During Ernie's class at MIT, the students and I were discussing why it is so hard to implement process improvements in clinical settings. I suggested that one aspect of the problem was that doctors, no matter how well intentioned, were not trained in such matters. Further, I suggested that there is very little in the career advancement pattern of successful doctors in academic medicine that rewards attributes that are so important in most other fields of endeavor, i.e., interpersonal skills and teamwork.
Well, along comes Linda Pololi, an MD who has been doing research at the Women's Studies Research Center at Brandeis University, who today conducted a seminar about her new book, Changing the Culture of Academic Medicine. (Dartmouth College Press.) The book is mainly about the perspectives of women faculty in medical schools, but it also has observations from men. It is based on extensive surveys and interviews with faculty members from a number of prominent medical schools.
Not only did Linda confirm my hypotheses, she provided thorough documentation of a pattern among the faculty of medical schools that can hardly fail to have an impact on those trained in the system.
Here are some excerpts:
Our data show that the way medical schools are structured and the norms of behavior among faculty can create huge barriers to effective relationship formation . . . a medical school environment that could at times negatively impact patients and our system of health care as a whole.
Problems with personal interactions in the academic medical culture emerged as a central theme in our interviews. . . . Comments about relationships tended to arise spontaneously rather than be elicited by the interviewer. . . [and] both women and men spoke similarly about relationships in the interviews.
Two fundamental worrisome experiences . . . were a sense of disconnection and having few trusting relationships with colleagues and supervisors.
Interviewees described an intensely individualistic, competitive environment where rewards usually went to individual accomplishments. . . .[I]ndividuals and institutions tended to function on behalf of their self-interest, making decisions and choices that benefited themselves rather than contributing to the common good -- and sometimes came at the expense of the common good.
The system is designed to create barriers at all levels to collaboration and collegiality.
Numerous faculty complained of not being recognized as a person beyond their professional role. No attention was paid to what people were feeling. . . . [T]his refusal to engage them as individuals had a depersonalizing effect. The culture seemed to ignore the qualities that made them able to address human needs and show compassion and sensitivity to others.
We found little indication that medical schools cultivated appreciation of people's efforts. Rather, the focus was on finding fault.
Now, let's draw the connection between all this and patient care. It is obvious that process improvement is hampered when there is a lack of trust, collegiality, and collaboration among the medical staff. But sadder still, consider the implications for those being treated. Linda notes:
There is a parallel between disconnection and emotional detachment among medical school faculty and ineffective communication between doctor and patient. If faculty feel disconnected and cannot communicate among themselves, they are less likely to create good relationships with students and patients. Similarly, in a culture where faculty and administrators themselves do not receive consideration and compassion, it is less likely that they will treat students and patients with compassion.
And what about improving quality and safety and reducing harm to patients?
Research shows that physicians remember for decades mistakes they have made, feeling guilty and humiliated and isolated in their shame. Only by creating transparency, so they can discuss mistakes openly, can these destructive feelings be relieved. Equally important, open discussion enables the physician and others to learn from these mistakes and prevent them from recurring.
If the training ground of American physicians works against this common sense view of the world, is there any doubt as to why we have such problems in patient care? Clinical and administrative leaders in hospitals must strive to undo the culture that is embedded in these centers of learning and help those who have devoted their lives to alleviating human suffering to start, first, to alleviate their own suffering and sense of loneliness and isolation.