Medical culture: can silence kill?
I remember sitting in the Intensive Care Unit (ISU) attending a patient after cardio surgery. The usually quiet atmosphere of ISU was interrupted by electrifying fuss: the physician on duty was peeping into the corridor, the assistant was nervously sorting patients’ charts. It was clear that the Doctors’ Round was about to start. Indeed, in about 10 minutes the doors of ISU opened wide and He appeared: the Chief Medical Doctor, the head of Cardiology Department surrounded by his suite, with medical students bringing up the procession rear. He looked at the monitors placed above patients’ beds. The ISU doctor rashly stepped forward attempting to provide the Chief with some comments on patients’ charts, but apparently it was not part of the ritual. He was immediately dismissed by a haughty remark: “Ich bin hier” (“I am here”). In a few minutes the show was over and the King departed silently, followed by all his men.
I came up to the ISU caregiver (German: Krankenpfleger) who was sitting during the whole ceremony impartially studying patients’ charts over his computer. Apparently he did not have a role in the “Doctor’s Rounds” scenario: he got his own line of reporting through the Chief Nurse. “Why did not anybody tell the Chief Doctor that the patient is still having chest pains?” The caregiver (who obviously was intelligent and educated) smiled ironically: “Because the Chief Doctor did not ask about it.” I looked at the electronic medical record (EMR) at the computer screen. The information there pertained only to the patients’ conditions at ISU. Knowing that before getting to ISU the patient I observed was treated in the Cardiology Department, while initially arriving from the Neurology Department, I asked the caregiver if the doctor could see what had happened with the patient there. “No, he cannot. The physician from the Cardiology Department cannot see what happened to the same patient in the Neurology Department”. The reason was not technical: the SAP EMR system was running throughout the entire hospital, being able to collect and share data from all its departments and labs. It was a pure human factor: doctors did not want to share patients’ data (occasionally referring to some vague Data Protection Acts). “It is very simple, explained to me the ISU caregiver, if they control information they control the patient treatment and all accompanying processes. If they share it, somebody may disclose their mistakes”.
The fear of making a mistake and the ensuing punishment, be it administrative, financial or moral, seems to permeate the whole hospital culture. True, the stakes are high and although it is a common knowledge that “to err is human”, sometimes it is hard to accept this tenet for a sympathizing doctor when looking at the frustrated relative who has just lost his dear one or while talking to a supervisor who will be only too glad to give you a full blame. Yet the inability to handle mistakes, hiding them instead of analyzing their roots to avoid similar ones in the future is very close to a deliberate patient harm.
Silence and the breach in communication provoke medical errors that can lead to upwards of 1,000 deaths per day and cost trillions of dollars in health care costs each year as discussed recently at KQED’s Forum. A study from UC San Francisco discovered that improving communication between health providers can reduce patient injuries from medical errors by 30 percent.
So why despite all the evidence and discussions on the patient safety doctors are persistently ignoring the basic common sense principle that “one head is good, but two are better?” Why are they ready to sacrifice the well-being and, sometimes, the lives of their patients for the sake of control and unquestionable authority? One of the reasons is the authoritarian culture pervading most of the hospitals. Questioning your superior’s decision even on a minor issue and, in particular, in behalf of a patient may frustrate your boss and eventually impede one’s career promotion. Moreover, a mistake may undermine the authority, so it is better to handle it later in a closed inner circle. This “hidden curricula” that former medical students learn in the hospitals teaches them that patients’ satisfaction is finally not the prime objective of their professional activities.
Thus, the atmosphere of mistrust emerges that does not make people happy in any professional environment. One of the physicians that was working for a large, for-profit, hospital group published in the online discussion that the goal for patient satisfaction in his hospital was always set at 100%. The goal for employee satisfaction… 27%, and it never got close to even that. The doctors’ satisfaction always hovered around 15%. Can an unhappy doctor make a patient happy?
A stiff hierarchical structure is the underlying problem in the majority of European Health organizations. It is going deep into the history of medical education when a medical student has for many years to be a silent apprentice, almost a servant, for his supervisor. In former times, this approach to educating the would-be doctors was partially justified: a physician should be able to do everything – from healing wounds to taking child delivery, and his decisions were solely based on his own experience and intuition. However, with the diversification of the modern European medicine and expertise going deep but narrow, unquestionable authorities coming from top to bottom could be dangerous.
The inability of openly sharing one’s concerns in regard to medical procedures, negligence of one’s colleagues observations together with the fear to speak up may lead to serious, sometimes fatal consequences. The results of the survey conducted late 1980s through the early 1990s by Australian researchers showed that the vast majority of medical errors, some 70‑80 per cent, are related to interactions within the health care team (Australian Commission on Safety and Quality in Health Care). Since that the Australian research team is prompting a range of initiatives. One of the most important is the “open disclosure” framework, under which patients and their families are told immediately when something has gone wrong. Slowly and painfully, it started bringing the results: overall, serious adverse events decreased by 10% in the five years to 2012. Of the 53 million patient interactions nationwide each year the chance of a serious medical error occurring has become significantly lower, at 0.000201% .
Nevertheless, the authoritarian, hierarchical structure still prevails in the medical environment and the majority of medical schools. A UCLA study UCLA study found that 85 percent of all third-year medical students had been subjected to bullying based on medical hierarchy. Another study published in 2012 and conducted over the course of 13 years at the University of California, Los Angeles David Geffen School of Medicine, showed that more than 50 per cent of medical students across the US said they experienced some form of mistreatment. The implications could be wide ranged. People bullied in their youth, later derive fear to speak up. To compensate for the loss of self-esteem they may tend to oppress others who are junior and socially weaker than they are. They may also choose to ignore their professional duty to protect the patients’ interests and safety for the sake of maintaining good relationships with their supervisors.
Thus, the researchers from the Maimonides Medical Center in New York have run the experiment among 55 students who had to go through a laparoscopic surgery simulator. Half of the students were encouraged to speak up their minds on the procedure whereas others were instructed to do what the supervisor was telling them. Subsequently, a surgical mistake was deliberately made by the senior surgeon when he instructed students to cut without burning. The students in the encouraged group were significantly more likely to speak up (23 of 28 [82%]) vs. 8 of 27 [30%] from the group that was told just to follow the supervisor’s instructions.
To interrupt the domino effect of silence and submissiveness, it is important to encourage medical students to flag errors on their patients behalf when the students are still full of humanistic aspirations and Hippocratic Oath to ”preserve the purity of my life and my arts” is not yet poisoned by a professional cynicism.
If the authoritarian culture of obedience and blame will prevail in medical environment, we shall see more and more Chief Medical Doctors ignoring the opinions of their assistants, more physicians neglecting nurses and disregarding their patients. The result will be an increased miscommunication between medical teams leading to the enhancement of medical errors ratio and eventually putting patients under a high risk.