Thursday, February 10, 2011

Huge barriers to effective relationship formation

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.


Unknown said...

Trust is based on personal experiences. Collaboration is much easier with those that you trust. It is the uncommon administrator who values and promotes this in her/his hospital staff...

wrinkledman said...

You rewarded the individuals who made insightful comments rather than the class as a whole, thereby promoting competition over collegiality. Considering the topic, it would have been more apropos to take a picture of the whole class and praise them for fostering an environment where insightful comments redound to the benefit of the entire group.

Paul Levy said...

Hah! You are so right!

Thanks for pointing this out, but I am still only going to post the best essays next week!

Anonymous said...

Regarding wrinkledman's and Paul's exchange, let me comment as a product of the culture described in this post. It goes to the heart of what motivates humans. Remember how people are complaining about schools where every student is rewarded and everybody gets a trophy whether they win or lose? Apply that attitude to medicine, and what will be the effect? In a field where a mistake kills people, should we have this attitude? Does it encourage the mediocrity and laissez-faire attitudes bemoaned among today's school pupils? On the other hand, does scaring the bejesus out of med students and residents produce the desired effect either?

I think many physicians feel the 'touchy-feely' culture in some of the ancillary areas of medicine encourages sloppiness. Hence you have the culture Dr. describes. So the question is, exactly what do we want to replace it with?

I do not know the answer - just posing the question.

nonlocal MD

Paul Levy said...

The term "touchy-feely" is so loaded with negative connotations that it would seem to exclude normal human relationships based on trust, cooperation, and collaboration. Couldn't we just start with those attributes?

I bet if you ask Gary Kaplan, at Virginia Mason Medical Center, he would say that trust, cooperation, and collaboration are essential in delivering high quality medical care, not inimical to it. Indeed, he would be able to prove that they reduce the likelihood of patient harm.

Anonymous said...

OK, Paul; my mouth got me in trouble again. By 'touch-feely' I am referring to the necessity for paying attention to BOTH the medical needs of a patient as well as comfort needs, and not neglecting the former in favor of the latter. The same pertains to staff to staff relationships. Both are critical; the question is what teaching method will foster both equally.
If that doesn't get me in even deeper trouble......


Anonymous said...

Sounds like the debate in the mothering world these days: are you a Chinese "tiger" mother or a Western "touchy feely" mother? Nothing much is to be gained by polarizing this issue.

Medicine is not a zero sum game with winners and losers. Much good science has shown that caring is essential part of healing whether the patient ultimately recovers from the illness or not. Family members remember how they were treated - and like it or not, the patient safety issue is galvanizing families because they can't necessarily trust the care their loved one is receiving in the hospital. A collaborative approach, recognizing the humanity of care providers and the limitations of science/medicine to solve all issues, will go a long way in reviving public trust in healthcare as an institution.

Is it too much to ask for compassion AND quality care (i.e., not sloppiness?)

a medical sociologist (one of the 'soft' sciences which has great resources for changing the culture of medicine)

Julie Rosen said...

Hi Paul,

We agree that changing the culture of medicine must begin with the support of clinical and administrative leaders in hospitals. Though many have focused on boosting empathy among medical students, we must also focus on practicing physicians through continuing medical education programs. Research has shown that such programs can have a measurable impact on the ability of clinicians to show compassion for patients and families and help them feel more comfortable discussing sensitive issues or dealing with difficult situations. (Academic Medicine, June 2010; Lown & Manning)

We hope Linda’s important work continues to get the attention it deserves.

Julie Rosen
Executive Director
The Schwartz Center for Compassionate Healthcare

Jalestra said...

I saw this in this week's Ground Rounds and wanted to respond as a patient:

I've met a lot of doctor's in my time. The ones I remember with fondness genuinely CARED and a lot could be worked around for that point right there. I had a doctor who cared and was communicative, and that was great. I've also had a doctor who cared and was the "cranky old man" and he was one of my favorite doctors.

This wouldn't be a discussion if many doctors all genuinely cared. I've had the docs who fake caring and it's painfully obvious that it's a taught bedside manner and not from the heart. I can't trust those types. They are already dishonest right there. You can't care just about the patient, but the individual and there IS a difference. My care with those docs was always based around what was best for ME, not for people "my age", "my weight", "my gender" or whatever box I fit in that day. They were interested in me and what I wanted as well as what I needed medically and never tried to harass, intimidate, lecture, or browbeat. In a few cases they even went against popular medical opinion because they were thinking of ME personally and not what's "average". That's a doctor worth trusting. No extra time in the room, no excessive care, just standard care that took no extra time and was actually CARING.