29 January 2014
MEDICAL DISRESPECT
Bullying doctors are not just
unpleasant, they are dangerous. Can we change the culture of intimidation
He comes to the operating room late,
greets no one, and berates the nurse for not setting up the stepstools the way
he likes. He tells the resident she doesn’t know the anatomy and sighs when she
adjusts her grip on a surgical tool. He slaps the hand of the medical student
when she reaches for the retractor to pull back skin for a clearer view. The
operating room is tense for hours. ‘I need a different clamp,’ he says at one
point, ‘this one is too dull.’ ‘I’m on it,’ says the scrub nurse. ‘You’re not,’
he retorts, ‘or else it would already be in my hand.’
All of us adorned in blue scrubs and
surgical caps stand on edge, braced against the next wrathful outburst. ‘I want
to see the tip of my blades,’ the resident explains, staring intently at the
monitors where her laparoscopic instruments have not quite come into view. ‘Just
cut,’ the lead surgeon barks at her. By the end of the operation, the
intern’s hand shakes as he sutures the wounds closed, to the beat of the
running condescending commentary on his halting speed and less-than-perfect
stitches.
One doesn’t have to work in a
hospital long to experience or observe some form of disrespect. This is hardly
a secret. The bullying culture of medicine has been widely written about and
portrayed in popular media. In one study, published in 2012 and conducted over
the course of 13 years at the David Geffen School of Medicine at the University
of California, Los Angeles, more than 50 per cent of medical students across
the US said they experienced some form of mistreatment. Behind closed doors, we
share advice on whom to hang around and whom to avoid.
At the start of my third year of medical school,
when we would finally enter the hospital wards, we had an orientation: ‘Wear a
raincoat,’ the doctor standing at the podium advised. I could expect to get
rained on.
For the most part, I’ve been
pleasantly surprised. The majority of doctors, nurses, and other health care
professionals I’ve worked with have been courteous and respectful: strong
teachers and compassionate caregivers. I have met colleagues whom I would feel
honoured to work alongside in the future and mentors whom I’d want to treat my
own family should they become ill. I’ve been amazed by residents who work
24-hour shifts and somehow still have the energy to teach those who do not yet
know as much as they do. I both admire them and am grateful for them.
But there is a reason those
orientation warnings exist. The surgeon who chides the nurse for her inability
to be in two places at once? The nurse who snaps at the medical student for
reading the patient’s chart the same moment she wants to write it in? They are
a substantial, troubling minority, and they can set the mood for the rest.
Most of my friends in medicine have
witnessed flagrant episodes of hospital bullying and have juicy tales to tell.
But medical disrespect is usually far less dramatic, dished out in the form of
‘micro-aggressions’: exasperated sighs, a sarcastic tone, the dismissal of
alternative ideas.
It’s the subtle put-downs about a
trainee’s competence that erode confidence; the public shaming for an incorrect
answer on rounds; or the denial of simple privileges such as taking a chair or
reading a chart. It’s the psychological effect of being called by your rank
instead of your name, or having it made clear that your presence is a burden
instead of a help. It’s being ignored. It’s other team members looking on when
the disrespect occurs, afraid to challenge it and defend those lower on the
totem pole. These are the acts that affect our state of mind in small but
cumulative ways. This is the stuff that creates a culture.
You learn to deal. This is how it
is. That’s the system. It’s ingrained. You excuse bad behaviour with the
platitude: ‘That’s just the way (s)he is.’ You appreciate from your elders that
it could be much worse – at least they can’t throw scalpels at you anymore. You
make allies and whisper in solidarity with those in the trenches alongside you.
You train yourself, just as they advised you on your very first day, to wear a
raincoat. You start to wear it, and it becomes thicker as your training
progresses. You add boots and an umbrella.
Then, as you get better and more
confident, perhaps you become impatient with the inevitable lack of expertise
in the new trainees. Maybe in a few years, you start to rain on others.
We’ve known for years that entering
the ranks of medicine means developing a thick skin to criticism and being made
to feel small. For a long time there was a mystique that this culture held
everyone to high standards, and it was the price we paid for the care we got.
What is disturbing is the increasing recognition that bullies are not only bad
people to be around – they’re bad doctors, too.
Get admitted to any hospital, and
you might notice that no longer is a single doctor on your case. Contrary to
popular television scriptwriting, treating patients is rarely about the
inspired intervention of one brilliant physician or surgeon. Rather, we work
more like an ecosystem, with every organism in the hierarchy contributing to
the whole.
In the old days, interns straight
out of medical school would man the hospital wards, see very sick patients, and
learn to become doctors by practising on them. They’d experiment, they’d figure
out stuff, and they’d grow. And sometimes, when they were wrong, patients would
pay the price.
Today, we still recognise that newly
minted doctors must be trained, but there are more checks and balances in place
for patient safety. Interns still see very sick patients and propose plans of
action, but those plans are run by more experienced doctors before being
implemented. In teaching hospitals, we meet on team rounds daily, discuss
updates on patients, and talk through goals for the day.
Questions get run by senior
residents, and senior residents run things they’re unsure of by attending
physicians. Whenever there is uncertainty, the question works its way up the
hierarchy. At the same time, decision-making reports back down, so that the
newest of the doctors carry out the plans and learn by doing.
So far, so good – this is a better
system than it used to be. But it is also much more dependent on the
communication and relationships among different members of the team. Now, enter
the culture of disrespect. Suppose an attending physician makes withering
critiques or unreasonable requests. A resident, hoping to avoid such abuse,
slowly but surely starts to hold back. She holds back some questions for fear
of burdening and, under the constant stress of being scolded, becomes immersed
in details of efficiency. Whether she intends it or not, she gives off vibes of
unavailability, spending hours hunched over a computer in the physician’s
conference room cranking out progress notes and scheduling patient
appointments.
Meanwhile, a patient starts to take
a turn for the worse, but it’s not completely clear-cut – his vitals are just a
bit off, his belly seems distended, and he complains of abdominal pain but is
also known to the team as someone who complains. The nurse hesitates to voice
her concerns to the resident, who is swamped doing paperwork and updating
discharge summaries exactly the way the attending prefers. The patient
continues to go downhill, and by the time word gets out the patient is much
sicker – and needs to be treated far more aggressively – than would otherwise
have been the case.
A substantial body of data
attributes medical errors to interactions among hospital workers. Calls for
improved patient safety gained traction from the late 1980s through the early
’90s, when Australian researchers reported a shocking find: the vast majority of
medical errors, some 70‑80 per cent, are related to interactions within the
health care team.
In the early 2000s, a report by the
Joint Commission that accredits health care organisations in the US studied
adverse events over a 10‑year period and discovered that communication failure
was the number-one cause for medication errors, delays in treatment, and
surgeries at the wrong site. It was also the second leading cause of operative
mishaps, postoperative events, and fatal falls.
The link between harsh words and
medical errors was reignited in 2012 when Lucian Leape, professor of health
policy at the Harvard School of Public Health, published a two-part series in Academic
Medicine. ‘A substantial barrier to progress in patient safety is a
dysfunctional culture rooted in widespread disrespect,’ Leape and his
co-authors asserted. ‘Disrespect is a threat to patient safety because it
inhibits collegiality and co-operation essential to teamwork, cuts off
communication, undermines morale, and inhibits compliance with and
implementation of new practices.’
It’s not that jerky personalities
are reserved for those at the top. There are nice people and mean people at
every rank. But in a system dependent on the proper functioning of hierarchy,
it works like this: when anger and intimidation flow down, information stops
flowing up. The chain of communication becomes clogged.
In a system dependent on hierarchy,
it works like this: when anger and intimidation flow down, information stops
flowing up
This information block goes beyond
doctor-doctor interactions. In a now-classic, 1986 study by William Knaus and
colleagues at the ICU Research Unit in Washington DC, communication between
nurses and physicians was the single factor most correlated with increased
mortality in hospital intensive care. Meanwhile, newer research by Alan
Rosenstein and Michelle O’Daniel at the healthcare alliance VHA West Coast in
California has identified a pervasive trend in which nurses are reluctant to
call physicians – even as a patient deteriorates. Some of the most popular
reasons provided, according to their research? Intimidation. Fear of
confrontation. Concerns about retaliation.
In another study by Rosenstein and
O’Daniel, nurses and physicians self-reported behaving badly in near-equal
numbers. Most felt this behaviour resulted in increased errors, lower quality
of care, and lower patient satisfaction. Seventeen per cent could name a
specific adverse event that occurred as a direct result of disrespectful
behaviour.
When someone is unpleasant or
demeaning, something switches in the minds of those on the receiving end: they
sacrifice honest communication to save face. I’ve seen it in action so many
times that the pattern has become predictable. Preoccupied with fear of
appearing incompetent, team members keep uncertainties under wraps. Other times
the opposite occurs. Annoyed that they’re being denigrated and prideful
themselves, others fight back – even when they’re unsure of the thing they’re
fighting about. Once I saw two residents argue back and forth in front of the
attending about a finding on a physical exam; the issue was unrelated to the
patient’s illness, and the fight, a clash of egos, took mental energy and focus
away from the patient’s needed care.
Many in medicine actively protect
the culture of disrespect because they hold a fundamentally flawed idea: that
harshness creates competence
Contrast that with cultures steeped
in mutual respect. I’ve been on some truly outstanding medical teams that
worked in opposite ways. Though everyone knew their place in the hierarchy, it
also felt more egalitarian. Patients came before pride. The senior staff told
others how to reach them and opened the lines of communication. Nurses attended
morning rounds with the doctors; their input was valued and they were kept in
the loop at every step.
One night, we were on call with a
‘watcher’ – that is, a patient who could take a turn for the worse quickly. The
resident made clear her door was open – literally and metaphorically. The
nurses came by often and clarified orders. When the patient began to look even
slightly ill, the nurse immediately got the doctor. They examined the patient
together as the doctor explained what to do next and why. Questions were
encouraged. Communication was crystal-clear. And the patient did well.
Yet despite such outcomes, many in
medicine actively protect the culture of disrespect because they hold a
fundamentally flawed idea: that harshness creates competence. That fear is good
for doctors-in-training and, by extension, good for patients. That public
shaming holds us to higher standards. Efforts to change the current
climate are shot down as medicine going ‘soft’. A medical school friend told me
about a chief resident who publicly yelled at a new intern for suggesting a
surgical problem could be treated with drugs. The resident then justified his
tirade with: ‘Yeah, yeah, I know I was harsh. But she’s gotta learn.’
Arguments such as these run counter
to all the data we have on patient outcomes. Brutality doesn’t make better
doctors; it just makes crankier doctors. And shame doesn’t foster improvement;
it fosters more mistakes and more near-misses. We know now that clinicians
working in a culture of blame and punishment report their errors less often,
pointing to fear of repercussion. Meanwhile, when blame is abolished, reporting
of all types of errors increases.
We can no longer deny the facts. Bad
cultures lead to bad outcomes. Jerks do not make good medicine. They foster a
backwards atmosphere that degrades trust, tarnishes open communication, and
promotes cover-ups.
Creating a culture of respect is not
just about feeling good, for its own sake. It’s better for patient care.
Pointing out dysfunction is easier
than solving it. The million-dollar question is: does it have to be like this?
And if not, how can it be improved?
Some medical programs are already taking
steps to tackle disruptive interactions. A leader here, the David Geffen School
of Medicine at UCLA, began to address the problem as early as 1995; they
created workshops and training sessions, established a Gender and Power Abuse
committee, and developed mechanisms to accept confidential reports of
mistreatment. More recently, Massachusetts General Hospital in Boston developed
a model for team restoration following disruptive interactions.
Programs to spot and eliminate
disrespect work well with one-time instances of explosive behaviour. But from
my experience, the worst offenders are serial offenders. That some have made it
to the top of the food chain suggests there was no sufficient deterrent for
behaving that way. That must change. Medical trainees are already evaluated on
many qualities these days. The powers-that-be can prioritize respectful
behavior on that list. If we evaluate and ultimately promote trainees on honest
communication and keeping their egos in check, we’ll cultivate good behaviour
from the start.
We can’t ignore a system that takes
loads of formerly ‘nice’ people and churns out jaded, bitter, and gruff ones.
At the same time, change should
emerge from within the hospital itself. Instead of looking away sheepishly when
our colleagues are mistreated and apologising for bad behaviour with tired
mantras, we should push back. Bullies have ripple effects. Medical students
mimic the behaviour of residents who mimic the behaviour of attendings until a
problem with attitude can extend from a few people to an entrenched culture.
Instead of riding that wave, we could shun bad behaviour. This is easier said
than done. But cultures change because people within commit to changing them;
it won't come by decrees. A culture that shames bullying makes the bully look
like the bad guy, rather than making the recipient look weak.
In a similar vein, we should put an
end to the premium that the medical establishment places on saving face. This
is a hazard. It feeds the egotistical environment that can lead to ignoring
input and failing to ask for help. It creates doctors who value looking like
they know what they’re doing at all times more than actually doing what is
best.
Finally, we should be getting to the
root of the behaviour. Why do people behave badly?
Some are just jerks. Some imitate
jerks. But we also can’t ignore a system that takes loads of formerly ‘nice’
people and churns out jaded, bitter, and gruff ones. We have to call attention
to the external factors that can contribute. The lack of sleep. The poor hours.
The system that overbooks and overworks. Environments such as these persist in
part because of our unique vantage point in taking care of others at some of
the worst points in their lives. How can I say ‘I’m tired’ or ‘I’m hungry’ or ‘He
hurt my feelings’ in the face of such profound human suffering? Yet it’s hardly
absurd to ask for better working conditions.
When working in a system that treats
us all humanely, we’re more likely to be humane to each other, and to our
patients
