Monday, January 05, 2015

Seeking a system that treats us all humanely

As 2015 begins, let's turn back to last January's aeon article by Ilana Yurkiewicz.  Simple, direct, and incontrovertible.  (Thanks to long-time reader Mitch for the reminder.)  Key excerpts:

Creating a culture of respect is not just about feeling good, for its own sake. It’s better for patient care.

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.

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.

How to fix this?

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.

11 comments:

David Withington said...

This article spoke to me. So, so true. I'm involved in the health care field (20+yrs.) on the supplier side as a medical device rep. I over the years could definitely notice certain hospitals with much different cultures just by working with nurse managers (OR, ICU . . .), Purchasing Mgrs.

The culture was created from the top down and it was unfortunate when you had a new fresh, friendly, honest person take on a new position to eventual see them change for the worse.

Thanks for sharing such wise words.

Paul Levy said...

Thanks, David. I felt the same way. So pleased you like it, too.

Lars Peterson said...

Love this post - I know my system would be significantly improved if we made these changes.

Barry Carol said...

As a patient, I would like to think that the hospital has a culture that allows nurses and techs to feel empowered to speak up without fear of retribution if they notice a problem, especially about something a doctor did but shouldn’t have or didn’t do but should have.

Some doctors are arrogant and don’t appreciate being questioned by people of lower rank and pay. Those same doctors may also generate a lot of business for the hospital. For a hospital management to fire a rainmaker doctor or revoke his practice privileges for bullying behavior is easier said than done especially if the hospital’s financial position is precarious. If the CEO’s mandate from the board is to grow revenue, profits and market share, it probably makes creating and sustaining a humane culture even harder.

Isabel C. Legarda said...

From Facebook:

I have seen similar commentaries throughout my career and the rhetoric has remained largely the same. Change is slow, I think, because while these ideas are right and just, they are not enough to remove the variable of power inequality from the equation. When the bullies are the same people who write the paychecks or determine advancement (or even just continuation in the same position), how can a culture shift?

Sheldon Jenkins said...

Mr. Levy,
Considering the push for the collaborative approach associated the medical home models of care requires clear communications. The collaborative team approach provides eclectic care and lower cost. Positions of authority and knowledge held by bullies corrupts and disrupts this system and should not be tolerated. However we know it exist but should be routed out by leadership regardless of the short term cost.
www.linkedin.com/pub/sheldon.jenkins-mba-mha-otr=l/56/604/16

nonlocal MD said...

It really all comes back to fee for service, doesn't it. Until that changes, the rainmakers will rule the roost and they are often the bullies. In addition, there are a number of 'copycat bullies' who are not rainmakers but are all too willing to ape the behavior. (How it spreads down to residents, etc.) It all cascades and creates this culture but, in the absence of either physician or CEO courage to buck the bucks, so to speak, nothing will change.

By the way, that article sounded very familiar to me too. The culture is clearly widespread.

Theresa Willett said...

So much truth, here! I have experienced the bullying, always from the 'top' in several different medical workplaces. When the system was accessed to try to address the behavior, we 'trouble makers' were told that we had to back up our clinic admin / chief / whomever, and that the happiness of our staff was not our issue. Very discouraging!
Also, in my training institution, there was a dreadful attitude among residents regarding calling the PCPs of admitted patients. Even the PICU team did not seem to understand the need to reach out to the primary. It turns out, the issue started at the top, again, with attending who were dismissive of the task and treated it like an odious hot potato. As an attending and primary care provider in the same institution, I found this disrespect unbelievable. When my colleague attempted to encourage better practices, she was shut down for being bothersome. Our egos may have been wounded by the disrespect, but the patient care is the ultimate sacrifice. How am I to plan follow up care when I don't know what has happened?
Thank you again for eloquently expressing the way things can and should be.

pheski said...

Eloquent and on target. As I read it, though, I kept asking myself how one 'fights back' against a culture of disrespect and bullying when that culture is created and maintained by top level leadership and management?

rhlcorder said...

Right on! Thanks for posting this Paul and for the eloquent reminders.

The further into my life I get the more and more I am convinced of the underlying truth that we are culture. How we behave, how we speak, how we listen, what we tolerate, and who we tolerate.

If it is to be it is up to me.

I’m not saying that standing up and speaking up against the establishment and the ego’s is easy but the alternative has got to stop being an option. We need to collaborate and share stories of how, with quivering voice and shaking hands, colleagues, friends, co-workers and peers are making a difference by calling out and pushing back on behavior and language that is anything other than kind, professional, respectful and open.

A culture of respect makes for a better care environment, and in turn makes for better care.

Richard said...

Thanks for posting this Paul and for the reminders.

The further into my life I get the more and more I am convinced of the underlying truth that we are culture. How we behave, how we speak, how we listen, what we tolerate, and who we tolerate.

If it is to be it is up to me.

I’m not saying that standing up and speaking up against the establishment and the ego’s is easy but the alternative has got to stop being an option. We need to collaborate and share stories of how, with quivering voice and shaking hands, colleagues, friends, co-workers and peers are making a difference by calling out and pushing back on behavior and language that is anything other than kind, professional, respectful and open.

A culture of respect makes for a better care environment, and in turn makes for better care.