Physician Culture Must Change

No sooner had I finished my last column with the idea that we would be better served in medicine if we showed more mutual respect among each other than I heard Lucian Leape, MD, of Harvard speak to the importance of the same idea. And everyone loves to hear from someone who agrees with them, especially an evidence-based academician.

Dr. Leape was coming to this conclusion from ground-breaking research done on preventing medical errors. He was led by his findings to encourage improvement in the systematic way that doctors organize their medical work. He soon realized that what was needed to achieve reduced medical errors in these office and hospital systems was a greater reliance on an integrated team approach. Doctors need to be thinking in terms of systems, not just individuals. And finally, he came to the realization that to make a team approach really work, there had to be a higher level of mutual respect among the team members than was being observed.

I was surprised when he cited that within a large group of nurses surveyed, 90% attested to being humiliated or spoken to in a derogatory manner by a physician within recent memory. In part I was surprised because many of us can recall such behavior by other doctors that we have witnessed and just shrugged off. "Not my affair," "I'm busy," "That's just John/Mary," and etc.

And of course, dear gentle reader, not only have such travesties never left our lips, but we can probably add some examples where we ourselves could have been shown more fair play from the occasional colleague, let alone attending during training. Teachable moments can be negative as well as positive.

For that is where the culture of medicine is set, by our observations and interplay with established physicians during our impressionable medical school and resident years. Simply put, if we are to optimize our mission of efficiently and effectively helping patients — let alone improving the quality of our own lives, professional and personal — our culture must change. Simply put, we established physicians in responsible positions must change our attitudes and ways of relating to each other and those around us.

To emphasize the point, Dr. Leape cited the high measured rates of burnout, depression and even suicidal ideation among doctors in training, when researchers first bothered to start looking. These things lead to medical errors, he has found, along with irrationally long hours, another contentious area among curriculum managers. It's all too redolent of the old "I had to put up with it and dammit, so should you" hazing mentality. And I remember the righteous indignation oozing from the pores of the attendings when my intern class was the first to get a raise to the magnificent sum of $5,000 per year.

The other area of disrespect that needs an overhaul that Dr. Leape is pitching to the medical establishment is that of medical staff to the patient. Examples abound: speaking to family instead of the older or ill patient; ignoring what people say or what they feel as unimportant; a curt or brusque attitude when we are under pressure; and each of us, if we are honest with ourselves, sheepishly could go on. But it never was, and is not, OK to show disrespect to colleagues and patients, the result being errors of omission, commission, ruptured relations, needlessly expanded costs and an inchoate unease.

Medical errors are not only inherently indefensible and interfere with what we are about, but also they cost a mountain of treasure in consequences — our money, the patient's money and everyone else's money. And the timing for this growing realization could not be worse.

This focus is not just on what I called in last week's column "the bad apple" — the 1% to 5% of serially disrespectful and disruptive doctors upon whom hospitals and medical groups spend a disproportionate amount of time and effort to legally cope with. They are just the visible tip of the iceberg.

Rather it is the majority of us who may err or speak unthinkingly in a more casual way that just seems to be part of the usual daily background noise of medical practice that should also be part of the needed cultural shift.

For instance, and ironically, while writing this article I was called by a charge nurse who made a bone-headed, but thankfully non-injurious, mistake. We discussed it calmly, she apologized and that was that. But on reflection, a lack of appropriate training and/or review about important policies can also be a subtle form of disrespect. You know, if you don't explain to a staff member how to handle a particular situation, but then take the person to task when it actually arises and they do not optimally manage it.

In an interview in this month's "Physician Executive Journal" of the American Academy of Physician Executives (an exceptionally good organization that "gets it," by the way), Dr. Leape concludes by saying, "The single greatest challenge the (health care) industry... faces right now … is the whole issue of respect for others, colleagues, co-workers and … patients."

Amen, brother.

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