I recently read, as I’m sure many of you did, the New York Times story recounting the illness and death of Rory Staunton. It is a haunting story. . . one that keeps coming back to my mind. The tragic death of a previously healthy twelve-year-old child. A child full of life, cut short.
As a mom, I am devastated for Rory and his family. I cannot imagine the pain. The loss. The hole in their lives that can never be filled. The what ifs and the questions that will likely never fully be answered. This is the kind of story that rocks us as parents. To even imagine the loss of a child. . . . it is unimaginable, unthinkable.
As a pediatrician, I am saddened for the physicians who cared for Rory, and who now are forever changed by his death. His story imprinted on their hearts and brains. This is the kind of story that keeps physicians lying awake at night. Medicine is an ever advancing science. But it is also an art, and an imperfect one. The human body is fantastically complex and sometimes mysterious. We all ask ourselves. . . Did I make the right decision? Did I order the right labs? Did I miss anything? Did I make sure to describe all of the warning signs of when to return? Was my best good enough? Did I make a mistake?
The sad truth is that we are practicing the art and science of medicine in an imperfect system. And, Rory’s death is really a story of systems failure. It is the story of a system that asks physicians to see and do more, instead of doing better. A system that sometimes foments poor communication. A system that failed Rory, his family, and those medical professionals who encountered him in his final days.
Certainly there will be changes to the system at the hospital where Rory was seen. Checks and balances. New protocols. As there should be. But, this is not about one hospital. My hope is that Rory’s death will bring urgency to a movement, already begun, to change the way that medicine is practiced. A movement that is important for both patients and providers. I hope that quality will be valued more than quantity. That counseling and education will be equally valued with procedures. That smart technologies will assist in diagnosis and treatment. That teamwork will be valued. That mistakes will trigger evaluation and improvement, not blame.
Every physician I know desires to heal their patients. Even on our worst days, we all desire to do the right thing. To arrive at the right diagnosis. To first, do no harm. To heal. It is this desire that sometimes drives us to do more, to send more tests, to order a scan. But, there can be harm in this as well. And so, we continue our delicate balancing act of doing just as much as is prudent. Just as much as each patient needs. And still sometimes the illness tricks, defeats. As a pediatrician, I am frequently moved by the honor of caring for children. Every day I work to live up to that honor. But, we are all imperfect, human. This must be acknowledged.
I am haunted by the story of Rory Staunton and other children like him. I hope that time will bring peace to families and others affected. I hope that, in their names, we will create meaningful systemic change and continue to strive for improvement. I hope that we will continue to heal, together.
For more on reducing errors and improving safety in medicine, I highly recommend Dr. Atul Gawande‘s work.