Monday, February 03, 2014

When doctors refuse to hold their colleagues to account

A recent comment on Bob Wachter's blog caught me up short because of its obvious applicability to the situation at the University of Illinois Hospital and Health Sciences System.

Bob had written about the recent case involving Charles Denham, who has been accused on conflicts of interest with regard to several patient safety matters.  Many of us know of Chuck's excellent work  over the years, and so we are all in a bit of state of denial over the case.  Indeed, much of the commentary on Bob's blog has been about how to ensure that there are systems in place to help avoid such conflicts of interest.  And many of us, including me, have also tried to make the case that Chuck's many good deeds should not be forgotten in all of this, even if some of his actions may be inexcusable.

But look at this thought by Debra, responding to human factors expert Terry Fairbanks:

Terry, not all problems are systemic. Some problems are a result of people taking advantage of situations and other result of people who don’t care about others. When a pilot shows up drunk for a flight, he’s relieved and there is no long and drawn out discussions of what noble acts he has done in the past, how good his intentions are, or how misguided he might have been by circumstances in his personal life. The first and pretty much only concern is that of the flying public. And that means he or she is not flying a 747. Period. 

I used to be part of the missile community. Some problems are system issues, process issues, equipment issues, design issues or engineering issues. But not all problems are system issues and one will minimize system issues when you properly manage people and enforce conduct that conforms to expected norms. Some people issues are leadership, but sometimes people ARE the problem, period, because they refuse to conform the the requirements. Systems are ultimately made up of people and if there are people who are greedy, or sloppy or not competent, the solution to that problem is removal of the person. Leadership means making those decisions. And that doesn’t happen because doctors in particular refuse to hold their colleagues to account when needed. 

It is the last line that is apt in Chicago.  Recall that this issue was a national advertisement that resulted in the misappropriation of the University's name in support of a private company, a matter that violates the University's code of conduct, its administrative procedures manual, and maybe state law.  The ad contained pictures of 12 people, including doctors, nurses, a surgery technician, and a non-medical staff person.  I have learned enough now to know that a number of the people who were in the photograph did not know their image and name were going to be employed in that manner.  I hear that some of them were quite upset to learn they had been used that way.

Did any one of these people report the incident to any person of authority in the hospital or the University?  I bet the answer is no.

Now, I don't expect a surgery technician to risk her job by doing this, but I do expect physicians to hold their colleagues to account when there is a clear violation of the conflict of interest rules.

Why didn't the doctors hold their colleague accountable?  Fear?  Sympathy?  Concern for the reputation of the program?  It is an analysis of these matters that should be at the core of the Trustees' investigation of the incident.

Oh, but the Trustees themselves have now fallen victim to the underlying problem.  They are so concerned that a major surgical program (read, financially important program) of their hospital system will be tarnished by this event that they have started to stonewall the issue altogether.  In so doing, they have now become complicit to a culture that refuses to hold their medical staff accountable--in Debra's words--to matters of personal greed, sloppiness, or incompetence.


Anonymous said...

Exactly because of what Debra said and knowing the issues and personalities there, I doubt they didn't know what they were posing for.

Paul Levy said...

Not what I hear (at least for some), but either way, the conclusion holds.

Anonymous said...

I agree. If this was the issue then why are the Trustees not answering the stakeholders' concerns? We'll see. You are right.

Anonymous said...

I too was struck by Debra's hard-hitting comment on the other post, and mulled over its applicability not only to that case and the UI case, but to many, many cases doctors see every week. I am afraid our profession turned a blind eye while these sorts of conflicts of interest built and built and now could fairly be described as pervasive. (Witness the renewed concerns over other NQF clinical guidelines.)
The very integrity of the profession is at stake. Are we going to be regarded in the same category as lawyers and used car salesmen now?

nonlocal MD

Mark Graban said...

"Terry, not all problems are systemic. Some problems are a result of people taking advantage of situations and other result of people who don’t care about others."

Yes, as Dr. Deming said, 94% of problems (or so) are caused by the system. He never said 100%. Wachter has written effectively about finding the balance of a "no blame" culture not becoming "never blame." Sometimes a person does make bad choices when they knew better... I think the "just culture" algorithm is really helpful in most cases to help determine if it's a system problem or an individual.

Anonymous said...

In my former institution when a marketing opportunity arose, physicians were first contacted by the marketing and media departments to discuss strategy and the physician's take on the opportunity was assessed. In a few instances, conversely, physicians were those who first reached out to those entities. As a matter of afact, I remember one day I was contacted by photographers hired by the media department and we then shot a bunch of photos for a local magazine ad - of course after being briefed by the marketing dept about the idea and it's scope. After the shoot, I never saw the contact sheet and did not choose the final photo for the piece, although I knew well what I was doing. Interestingly, I later found out that the hospital owned the photos and their copyrights I also learned that hospitals cannot give that material away internally or externally if not for a specific purpose and after approval. This "approval" process was very lengthy and extremely difficult for everybody (physicians and industry). All higher ups were involved in that process because the institution was - rightly - afraid to lose its tax exemption status. Same or similar systems should have been in place at UIC. Nowadays these processes are pretty much well codified and regulated.

So, if that photo was not taken by that company in the hospital premises, someone at the hospital must have given that photo to the company after someone approved its use. Again, this was a complex process in my former institution and the issue was not taken lightly.

Now, I am sorry but I can't see how about 10 people can coordinate their busy schedules to take pictures just for fun, since they all, or a few, didn't know what those pictures were for. It takes a lot of effort and in many cases months to coordinate more than 2 people to convene the same setting, nowadays. Wouldn't they have known/asked why? I don't know the answer. I would have wanted to know at least something. But that's just me.

Three scenarios, then, if I am allowed to think out loud:

Maybe UIC marketing needed to have some pictures in case an opportunity to display UIC robotic program would arise. It's plausible.

Maybe that picture was taken with the goal to give it to the company but this was known only to the leadership and not to nurses and administrators. It's plausible. Sidebar: if I were a nurse I would have not been worried of any COI because I would have rested assured that the hospital would have protected my interests. That might have mitigated some concerns.

Maybe nobody knew who they were doing it for. It's plausible.

We may speculate about which of these scenarios is correct. However, in any of the above, somebody must had answered the call from the company and agreed to provide that picture. That makes some administrators and some leaders accountable. Paul, in fact, correctly titled his first post "somebody must be fired". Not all portrayed in the picture. Only those accountable. It's not for any of us to say who, I think.

What is accountability, then? I didn't look at the Webster, but I draw an attempt of what it means for me from my conversations with exceptional individuals. I remember one episode that took place at a meeting with the top hospital executives. A colleague asked how to deal with accountability. One of the top executives then recalled when he served in nuclear subs. One morning he witnessed an official saluting the ship and leaving the sub because inspections the night before showed that his direct reports failed to comply to some specific rules. It didn't matter if the superior was unaware of his reports' conduct. It had happened under his watch. Period. That's it. End of the story. No whining. It was fair. The rules, all the rules, were clear. No system-errors. No double standars.


Anonymous said...

So, Paul, any way you turn this issue around, you are right. Furthermore, ignorance hardly protects a leader (or anybody, as a matter of fact) from his/her responsibilities. You pointed it out elegantly.

However, one may argue that in this specific case of UIC, the public has not been harmed (it has been deceived - and yes rules may have been broken .... Credentialing is a whole different animal) but the setting is different than a ship carrying nukes or than a pilot flying 777s. Anybody is entitled to its own opinion, the reader will decide what description of the term best fits his/her values.
I, personally, love the nuke story and I always use this anecdote as a moral compass in all situations I face. But that's me. I speak for myself.
However, I agree with Paul that someone should say something in regards to this debacle of institutional reputation (remember that this is a State institution funded by our tax money). In fact, you are right, Paul, silence makes one wonder, it negates transparency (which is vocal by definition) and it stifles magnificent opportunities to create a better and more enjoyable working environment. I would like to add that many individuals in other state of affairs have turned their own crises in great opportunities for their companies and themselves, without fear and boldly. In those instances, nobody got fired for their mistakes, actually the opposite: new opportunities for improvement were created for the benefit of all. Examples abound.

You may also turn this last argument around: if few or all those individuals made a mistake in good faith by posing for that photo, then why not saying so? The longer the silence, the greater my wonder. The more deafening the silence, the greater the likelihood of maliciousness.

Great work Paul. Indeed you chose a hard task,I see. Therefore, you deserve my utmost respect. Never give up in fighting for transparency and for representing us, unharmed consumers of health care.

Isam Osman said...

I must confess at being a bit surprised by the uncharacteristically polemic tone of this blog Paul.Please don't get me wrong.I agree with your line of questioning and Debra's comments.I however would rather try to understand why decent well meaning professionals can remain quiet when they see behaviour (and indeed performance) which is clearly unacceptable.This phenomenon is prevalent amongst the medical profession all over the world.I hope the collective intellect and knowledge of your readership might try to address this question.
I am reminded of the Asch experiment on conformity.80% of us are programmed to socially conform and 'not rock the boat".I have seen good doctors keep quiet about practices far worse than this because they just didn't want the hassle.There is no such thing as a whistleblower who can say that whistle blowing made his professional life better! Lets talk about how we can change that.

Bob said...

I'm so glad you are on top of this issue. It isn't always the system.

But now, if the Trustees are stonewalling and the wagons are being circled, there is also something about the system. There should be something that promotes self-correction - this is probably the role of democracy, and a state legislature. Did I say state legislature? In Illinois?

Somewhere, the forces for good government will have to arise. Sometimes it can be an issue like this that brings things to a head. You just never know. But it is voices like yours that must not be stifled, and disappointed as we frequently are in our country, this is something in which we actually excel.

Anonymous said...

Isam, I believe you are asking an essentially existential question regarding the 80% who are programmed not to rock the boat. I have often said, somewhat cynically but, I think, correctly, that people are sheep. That is what leadership is all about; the 20% who don't mind rocking the boat speak out and inspire the 80% that action needs to be taken. I don't really think this human tendency is stronger in medicine than elsewhere; it's just that the medical culture takes advantage of this tendency.

Paul is being a leader by speaking out, and the polemic tone from someone who normally doesn't do so is a strong signal, isn't it.

In my mind, any doctor who "keeps quiet about practices far worse than this because they just didn't want the hassle' is being unethical himself. Hmmm?? You have to care, and then you have to have some courage.

nonlocal MD

Anonymous said...

Coming from a resident's perspective, I think the ability to shift culture has to start at the level of medical school. It seems recruiting for medical school is now a product of finding students who will do best on their USMLE Steps. An emphasis for ethics has all but disappeared. Residency recruiting now emphasize scores, but in a way that defies logic when today's healthcare system is emphasizing teamwork, communication, and leadership/ownership/problem-solving. At the stage of residency recruiting, the focus should shift more towards the total package as a physician, including ethics and values. Someone with great scores and questionable ethics is favored time and again over perhaps the less impressive scorers with evidence of being team-oriented, patient-focused providers.

Recruit differently starting at medical school, reward good behavior (teamwork during school, candor and honesty, speaking up about anything), don't award bad behavior.

Isam Osman said...

Thanks Non Local MD.I agree with everything you have said.I guess I am asking in order to become a 'Highly Reliable' sector like say the Aviation, Industry where everyone feels empowered and obliged to speak out and challenge in the situations we are alluding to, what systemic structural,organisational and cultural changes do we have to make in health care? Or is it enough for leaders like Paul to remind us medics of our ethical and professional obligations to overcome what we have agreed is 'human nature' .I think we need the changes that will provide incentives systems to overcome these behavioural traits. Indeed Bob refers to the Trustees who must also be held accountable.None of this would happen in the Aviation or Nuclear industries.What can we learn from them I ask.?
p.s. 'you have to care,and then you have to show some courage' Why hence do you deprive us of you identity after such a rally cry to the profession ?!

Paul Levy said...

Thank you. Well put.

Someone at the top has to want that to happen. Maybe start with the Dean?

Anonymous said...

The answer to the question, ”Why didn't the doctors hold their colleague accountable? Fear? Sympathy? Concern for the reputation of the program? It is an analysis of these matters that should be at the core of the Trustees' investigation of the incident.”, is, simply, retribution or the fear thereof. As I have said to you before, doctors, especially contracted employed physicians, but certainly any physician with privileges that must be renewed based on their evaluation by others, have their necks on the chopping block because of any or all of the aforementioned. Throw in large education debt, living large, family with kids and/or the possibility of divorce and the fear of interruption of that revenue stream trumps all. So, keep your head down, blinders on, do as you are told (show up for that photo), keep seeing patients and shut up are the orders of the day for the physician in the trenches and I defy any physician to argue against that.

Isam Osman said...

Thank you for your honesty ! Now we are starting to get to the real core issues.The system described above is rotten and needs to change.

Barry Carol said...

I think the comparison between medicine and aviation is a bit unfair because aviation lends itself much better to the use of checklists and other well established procedures than medicine does. Checklists might be appropriate before starting a surgical procedure or inserting a central line but what about primary care, psychiatry, or just trying to figure out what is wrong with a patient in the first place and what to do about it? Aviation, by contrast, is just about safely flying passengers (and cargo) from point A to point B.

In a discussion several years ago on the subject of disciplining doctors, I think it was nonlocal who suggested that there were three main reasons why this was hard and the path of least resistance was to give the doctor the benefit of the doubt. Those reasons were (1) there but for the grace of God go I, (2) he/she probably has a spouse, a family to support and a mortgage to pay, and (3) in light of #1 and #2, let’s not take away his/her livelihood.

The University of Illinois situation specifically demands leadership that creates a culture that makes it clear that an advertisement like the one being discussed here is not appropriate. Disciplining doctors who make more than their share of mistakes and revoking their license if necessary is a different and more difficult issue, I think.

I also note that police departments are notorious for their blue wall of silence when a police officer does something wrong. The culture is to protect their own at all costs even if an innocent person goes to jail.

Isam Osman said...

True Barry that not all medicine is about check lists. However the analogy with Aviation and indeed the Nuclear industry does not just stop here.It is about creating high reliability espousing 5 core system qualities:
1.Preoccupation with failure
2.Reluctance to simplify interpretations
3.Sensitivity to operations
4.Commitment to resilience
5.Deference to expertise
All of medicine would benefit from these cultural changes don't you think?

Anonymous said...

Isam, the handle nonlocal MD is a relic from the early days of Paul's blog and my retirement, when I wanted to be able to tell stories from my former hospital anonymously. Then I retained it because now it gives a predictable idea of my philosophy. The name is Beverly Rogers M.D.; are you any the wiser? (:

Although I cannot disagree with the others' comments, again these things are not unique to medicine either. Workplace bullying, bad bosses and threats to one's job are unfortunately ubiquitous and, in some industries like manufacturing, just as dangerous as in ours. (Think BP oil spill) If anything, our advanced level of education as scientists and academicians should make us better able to cope with it than other workers. I don't accept that as the entire explanation.


Anonymous said...

Barry, it's scary to have my own words repeated back to me when I don't even remember them! However, i agree with myself; these were the main reasons I perceived for non-discipline of medical staff members during my several years on Medical Executive committees.


Barry Carol said...


Since I’m a retired financial guy who has never worked in the medical field, I’m not sure I understand what those five principles mean in terms of how a doctor actually does his or her job every day. I do have considerable experience as a patient though. From that experience, my perception is that most doctors are quite competent, work hard and do the best job they can often under difficult and stressful conditions. Medicine is far from a precise science. There are difficult cases that even the experts at the NIH can’t figure out. I’m told that doctors are much more likely to encounter a rare presentation of a common condition than a textbook presentation of a rare condition.

That said I am concerned about cultures within hospitals that make it difficult if not impossible for nurses, techs and others to speak up if they see a doctor making a mistake. I would like to think that the hospital’s leadership would create a culture that empowers these people to speak up and will protect them if there is any attempted retaliation from sometimes arrogant doctors, especially surgeons, who bring a lot of profitable business to the hospital.

Anonymous said...

Nurses do report MDs but in some institutions MDs choose to "protect" some in their brotherhood. "Rebels" are not protected, the opposite. Sadly but true.