Mamas, Don't Let Your Doctors Grow Up To Be Assholes...(Or Is It The Other Way Around?)

From Aeon Magazine comes an interesting and somewhat overdue piece on one of Medicine's worst-kept dirty little secrets: Doctors (and nurses) can be mean, and that impedes patient care. 

The author, Ilana Yurkiewicz is a third-year medical student at Harvard,  and blogs for Scientific American. She does bioethics research at Harvard, and her work has been published in the Knee-Jerk (I mean New England) Journal of Medicine. Clearly, she has the credentials to speak of what she speaks.

Her Aeon article, Why Rude Doctors Make Bad Doctors, is a must-read for anyone in this business. Ms. Yurkiewicz bemoans the culture that allows and even encourages bad behavior, and points out how it might end up damaging the patient, not just the tender ego of a doctor-wannabe.  

One doesn’t have to work in a hospital long to experience or observe some form of disrespect. This is hardly a secret. The bullying culture of medicine has been widely written about and portrayed in popular media. In one study, published in 2012 and conducted over the course of 13 years at the David Geffen School of Medicine at the University of California, Los Angeles, more than 50 per cent of medical students across the US said they experienced some form of mistreatment. Behind closed doors, we share advice on whom to hang around and whom to avoid.

At the start of my third year of medical school, when we would finally enter the hospital wards, we had an orientation: ‘Wear a raincoat,’ the doctor standing at the podium advised. I could expect to get rained on.

Those of you reading this who are not directly part of the health-care universe might not be able to relate. But most of you will understand. The myth of the malignant surgeon throwing instruments is not all that far from the truth. These days, the flying projectiles are mostly verbal, and sometimes subtle, but they cut just as deep.

Most of my friends in medicine have witnessed flagrant episodes of hospital bullying and have juicy tales to tell. But medical disrespect is usually far less dramatic, dished out in the form of ‘micro-aggressions’: exasperated sighs, a sarcastic tone, the dismissal of alternative ideas. It’s the subtle put-downs about a trainee’s competence that erode confidence; the public shaming for an incorrect answer on rounds; or the denial of simple privileges such as taking a chair or reading a chart. It’s the psychological effect of being called by your rank instead of your name, or having it made clear that your presence is a burden instead of a help. It’s being ignored. It’s other team members looking on when the disrespect occurs, afraid to challenge it and defend those lower on the totem pole. These are the acts that affect our state of mind in small but cumulative ways. This is the stuff that creates a culture.

You learn to deal. This is how it is. That’s the system. It’s ingrained. You excuse bad behaviour with the platitude: ‘That’s just the way (s)he is.’ You appreciate from your elders that it could be much worse – at least they can’t throw scalpels at you anymore.

And it was bad enough in my day. I dodged a lot of it, but I felt, saw, and heard enough to confirm Ms. Yurkiewicz's observations. As a medical student, and even as a Radiology resident, I have seen the snide looks and snarky remarks flowing like sewage from the more arrogant and nasty of residents and attendings downhill to the objects of their scorn. And I've been the victim of this, often deservedly, often not.

But it is also much more dependent on the communication and relationships among different members of the team. Now, enter the culture of disrespect. Suppose an attending physician makes withering critiques or unreasonable requests. A resident, hoping to avoid such abuse, slowly but surely starts to hold back. She holds back some questions for fear of burdening and, under the constant stress of being scolded, becomes immersed in details of efficiency. Whether she intends it or not, she gives off vibes of unavailability, spending hours hunched over a computer in the physician’s conference room cranking out progress notes and scheduling patient appointments. Meanwhile, a patient starts to take a turn for the worse, but it’s not completely clear-cut – his vitals are just a bit off, his belly seems distended, and he complains of abdominal pain but is also known to the team as someone who complains. The nurse hesitates to voice her concerns to the resident, who is swamped doing paperwork and updating discharge summaries exactly the way the attending prefers. The patient continues to go downhill, and by the time word gets out the patient is much sicker – and needs to be treated far more aggressively – than would otherwise have been the case.

The more you fear being caught in a mistake, the more likely you are to make more, and to cover them up. Rather than worry about harming the patient, the young skull full of mush learns to dodge bullets directed at him, and the patient be damned.

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.

{snip}

The link between harsh words and medical errors was reignited in 2012 when Lucian Leape, professor of health policy at the Harvard School of Pub­lic Health, published a two-part series in Academic Medicine. ‘A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect,’ Leape and his co-authors asserted. ‘Disrespect is a threat to patient safety because it inhibits collegiality and co-operation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.’

It’s not that jerky personalities are reserved for those at the top. There are nice people and mean people at every rank. But in a system dependent on the proper functioning of hierarchy, it works like this: when anger and intimidation flow down, information stops flowing up. The chain of communication becomes clogged.

It bears repeating in large font:

In a system dependent on hierarchy, it works like this: when anger and intimidation flow down, information stops flowing up.

And THAT is when the mistakes propagate further and faster, and the patient is the one that suffers. Ironically, the perpetrators often realize that this is the case:

In another study by Rosenstein and O’Daniel, nurses and physicians self-reported behaving badly in near-equal numbers. Most felt this behaviour resulted in increased errors, lower quality of care, and lower patient satisfaction. Seventeen per cent could name a specific adverse event that occurred as a direct result of disrespectful behaviour.

You are probably asking at this point, "WHY does this happen?" The answer, like so many in medicine, is TRADITION. For many years, interns, residents, and even medical students were kept up for days on end, struggling just to stay awake, let alone actually learn something and treat sick people. This tradition lasted for years and years, mainly because their elders did it too. Medicine, being more of an apprenticeship than anything else, can sometimes ignore facts that contradict long-held opinions:

Yet despite such (bad) outcomes, many in medicine actively protect the culture of disrespect because they hold a fundamentally flawed idea: that harshness creates competence. That fear is good for doctors-in-training and, by extension, good for patients. That public shaming holds us to higher standards. Efforts to change the current climate are shot down as medicine going ‘soft’. A medical school friend told me about a chief resident who publicly yelled at a new intern for suggesting a surgical problem could be treated with drugs. The resident then justified his tirade with: ‘Yeah, yeah, I know I was harsh. But she’s gotta learn.’

Bottom line, this crap kills. And it needs to change.

We can no longer deny the facts. Bad cultures lead to bad outcomes. Jerks do not make good medicine. They foster a backwards atmosphere that degrades trust, tarnishes open communication, and promotes cover-ups.

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

There are solutions out there, mainly dealing with individual, solitary incidents. But how do you change a culture?

...(W)e 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.

(W)e 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.

The suffering we see among our patients overshadows our personal pain, but...

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.

I'm not the world's best radiologist, although I think I hold my own. This will sound like whining, and it is, but I truly think I would have been a better physician, and a better radiologist, had the culture been different. Had my many mistakes (and we've all made them in this business) been used more as teaching opportunities, and less as excuses for public humiliation, I think I would have learned more from them. To be honest, the majority of my mentors in medical school and residency were indeed wonderful teachers, with the gift of making you happy you had made the mistake they were correcting. But I had a few, and they tended to be the BIG NAMES in the field, who would take off after any answer and any action that was less than perfect. As one of the more mediocre trainees, I got a lot of that from these people.

In radiology, our mistakes are laid out for all to see, available at the click of a mouse. Arrogance has no place here. Every single radiologist has missed more stuff than any of us will admit. It is part of being human, and having by definition limited knowledge and limited perception. Some of us are certainly better than others, and I can tell you who in my group has the fewest misperceptions (not me) and who has relatively more (also not me, at least on good days). Pointing out the mistakes of others in the current climate helps no one but the trial attorneys. Sadly, a corollary of this whole discussion is that the same arrogant, nasty SOBs who think they are God's gift to humanity are quite happy to point out to their patients when someone they deem beneath them has not performed to their standard. Why do this? Because they can. Because the rest of us don't call them on it. Because sometimes they are right, and we did make a harmful error.

I've addressed this in a prior post, wherein I address those in the big medical Mecca who took it upon themselves to tell a patient I had missed something...when I had done no such thing. Some would advocate legal action for this libelous stuff, but I don't believe in social engineering via the legal system. What we have to change is indeed the culture of what boils down to bullying. As Ms. Yurkiewicz puts it:

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.

Of course, I'll be long-retired before we see this sort of sea-change in medical culture. But it is reassuring to know that it might be coming after all.