessons learned that we’ve had and the developments with Threat and Error Management, Crew Resource Management, Safety Reporting, and so on. 

Dr Goldman: Paid for as Sully Sullenberger once told me in blood. Those lessons were paid for in blood.

TK: Paid for in blood. Exactly. And we ignore them at our peril. You obviously are no stranger to these facts. And you’ve mentioned them at length in both books. I’ve only read two of the four books. So what are your other two titles?

Dr Goldman: So the other two books are ‘The Power of Kindness’. Why empathy is important in everyday life? And it’s basically it was my quest to meet the kindest people on the planet, learn their stories, and you know, find out, learn about their acts of kindness, but then ask questions like, were you always that way? Were you born that way? And some people are hardwired to be super empathizers. And then, but I think I think the majority of people develop deep empathy by suffering, they suffer, they’ve suffered a loss in childhood, a divorce of their parents, when they were small kids, maybe they lost a parent, or they suffered, you know, terrible dislocations, from immigration, you know, moving to another country having to having to start over whatever it is. And they became kind and they developed kind of an empathy for other people in similar circumstances. And then the other book that I wrote, which is kind of if, if ‘The Power of Kindness’ is the Yang, the Ying was the ‘The Secret Language of Doctors’, which is basically a look at the culture of modern medicine, warts and all, as evidenced by the slang that we use to describe unpleasant situations in patients and family members as well. And I got a lot of criticism for that book, and to cleanse that to cleanse my palate to get out to overcome that I wrote ‘The Power of Kindness’.

TK: So expanding on empathy, maybe in healthcare, I wonder, obviously, it’s important to retain a sense of empathy, especially for your patients, but there must be a certain steeling over of your nerves or a dark humor that you’re that manifests itself amongst both physicians and nurses who have to deal with that in order to be able to go on doing the job that you’re doing.

Dr Goldman: So that’s true. Dark humor is important. And you know, one of the reasons why I was interested in the in ‘The Secret Language of Doctors’ is that there’s a lot of dark humor, in the terms that are used, for instance, to describe death. You know, a patient who is waiting in the ICU to die. Sometimes the expression we use is ‘actively dying’. And care has been withdrawn. They’re receiving comfort measures only. And, you know the family is coming to grips with their gathering, they’re coming to grips with the fact that their loved one is dying. And meanwhile, outside the ICU room, in the the room where they have rounds, or just outside the hall, they might be saying something like, you know, “Mr. Jones, is waiting for a pathology consult.” Pathology meaning autopsy or is about to be admitted to the 19th floor of an 18th floor hospital. Discharged to heaven. You know, those are, and that’s one of the ways that we cope. But I think in many respects, we don’t cope. And that’s, you know, humor is a device. But, you know, we find it very difficult to empathize, because it’s because the feelings are overwhelming.

TK: I mean, for most of us death, it’s a rare and unpleasant thing that punctuates certain periods in our lives, usually with loved ones or friends, and it’s not our profession to deal with it.

Dr Goldman: If we haven’t experienced death ourselves, we find it hard to empathize with our patients. And that’s why younger physicians, nurses, respiratory therapists, they have to live a little they have to grow into their adulthood. Begin to lose their parents to begin to have an appreciation of what it’s like to be our patients. Very hard to empathize with the situation that you, for which you have no kind of frame of reference. So that’s one thing. Second thing is for, for people, and I’m an emergency physician, and when death happens suddenly, unexpectedly in the emergency department, the reaction of family members is understandably very strong.

TK: In terms of laying blame, or… 

Dr Goldman: Laying blame. Or just being grief stricken, shocked, and, you know, the first time I have that conversation, first of all, if I’m, if I’m afraid that I’m being that I’m about to be blamed, that’s a terrible attitude to bring into a room where you’re telling somebody that their loved one has died. And I’ve had to learn how to put that aside and be there for the patient. And you know, it’s not just a method, you know, there are ways of approaching somebody breaking bad news to them, but you also have to be able to park any feelings of internal distress that you have, and we’re often not good at that.

TK: It’s tremendously difficult thing to do. And it’s, it’s, it’s a non medical aspect of your profession, that you have to debrief a close family member in that way, often, when emotions are highest. So how do I know in an aviation we have the benefit of centralised governing bodies, like the FAA, the NTSB, Transport Canada in Canada. CAA in New Zealand, and they were able to require mandate that certain carriers, Part 121 carriers, or the the Air Force adopted specific Crew Resource Management, Human Performance in Military Aviation, Flight Safety models, that became self regulatory, in a sense, who were charged with the responsibility of increasing aviation safety. So we were able to do that kind of from the top down whether people liked it or not, it was mandated, you shall take this training once a year. And over time, people became more and more totally aware of the training and the the intent behind the training, but in cultured, I suppose.

Dr Goldman: But you’ve also had… don’t sell it short. Because you’ve become successful, you have outcomes, you know, it is vanishingly rare to for a plane for a passenger plane to go down. I mean, it happens, but not at the rate it happened 40 or 50 years ago, and I haven’t seen any equivalent in healthcare. Now, part of the reason we’re also like aviation, healthcare is becoming a lot more complex. We’re dealing with patients who are older and have 10 diagnoses. We’re able to find more, discover more, treat more. The treatments themselves are more complex, there’s a greater risk of drug interactions. There’s interactions between technology and the human, you know, and the human patient. And, you know. I think, at some point, the analogy between, you know, patient and aircraft breaks down. I think human beings are a lot more complex. And I think, you know, you’re dealing with, you’re dealing with thousands of diagnoses. You’re dealing with one plane, and the avionics and the general principles are the same.

TK: Yeah, I would agree. Healthcare is far more of a complex adaptive system. And aviation, while a complex system can be maybe relegated to a complicated system at times rather than a complex. And the it’s not as litigious either.

Dr Goldman: No, it isn’t, but I think it’s harder to do the studies that can demonstrate conclusively that we can zero the error rate. We can improve outcomes by zeroing or substantially reducing the error rate. Now, there are very specific successes, one of them is heart treatment, you know, developing a time as muscle approach, so that you want to be able to do is arrange the system so that you’re diagnosing the heart attack as quickly as possible. So you get the patient either blood thinners, or clot busting drugs or get them to a catheter suite where you can do an angioplasty and unblock that blocked coronary artery. There have been great successes there. A little less success on stroke management, but also successful. So there are there are very specific examples, but those are three or four out of thousands of diagnoses. And you know, and there are you know, we can do across the board initiatives like reducing catheter infections in elderly patients by taking out the catheter as soon as possible instead of using it as a tool for Patient Management. You know, use it to get a urine sample if you need it and remove it as quickly as possible so that the patient doesn’t get infections? So that’s creating rules that improve safety and and better patient outcomes?

TK: Is it? Would it be fair to say, it might be easier to advance safety and health care from a medical device standpoint, rather than a culture standpoint, in that you can you can bring a medical device through a series of trials, you can demonstrate in the trials that it has fewer adverse outcomes than competing brands, or competing medical device, and it’s a technical solution that’s more easily adopted. Where as trying to trying to drive home that the culture towards how we perceive risk, or how we perceive error needs to be changed over a multi-year, perhaps multi-decade long approach. Before you’re going to see the decrease in incidents.

Dr Goldman: Yes. I think, you know, in theory, the answer is yes. The problem and there are a number of problems. Unlike avionics, unlike communication devices, you know, radar devices, proximity detectors. Whatever kinds of devices you have on aircraft. You have systems that are designed to talk to each other. What if I told you that in health care in the intensive care unit, that the cardiac monitor doesn’t talk to the blood pressure monitor doesn’t talk to the temperature monitor? Because, and that different device manufacturers have a source code that they could share with one another, but don’t share it with one another because it’s proprietary. Like we’re shooting ourselves in the foot, and patients are suffering at the same time.

TK: And that places an additional burden on the healthcare professional to be the intermediary between all of these systems that don’t talk with one another.

Dr Goldman: Yeah. And bear the consequences, because it’s got to be somebody’s fault. And I know I’m sounding like a cynic when I say that, but you know, I think the difference between Sully Sullenberger, who I had the pleasure of interviewing on ‘White Coat Black Art’, you know, one of my idols, you know. Anthony Fauci was another one. And, you know, I’ve got I’ve gotten to speak to, to some great luminaries, but he, you know. Sullenberger talked at length, he’s now become, you know, now that he’s retired, he’s become a consultant and is trying to teach the lessons of aviation safety to healthcare. 

TK: Really?

Dr Goldman: Yeah, he is. He is. So he told me, you know, what are some of the differences between between, you know, dealing with the consequences of aviation mishaps and dealing with medical malpractice. First of all, a shared sense of destiny, that, you know, if the plane goes down, it’s not just going to kill the passengers, it’s going to kill the cockpit crew and the cabin crew. And, and so, and I can tell you that, until COVID, we tended to have this dichotomy where, you know, well, the patient, you know, you know, the surgeon is going to feel very bad, the anesthetist is going to feel very bad, the internist, the emergency physician, the nurses, but they don’t, they’re not going to die, they’re not going to suffer the consequences. You know, that’s not exactly true. I don’t know a physician or a surgeon or nurse or respiratory therapist who wants to be party to a negligence lawsuit. To have to relive those moments again, and again, and again, where everybody knows what you did, in retrospect, you know, dealing with college, you know, complaints to the College of Physicians and Surgeons, the College of Nurses. I don’t think anybody wants to, I think, in fact, I’ve met plenty of health care professionals who take 10 years off their life to undo a mistake. If it’s grievous enough, until COVID, there was no sense of shared destiny. With COVID, that was the first time in my lifetime in my professional life that I saw shared destiny, that suddenly the same disease that could kill patients could kill health care professionals, too. And boy, did we suddenly galvanize together. You had these protected code blues, where it once it was called in the hospital, people would rush from different parts of the hospital and they would all be there, how can I help? How can I help you? Which we often don’t have in healthcare, it’s kind of like your, it’s your problem, you deal with it?

TK: You know that brings up an interesting point, because we talk a lot about sharing the mistakes that happen. And that obviously, is is actually a healthy way of doing things if we’re ever to learn from any of them. But we also ought to share the things that go well, and with a code example. I’ve got an observation here from one of your books about a… a ‘Code Orange’ from a mass casualty event and I’m trying to find

Dr Goldman: In Ottawa. 

TK: In Ottawa, and how it galvanized an entire team together and I just wonder if examples like that are well shared so that other people who perhaps will never experience or maybe only have a mass casualty event, once every 10 years, they can learn from everything that went well, and then try and replicate it in the same way. Sully’s you know, incredible landing on the Hudson is a perfect example of something that’s been well shared, because it went so well. So probably pilots everywhere have watched it, read the book, thought about it to themselves. Now, what would I have done? What What could I do if I’m, I’m in a similar circumstance? So was that well shared? Is there? Are there some things that happened during COVID, that galvanized teams together that people ought to know about? But don’t? 

Dr Goldman: Oh, yeah, I think so. And, you know, I think the the example, the Code Orange that I that I wrote about that was involving OC Transpo. And it was a bus that crashed into a station and the top was sheared off. And it was a mass casualty event. And the interesting thing about it, is that it followed another Code Orange, in which the Ottawa Hospital prepared to receive mass casualties and receive no one and they wondered how that happened. How could that have happened, and they did a root causes analysis and did a simulation. And funny thing, that simulation that they did, which was which they completed days before the actual incident, resulted in a textbook operation, because it was well done. And it was well disseminated within the Ottawa healthcare community. It was in the Ottawa Hospital in the Ottawa and the Allied services, first responders. And so they, you know, they learned some lessons, one of the lessons they learned was it was two way communication. So you have the paramedics in the field, communicating with the dispatchers, and giving them a perfect sense of, or at least an optimal sense of how many casualties are going to be? And who’s going to go where, and how many minutes until they arrived? And oh, by the way, it’s in the middle of the winter. There’s hyperthermia going on. And we’re going to be treating that as well, yes, we need to treat that as well. So, you know, all of that came from dealing with a bad situation. And it is so important to talk about mistakes.

TK: All right, so we’re getting to the end of our conversation here. I do have to thank you very, very much for your time this afternoon. 

Dr Goldman: My pleasure.

TK: There is a ton of overlap between aviation and healthcare, and I could talk about it with you for hours. I think I’d like to finish up with a quote from your book, your most recent book on teamwork, and then I’ll let you close it out with your thoughts on this quote. “Every single day without fail, if I tried to do my day on my own, every single day, there would be an element that would not function as well, because without the team, I wouldn’t have the input of somebody else.”

Dr Goldman: So that was uttered by Dr. Jonathan Fitzsimon, who is a family doctor in Arnprior, which is part of Renfrew County. It’s in the lovely and austere and remotely populated part of northeastern Ontario that encompasses the Ottawa Valley, Algonquin Park. And, you know, the County of Renfrew has, in addition to stark beauty, it has some logistical problems. It has a large number of older patients who don’t have a family doctor, and who, you know, they can’t drive a car, can’t get to a medical facility. There are almost no walking clinics. There’s there’s no public transportation. And so they have two options, they can call 911 and be brought to an emergency department. Or they can sit at home and get sicker and sicker. Or, you know, maybe if they’ve got a loved one, you know, an adult child who can transport them to a doctor’s office, and then that would be helpful. So in that system, they discovered that they had a huge problem. And that is how do you care for people who don’t have a family doctor, don’t have access to health care. And they invented a teamwork model that is now inspiring, similar efforts across Canada and around the world, where you have Jonathan Fitzsimon, who’s functioning as a family doctor, if he had to go out and do house calls on every patient, he’d be spending his entire day driving from place to place. Well, that’s not very efficient. So he stays in his office. There is a dispatcher, you know, there’s a toll free number that patients can call and it’s for unattached patients, patients who don’t have a family doctor, and they get plugged into the system. And they’ll talk to either a family physician like Dr. Fitzsimon, or they’ll speak to a nurse practitioner. And if it would be beneficial for them to come to the office. If someone can transport them they’re fine. If they can’t, then they’ll send a paramedic to the patient’s house. And they function as the eyes and ears of the primary care provider. They can take vital signs. So this is a different kind of paramedic. It’s not the paramedic who is a first responder to emergencies. This is a paramedic who arrives in a specially equipped vehicle. They have special training, they can do sutures, they can put in IVs, which every paramedic can do. They can take vital signs, they can do point-of-care ultrasound, electrocardiogram, bloodwork, they can deliver medications. And you know this system was in place prior to the pandemic and with the pandemic, they had the added pressure. In the early days of the pandemic, they didn’t want patients with COVID to be brought to the emergency department if it wasn’t necessary. So they developed something called the Virtual Triage Assessment Center, VTAC. And so this was a toll free number that patients could call and could get advice on managing COVID could also by the way, get advice on managing everything else. And they were accepted and recruited into a team, where the team would consist of a family physician, nurse practitioner, nurses, community paramedics as the eyes and ears doing the house calls, registered dieticians, psychologists, physiotherapist, occupational therapists, speech and language pathologist as necessary, pharmacists all functioning in a team work model. And what they found is that they were able to take care of patients who previously had no family doctor who would have had no option but to go to the emergency department, they were able to dramatically reduce the number of unnecessary visits to the emergency department. And they did it without transmitting COVID-19. And the program was so successful, that it recently received full funding to carry on indefinitely. We should all be doing something like that. Now, one of the things that people who’ve been watching the healthcare system as I have for decades, we get tired of pilot projects that go nowhere. We want this thing can be scaled up. And we know for instance, that, you know, community paramedicine in Alberta, which also has austere and remote areas of the province that are not well doctored Well, in a teamwork model, you can look after those patients where they live. And I think this is the kind of thing I’d like to see right across Canada, and certainly in the United States and around the world. And, you know, it’s the brainchild of Chief Mike Nolan. Michael Nolan is the Director of Paramedicine for the County of Renfrew. And he’s a visionary management expert who has learned how to get the different silos, you know, the hospital culture, the family medicine culture, the specialist culture, paramedicine, other first responders to play nicely with one another. And, you know, it takes a special kind of leader to be able to make that kind of kind of thing happen. He’s done it very well.

TK: It’s best to finish on a positive note.

Dr Goldman: Yes, it is. 

TK: That’s a positive story. 

Dr Goldman: Teamwork works. You know, teamwork saves lives in aviation, it saves lives in health care. And the more we espouse to the principles of teamwork, not only will we do better, but we’ll feel better, will actually have less burnout. Fewer, you know, fewer accidents, better safety record, better job satisfaction and a better sense of bliss, ecstasy, from all of us doing a job well done. Like when was the last time you said we did it? We did it. We all did it. And I think that’s the juice of healthcare, just as the juice of aviation as well.

TK: I couldn’t agree more. Thank you so much for your time, Dr. Goldman, I encourage our listeners and viewers to go out and purchase ‘The Power of Teamwork’, and to take a look at ‘White Coat Black Art’ because it’s an excellent podcast. Even for folks like me who aren’t healthcare professionals. A ton of overlap with aviation and thoroughly engaging. So thank you so much for your time this afternoon. I wish you all the best and I hope I’ll see you again in the near future.

Dr Goldman: You bet. Me too. 

TK: Cheers.


Related posts

Part 2 – Dr. Bill Bestic, Ex-special Forces Operator Turned Trauma Physician Talks Human Performance In Medicine & Aviation

A uniquely talented commercial helicopter pilot, special forces officer in the NZSAS, anaesthetist, and trauma physician; Dr. Bill Bestic talks about human performance, excellence, and fallibility in medicine from an Australian perspective.

Michael Sandler Describes A Medication Error Due To Fatigue

Our Chief Nursing Officer candidly recalls time when a series of small events and a large dose of fatigue led to a medication error; highlighting systemic problems with the way both fatigue and reporting is viewed within healthcare.

Full Interview – Dr. Brian Goldman On Improving Healthcare Delivery In Canada

Dicerra's full interview with Dr. Brian Goldman from CBC's White Coat, Black Art where he discusses human performance, human kindness, and the obstacles that must be overcome to improve healthcare delivery.

Part 1 – Dr. Bill Bestic, Ex-special Forces Operator Turned Trauma Physician Talks Human Performance In Medicine & Aviation

A uniquely talented commercial helicopter pilot, special forces officer in the NZSAS, anaesthetist, and trauma physician; Dr. Bill Bestic talks about human performance, excellence, and fallibility in medicine from an Australian perspective.

Related posts

Part 2 – Dr. Bill Bestic, Ex-special Forces Operator Turned Trauma Physician Talks Human Performance In Medicine & Aviation

A uniquely talented commercial helicopter pilot, special forces officer in the NZSAS, anaesthetist, and trauma physician; Dr. Bill Bestic talks about human performance, excellence, and fallibility in...

Michael Sandler Describes A Medication Error Due To Fatigue

Our Chief Nursing Officer candidly recalls time when a series of small events and a large dose of fatigue led to a medication error; highlighting systemic problems with the way both fatigue and...

Full Interview – Dr. Brian Goldman On Improving Healthcare Delivery In Canada

Dicerra's full interview with Dr. Brian Goldman from CBC's White Coat, Black Art where he discusses human performance, human kindness, and the obstacles that must be overcome to improve healthcare...

Part 1 – Dr. Bill Bestic, Ex-special Forces Operator Turned Trauma Physician Talks Human Performance In Medicine & Aviation

A uniquely talented commercial helicopter pilot, special forces officer in the NZSAS, anaesthetist, and trauma physician; Dr. Bill Bestic talks about human performance, excellence, and fallibility in...