Saturday, October 08, 2011

A Yom Kippur commentary on the Jonah story

Rabbi Robert Goldstein, of Temple Emanuel in Andover, MA, invited me to deliver a Yom Kippur commentary today on the Jonah story.  I'm not used to combining religion with health care, but thought I'd give it a shot.  Here it is, a bit longer than my usual posts.

            We all know the first part of the Jonah story, where he avoids a divinely mandated mission and eventually finds his way back to it, after a three-day visit inside of a whale.  After all, who wouldn’t change his mind while sitting in the dark in a roiling mess of bile and dead fish?
            This first part of the story has a clear message about taking on responsibility, even when you fear the consequences.  But let’s also remember the follow-on part of the story.  Jonah has gone to Ninevah, telling them it is time to get their moral and ethical act together.  The population repents, and the king of Ninevah dons sack cloth and sits in ashes.  Even the animals fast.  The Lord spares the city.
            Now, Jonah is really upset.  He sits around stewing.  In essence, he says, since God is merciful, he would have forgiven the city anyway, so why make Jonah go through all this pain and suffering and fish gut routine.   “Take my life,” he says.  The Lord says, “Art thou greatly angry?”  No reply from Jonah is noted.
Jonah stomps out of the city and sits waiting to see what will happen to Nineveh.  God makes a plant grow over him to shade him, but then he sends a worm to bite the plant’s root, and it withers.  Now, Jonah is exposed to the full force of the sun, becomes faint, and asks again to be taken out of this world.  It is time for God to crystallize the message. 

And God said to Jonah: 'Art thou greatly angry for the gourd?' And he said: 'I am greatly angry, even unto death.'
And the LORD said: 'Thou hast had pity on the gourd, for which thou hast not laboured, neither madest it grow, which came up in a night, and perished in a night;
and should not I have pity on Nineveh, that great city, wherein are more than six score thousand persons that cannot discern between their right hand and their left hand?'

            The book ends there, after four short chapters.  With God as our role model, what guidance are we given about the general approach we should take with regard to forgiving others?
            This is an important question in the health care world.  Let me frame the issue.  I hope you will agree with me that people who choose to be doctors are among the most well-intentioned people in the world.  They devote their lives to alleviating human suffering caused by disease.  They study for years in school, do biomedical research to discover the causes of and cures for illness, and spend time generously teaching the next generation of physicians.
            There is a paradox, though, in that this same group of extremely well-intentioned people, when working together in the nation’s hospitals, constitutes the fourth ranked public health hazard in the country – in terms of the likelihood that you or I as a patient will be killed or injured while in their care.  I am not talking about dying from disease:  I am talking about the 100,000 people per year who are victims of preventable death.  That’s twice as many as US soldiers who died in the entire Vietnam War.
            The reasons for this are mainly systemic, embedded in the nature of how work is organized in hospitals.  The solutions, though, are clear and have been implemented in many other complex industrial and service environments.  And yet, the people running most of the nation’s hospitals – administrators, physicians, and their Boards of Trustees – have failed to devote sufficient leadership, energy, and commitment to solving the problem.  Indeed, when harm occurs, most people in the hospital world say, like Milton Berle to Ethel Merman in It’s A Mad, Mad, Mad, Mad World, “These things happen.”
            To which Mrs. Marcus replies: 

Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us. 

At the most fundamental level, we might look upon this complacency as a betrayal of the doctors’ oath to “do no harm.”  How, though, could we reconcile such a judgment with the profession’s clear devotion to good intentions?
            Well, I hate to put it this way; but good intentions are not enough.  I used to sing with the BSO’s Tanglewood Festival Chorus.  One day, a famous conductor was rehearsing the chorus, and one singer rather energetically and persistently kept making a noticeable mistake.  After several takes, the conductor put down his baton, looked into the chorus, and said, “You know, enthusiasm isn’t worth a darn if you are singing the wrong notes.”
            How much more so in the medical setting, when a mistake can result in the removal of the wrong organ, can cause a preventable terminal infection, or where there is a huge variation in practice among residents and attending physicians, giving lie to the concept of evidence-based medicine.  Dr. Brent James from Intermountain Health in Utah describes this as, "well-documented massive variation in practice based on local medical myths."  He notes: 

We continue to rely on the "craft of medicine," in which each physician practices as an independent expert -- in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.) 

As Brent notes, physicians, unfortunately, have been trained to often sing the wrong notes.  The question, then, is how to persuade and re-train physicians to learn to apply a scientific approach to the delivery of care to the same degree that they have learned the scientific method in conducting medical research.  Well, oddly enough, the last portion of Jonah gives us a hint:  It is to be gracious enough in the presence of failure to forgive the offence.
Here is a representative story from my former hospital, something that happens in hospitals hundreds of times per year throughout the country:
In July of 2008, a patient woke up after orthopaedic surgery and asked her doctor, “Why is the bandage on my right ankle instead of my left ankle?”  It was at that moment that the surgeon realized he had operated on the wrong limb.  It would be hard to know who was more distraught at this moment, the patient or the doctor, who realized that he had violated a life-long oath to “do no harm.”
The surgeon immediately notified his Chief of Service and me, as CEO.  All of our department chiefs and quality assurance people met to review the underlying causes of the error.  It was quite clear that the “time-out” protocol that was our hospital’s policy, which was designed to avoid precisely this kind of error, had not been properly carried out.  In the weeks following this disclosure, a number of people asked me if we intended to punish the surgeon in charge of the case, as well as other people in the OR who did not carry out that protocol.
Some people were surprised by my answer, which was: "No, this person has been punished enough by this searing experience. He promptly reported the error to his Chief and to me.  He also took all appropriate actions to disclose and apologize to the patient, as well as participate openly and honestly in the case review."
This reaction was supported by one of our trustees, who likewise pointed out that it would be hard to imagine a punishment greater than the self-imposed distress already being felt by the surgeon.  But another trustee said that it just didn't feel right that this highly trained physician, "who should have known better," would not be punished. "Wouldn't someone in another field be disciplined for an equivalent error?" this trustee asked.
This was a healthy debate for us to have, but a wise comment by a colleague made me realize that I was over-emphasizing the wrong point (i.e., the doctor's sense of regret) and not clearly enunciating the full reason for my conclusion. He said, "If our goal is to reduce the likelihood of this kind of error in the future, the probability of doing that is much greater if this doctor is not punished than if he is."
I think he was exactly right. Punishment in this situation was more likely to contribute to a culture of people hiding their errors rather than admitting them. And it is only by having a culture in which people freely disclose errors that the hospital as a whole can focus on the human and systemic determinants of those errors.
We are left with a follow-on question, though: Under what circumstances does the need to punish someone trump the other concerns about institutional learning and a no-blame environment? Beyond the obvious case in which a doctor intentionally harms a patient -- where no one would doubt the application of punishment -- I am afraid that the answer is, "It depends."
How do you offset the predisposition of most people to want to assign blame, especially when those people are trained professionals, like doctors, whose education supported such an insidious cultural imperative?  Or putting it another way, how do you help people in an organization enjoy learning from mistakes? 
Hospitals are hotbeds of errors, so they offer us excellent laboratories within which to try and study different approaches to create a learning environment.  But, as a scientist might say, the substrate must be appropriate and welcoming.
If you are going to treat people justly when errors are made, you need a standard of justice.  In the medical world, we have a guide for just decisions about behavior.  It is a scale based on the nature of the event and the error.  In our hospital, it was formally voted upon by the medical leadership as a standard of review. 
The idea is that there are certain events that are always blame-free and others that are certain to require disciplinary action.  In the former category, we have mistakes that are made when there is no policy or process in place, when the person incorrectly interpreted an ambiguous policy or process, or when he or she was actually following the official policy.  In contrast, people can expect disciplinary action when they intentionally cause harm or tamper with the error reporting process (i.e., a cover-up); when they recklessly or intentionally disregard patient safety; or when they repeatedly violate hospital processes, policies, or standards.
But no formula can cover all events.  It is appropriate to acknowledge that judgment will be used in the “gray areas.”  This kind of formal template provides comfort to doctors and nurses that there is a standard by which their actions will be judged.  Here is an example of the virtuous response it can provoke, from a young nurse who wrote me just hours after I sent out an email to the staff explaining our view of this just culture: 

I feel inclined to respond to your email with an experience I had today on the floor. At work today I made a mistake, a medication error. My stomach turned, I felt faint . . . however I recalled my focus earlier in the day: on the integrity of the hospital and the type of light that it shined on my paradigm as I entered my day. I felt an immediate sense of freedom and put my attention on what I needed to do to correct the error. Although embarrassment and fear visited me, I wasn't overwhelmed by the emotions. I contacted the right people, and helped maintain the safety of my patient. It was a very challenging day . . . and I grew. I will go to sleep with integrity; knowing I was honest, feeling I had done all I could.

I know healthcare presents these types of moral dilemmas to all of us who choose this challenging field to work in. Beth Israel is a safe place to honestly confront these dilemmas and strive to achieve the excellence that I know can exist. 

But I need to lead you deeper into the wrong-site surgery case by suggesting that the discussion about disciplining the doctor was off point.  The question should have been:  Should we discipline the hospital’s leaders?  Let me explain.
There is a kind of team training, called Crew Resource Management (or CRM), developed by the military to enhance the functioning of crews in an airplane cockpit.  If the surgical team had gone through that training, it would have helped avoid the wrong-site surgery.
This advance in team training was not unknown at Beth Israel Deaconess Medical Center.  Just three years before the wrong-side surgery case, the doctors, nurses, and other OR personnel in the Obstetrics department in our hospital spent months learning CRM after an incident that left a baby dead and a mother near-dead for weeks.  The case was shocking to our staff, who had always viewed themselves as one of the best obstetrics departments in the nation.  Those reviewing the case quickly diagnosed that poor communications among the care team, not a lack of technical ability, was the cause of this tragedy.  Ben Sachs, the chief of the department, brought in trainers from the Department of Defense to teach his clinicians how to work together in the high-stress “cockpits” of the labor and delivery rooms.  The CRM training took many months and was mandatory for all personnel.  The result was a substantial improvement in patient outcomes, later documented in peer-reviewed journals.
We received awards for this program, as it was quite innovative in the health care community.  In the citation for one such award, it was noted: 

The success of this work has been broadly recognized and has driven or influenced similar initiatives, including those of the Harvard Risk Management Foundation, the Commonwealth of Massachusetts, the State of Maryland, and the District of Columbia, among others. 

You would have thought that, based on that experience, we in leadership positions would have encouraged and supported – if not mandated -- an expansion of that training program to everybody involved in any kind of surgical or interventional procedures.  But we failed to do so -- even though the work was “broadly recognized and influenced similar initiatives” elsewhere.  In so doing, we let a ticking time-bomb keep ticking.  It was only a matter of time before a process failure would occur in one operating room or another.  When it happened, it was more our fault than the surgeon’s.  If there was anyone to blame, it was I, the CEO, who had failed to assert our obligation to spread the learnings of the Obstetrics department to all of other medical specialties, to every appropriate team of clinicians in the hospital.
Ours was not the only organization to have learned that the leadership role in such matters is determinative of process improvement in an organization, but equally important, the personal and professional growth of people working there. Let me bring in an example from another field, oil exploration, one of the most dangerous occupations in the world.  A number of years ago, after being involved in an oil rig tragedy in which he personally had to call off the search for men left missing at sea, Tom Botts at Royal Dutch Shell decided that he would implement the most comprehensive program possible to protect workers’ safety at these remote outposts in the ocean.  Notwithstanding that program – the best in the industry – two men lost their lives on a North Sea oil rig when they mistakenly went into a portion of the facility that should have been off-limits.  It would have been easy to blame the two men who, after all, went where they should not have.  Instead, Tom launched a thorough, top-to-bottom review of the organization. He explained: 

We decided to be as open and transparent about the incident as possible and went through a Deep Learning journey involving hundreds of people that examined in detail all the root causes that contributed to the accident to get a clear picture of the system that produced the fatalities. Even though the two men who were killed could have made better decisions, my senior leadership team and I could find places where we “owned” the system that led to the tragedy. 

It was a defining moment for us when we, as senior leaders, were finally able to identify our own decisions and our own part in the system (however well intended) that contributed to the fatalities. That gave license to others deeper in the organization to go through the same reflection and find their own part in the system, even though they weren’t directly involved in the incident.

 Back to the second part of the Jonah story.  I hope you won’t think this sacrilegious, but maybe God decided not to punish the people of Ninevah because he realized that he was complicit in their bad behavior.  I guess this depends on your concept of God, but if there is an all-powerful being, shouldn’t he be pretty good at teaching us how to behave?  If he is going to intervene, why wait until we have gone so far down the wrong path?
There is an old joke about a guy who dies and goes to heaven, where he patiently waits in line to get through the admission process.  A fellow wearing a white jacket and stethoscope rather rudely pushes his way through the crowd to get in the entrance.  The new arrival says to his neighbor in line, “Who’s that?”  The reply, “Oh, that’s just God.  He thinks he’s a doctor.”
Perhaps the story of Jonah suggests that God is more modest than this joke implies, but only if there is a substrate upon which we can learn.  Perhaps it is our own attitude toward forgiveness that suggests whether we can be forgiven.
By the time I left my job at BIDMC, we could document that the steps we had made in process improvement and avoiding preventable harm meant that hundreds of people whom we otherwise would have killed and maimed were instead walking out of our hospital.  I had mixed feelings about that.  Of course, I was pleased; but I kept wondering whose mothers, fathers, sisters, and brothers we had caused to die in previous years – the years before we stopped saying “these things happen.”  The fact that other hospitals in the region and beyond had not gone as far as we had was no solace.  It was our mission to avoid harm, not cause it.
If it were possible, I would ask forgiveness of those families whose loved ones we hurt for so many years.  I would say, “It was I, as leader of this place, who should have worked harder, smarter, and faster to avoid the tragedy that befell your family.”  It would be my hope that such an acknowledgment would lead those people to forgive me, as God forgave Ninevah and as he ultimately forgave Jonah.
Let me end with a story of the transformative power of forgiveness.  Those who know me know of my passion for soccer, and especially for coaching girls in our community league.  I recently had lunch with one of my alumnae, now aged 28. Tovah said to me, "Do you remember that play I made in the tournament we went to in Connecticut?"
Even though 14 years had passed, I remembered her gusty play with clarity, "Of course, you made a great save in front of the goal.”  The goalie had run out to clear a ball, but an opponent had taken possession and fired at point-blank range at our net.  Tovah stood there in front of the goal and used her chest to knock down the shot.
"I don't remember that," she said, "I mean when I mistakenly headed the ball into our own goal and caused us to lose the game."
"I forget that one," I replied.
"Well, I was devastated and was sitting on the grass after the game, sobbing my heart out. You came over and said, 'Don't worry, Tovah, great defenders sometimes score against themselves. Only the best defenders go out aggressively after every open ball. Every now and then, it deflects and goes into the net. You did a wonderful job.'
"I stopped crying, stood up, brushed myself off, and walked off smiling, saying to myself, ‘I'm a great defender!’ That season was very meaningful to me.”
She remembered this 14 years later.
The lesson is so clear.  You never know when a kind or supportive word from you will make a lasting difference.  When you offer solace or encouragement to a person who has made a mistake, it matters.  To do so, though, you must truly believe that it is not the mistake that matters:  It is the lesson that can be drawn from it.
L’shanah tovah to Tovah and to all of you.


Hospitaldoctor said...

Excellent; a lot of wisdom and knowledge shared generously.

Barry Carol said...

In the case of the wrong side surgery, suppose the mistake happened because the surgeon was arrogant and thought that procedures like timeouts didn’t apply to him / her. Suppose also that nurses and techs knew not to speak up or challenge the doctor because he would berate them or even try to get them fired. At the same time, because of his reputation as a well established surgeon with an excellent overall outcomes record, he brings in a lot of well insured patients to undergo very profitable procedures. If the hospital is operating barely above breakeven or worse, it can ill afford to lose this business which makes CEO’s and Boards reluctant to impose any discipline under these circumstances.

It seems that if hospitals are serious about creating a culture of safety, senior management needs to support and protect nurses and techs willingness to speak up if they see a mistake being made in the OR, ICU or elsewhere. It also needs to be prepared to part company with “rainmaker” surgeons and other doctors who think the regular rules don’t apply to them even if doing so could have a significant adverse effect on the hospital’s bottom line. Presumably, if the doctors were actually employees of the hospital, it would be easier to get their full cooperation in building and sustaining a culture that includes patient safety as a core value and priority. It can be a tough conundrum sometimes.

Paul Levy said...

An easy call, Barry, if the medical staff and administration have jointly decided on the rules of the hospital -- whether the MDs are employed or not. Patient safety has to come first. That is the beginning and the end of the story. Sometimes, though, it takes a while for it to sink through the culture.

Barry Carol said...

That’s good to hear, Paul. If a rainmaker or two were dismissed or had their practice privileges revoked because of a serious patient safety error caused by arrogance and in clear violation of established rules, it would speak volumes that a patient safety culture is for real, at least at that hospital. Unfortunately, I think there are still too many hospital CEO’s and Boards that would come down in favor of protecting the hospital’s cash flow rather than risk losing a large piece of lucrative business.

Dokjim said...

[Not sure my last post came through. Just vanished as I tried, unsuccessfully, to log into Google. Also, forgot to add my email.]

I agree completely with your Yom Kippur message. Let me pick up on two threads.

I am a pediatric intensivist and use the “conductor” metaphor frequently. (In a previous life I played the viola). A colleague and I recently wrote a commentary for AHRQ that, in a few words, suggested a child’s death was directly linked to the lack of a conductor ( Also, your discussion of CRM triggered a link in my mind with a recent article Atul Gawande wrote in the New Yorker about the use of coaches for established surgeons (
I (as a senior faculty member) believe a coach would be wonderful but struggled deciding which skill set for which push for coaching.

So to tie my thoughts together, I need to find CRM coaching and I should have suggested CRM coaching to the intensivist and their colleagues in our AHRQ commentary.

Jim Fackler

Howard said...

Thanks for sharing your Yom Kippur commentary. It was meaningful and quite appropriate in today's environment.

Anonymous said...

I chant this portion of the haftarah each Yom Kippur, and the final phrase of the portion is, "...people who do not know their right hand from their left and many beasts as well." The metaphor in this can also been seen as helping animals and others who perhaps don't know how to behave. It also notes that Jonah doesn't know what to do either. Despite the fact that he is "educated" he can't see the need without G-d's intervention.

Anonymous said...

Thanks for a good story.this story teaches us to have a good heart towards the patientS. Nomatter what knowledge we have about work we must pray to god to guide us.

Anonymous said...

I had the same trouble as Dokjim but without the logon issue; maybe too many people tried to comment at once!

My resubmitted comment is directed in response to Barry's. We have been spoiled by reading Paul's blog into thinking that the majority of hospital CEO's are like him; unfortunately that is not the case. Worse than not punishing the rainmaker, Barry; many CEO's would decide it was too expensive, or too hard, or too much trouble, to embark on a serious (I emphasize serious, as opposed to JC-satisfying lip service) patient safety initiative. Sometimes the shoe is on the other foot; some of the physicians want to improve safety and encounter administrative resistance.
For that reason I used to advocate shared governance between the two groups. IMC(current)O (as the wise lean lady suggested below), I think patients should be included in all aspects of governance to ensure that the proper focus - on the patient - is maintained.

nonlocal MD

Kerry OConnell said...

Medical Culture teaches that the greatest experience a surgeon can have is bringing a desperately ill patient back from the brink of death. I believe that the greatest experience a surgeon can have is receiving unconditional forgiveness from a patient that you have permanently harmed. If you are so blessed cherish it and find the courage to tell the world.

George said...

Chag sameach Paul!

I liked this one.

Barry said...

I really enjoyed this post. I've often thought of how to combine a drasha with healthcare. Now I know it can be done...well.

Laurie said...

One of your best columns yet.

Paul Levy said...

Thanks to all!

Anonymous said...

Paul, Shanah Tovah. I'm unclear about your answer to Barry Carol as to how you would handle the arrogant rainmaker who thought the rules don't apply to him (and let's add that this is the first time he's ever done wrong side surgery even though he blatantly flouted the rules). So what would you do with him?

And another hypothetical for you, if I may: A full-code 90 year old woman with dementia and aspiration pneumonia goes into acute respiratory distress but isn't intubated and dies of resp. failure.

Her bereft daughter informs the hospital that the attending called in a pulmonologist who flatly refused to intubate, telling her intubation was inappropriate and that her mother was "dead the day she got here." The pulm, who doesn't recall seeing the patient on that day, didn't document or even bill for the visit. The attending also failed to document his handoff to pulm. No nursing notes.

After much effort the daughter is able to get the attending to fully corroborate her allegations (attending called in pulm for emergency consult, handed off distressed patient and left hospital without ever checking back). How would you have handled a situation like that?

Paul Levy said...

My answer, and not hedging, is that I wouldn't personally handle it at all. It would be fully discussed with our Medical Executive Committee, who would make the judgments. What I would have worked to make sure of was that the MEC had in place a standard of review for such cases.

Ditto on the surgeon. The MEC would rule on the case, not me alone. I would expect, though, and have seen our MEC suspend even rain-maker doctors for intentionally violating the rules -- even when patients were not harmed.