My Fight Against Medical Mistakes Earned a U.S. Senator's Praise

by Dr. Carol Gunn

The story of delays in the diagnosis of my sister's cardiac chest pain had been highlighted on one of the large LED screens at the entry way to the Summit, in the hotel foyer. Senator Boxer had read every heartbreaking story. Now, as I left, she was both smiling and nodding to me as the elevator doors closed.

And in that moment, I understood how very far I had come. What a great finish to my Quantum Leap year.

But I am ahead of myself. First, let me tell you my back story. Then, I will tell you how I made my Quantum Leap.

My New Mission in Life

On May 27, 2014, my entire life turned upside down. My older sister Anna, a single mom, died at a well-respected teaching hospital from medical errors.

After I reviewed her 14,000-page medical record, I was stunned. I kept asking her doctors, over and over again, why had there been a two-plus month delay in evaluating her new onset chest pain?

And what answer did I receive time and time again? Silence. Deafening silence.

Later, as I emerged from my grief of losing my closest confidante, I found my mission in life had changed. I was now compelled to go against the medical establishment and start speaking openly about the silent epidemic of medical errors.

What a Difference a Year in Quantum Leap Makes

In the fall of 2013, I began a course Steve Harrison offered about speaking for money so I could deliver better presentations. With Anna's unexpected passing, I put that course on hold. When I ultimately finished, Geoffrey Berwind helped me craft my “signature story" about Anna and her death from medical errors. I delivered, voice quivering, my signature story for the first time, at a course session in Philadelphia.

If only my interactions with the teaching hospital had progressed as well.

Eight months after Anna's death, I was still asking the teaching hospital to investigate why a 59-year old-woman who had complained for months of chest pain had not been fully evaluated. This time, I requested the hospital’s Risk Management officially review her case.

Then I joined Quantum Leap. When I joined, I had been happily media- and social media-averse, with only two mentions in newspapers in 35 years (one in 1982, when my hometown paper had a short article after I won an undergraduate chemistry research grant; the other in 2006, when my local paper’s business section had an announcement about me joining a clinical practice). During that same 35 years, I authored (as an original poster) two Facebook posts, tweeted eleven times, and had never once blogged. And in my entire life, I had never publically spoken out against the medical establishment.

What a difference a year in Quantum Leap makes!

Today I realize my Quantum Leap year was quite analogous to playing a solitaire version of The Game of Life. How?

In Quantum Leap, one of the primary goals is to be always moving forward. Sometimes movement is via small hops, and sometimes movement is via larger hops. Over a year, adding up all the hops, one makes a Quantum Leap.

And it is a game of solitaire—not because you are alone, but because you are NOT competing against others. You are in the driver's seat, with a primary coach next to you, giving you directions and guidance. You add additional passengers (other coaches) along your journey, all the while learning key media and marketing concepts.

Did I win? Absolutely! Let me tell you what principles I employed.

Principle #1 - Assume the Expert Role

• Gave a well-received TEDx talk called “Medical Errors: The Silent Killer in Medicine” to over 1,700 people. Geoffrey was a HUGE supporter in this effort. I then used all the publicity tools given to Quantum Leapers to publicize my talk to the widest possible audience possible.
• Presented “Putting a Face on Medical Errors. Could it Happen Here?” at a Medical Grand Rounds, to Providence Portland Medical Center’s physician staff, with great response.
• Called and asked the leaders of both the Patient Safety Movement and the Oregon Patient Safety Commission to support me on my mission. Both groups have! After speaking at an Oregon Patient Safety Commission meeting, I was asked to serve on the Oregon Collaborative on Communication and Resolution Programs subcommittee.
• Four months after requesting them to investigate, Risk Management at the well- respected teaching hospital acknowledged I was right about the delay in diagnosis in Anna’s death.
• Spoke at the teaching hospital where Anna died at an internal medical oncology conference, as the first family representative in over 30 years. Present were her physicians and nurses—I reminded them of the need to reassess a patient’s ongoing symptoms. I explained how their poor documentation put Anna at risk. I challenged them as a team to find safer ways to deliver care.
• Had blogs published in KevinMD (called the social media’s leading physician voice, with 100,000 subscribers), “It’s Time for Health Care to Stand Up to Medical Errors,” and in Disruptive Women in Health Care, “How Many More Annas Must Die?”
  
  

Principle #2 - Pitch and Establish Relationships with Media

• In the fall of 2015, the Institute of Medicine was to release a new report on delays in diagnosis in health care. In advance of this, informed a health writer from The Oregonian and shared Anna’s and my story. Was featured on the Sunday front page of The Oregonian, then again the Tuesday following, with a second page quote (the Sunday paper circulation is 375,000; the daily circulation 300,000).
• Contacted media and content experts via Linkedin In mail, by writing personalized notes to each. From one of those, Anna’s and my story appeared in Forbes, “One Doctor's Quest to End the Plague of Screwed-Up Medical Diagnoses.”
• Met with a Staff Reporter from Health Care Inc.Northwest, part of the Portland Business Journal. Was later featured in an online article about Anna’s and my story

Principle #3 - Meet with Leaders Already in the Field

• Contacted those in leading organizations, like the National Patient Safety Foundation (CEO, Dr. Tejal Gandhi), UCSF (patient safety expert, Dr. Robert Wachter), Society to Improve Diagnosis in Medicine (Board Member, Mr. Paul Epner), Providence Health Plans (COO for the Oregon region, Mr. Dave Underriner), and National Quality Forum (then CEO, Dr. Christine Cassel). I discussed with each leader how to pursue my mission.
• Set Google Alerts for “patient safety” and “medical errors” and reviewed the daily stories. Where my mission aligned with those in the story, contacted them via email, requesting a chance to speak with them by phone. Many responded.

Principle #4 - Go to Where Your Clients Gather

• Attended a national health care risk manager pre-conference training and conference, in Indianapolis (joined after finding the hospital risk managers to be part of my “tribe.”) On the plane, by chance, sat next to an incoming board member for the organization; she asked if could speak at her health care organization’s leadership conference. At the pre-conference training, one instructor asked me to speak to her hospital’s board, “Tell me your speaking price.” While milling about after the conference’s first keynote session, another am attendee ran up to me and asked, “May I ask you an odd question?” “Sure...” “Did you do that TEDx?” “Yes” “Thank you! You touched me deeply... may I give you a hug?” “Of course...” and we both were tearing up!
• Attended 2016 Patient Safety Summit meeting. That was where Anna’s story was featured and I met Senator Boxer.

Principle #5 - Take Responsibility for Your Own Progress

• Made Quantum Leap a priority. Calendared all the new member training sessions and the monthly calls to have protected time for them. Prepared in advance for the coaching sessions with an agenda, questions, and plans for next steps—and received great coaching. Besides Geoffrey, I met with Raia, Tamra, Danette, Gail, Brian, Anne, Stacy, Bob, Rob, and Martha.
• Attended Quantum Leap meetings in Philadelphia. One meeting included Jack Canfield speaking—he was fabulous.
• Met by phone, every two weeks, with three other Quantum Leapers in a mastermind group. We held each other accountable, shared successes, and supported one another during the less successful times.
• To prepare for my TEDx talk, presented it to Quantum Leap meeting attendees. A flail at best, but I received incredible and invaluable feedback. Because of that, asked and received additional coaching from Geoffrey. Took ballroom dance lessons to improve my stage presence. And, practiced my TEDx talk as much as possible: at a Boy Scout meeting, at a dentist office’ lunch meeting, to the trees in a downtown Portland park, and with a water aerobics class.
• Gave back to fellow Quantum Leapers by forming and nurturing a focus group (with masterminding and private FB page) to review Jack Canfield’s book, The Success Principles.

Despite my shyness, after my Quantum Leap, I now lean into the media spotlight, to gain more traction around medical errors.

I made a solemn promise to my ill sister to not let others go through what she did. I know speaking about medical errors may make others within the medical establishment uncomfortable. But I must tell Anna’s story about having a two-plus month delay in evaluating her new onset chest pain.

And I must tell my story of how difficult it was to get the teaching hospital to hear my concerns about patient safety, despite me being a physician. Placing focus on medical errors is still the right thing to do and I am the right person to do it.

Even though I completed my year in the program and reached Quantum Leap Nirvana, my mission continues. As Senator Boxer advised, I plan on keeping up the good work. I can only imagine what the future holds for me.

Thank you Quantum Leap!

This post is adapted from an essay Carol wrote as her entry in our "How I Made My Quantum Leap" contest, in which Quantum Leap members wrote about the difference the program made for them and their careers.