Tuesday, April 16, 2013

Tip 18: If doctors are afraid to speak up who will?

If doctors are afraid to speak up who will?

Bedside ImageIn her recent New Your Times article, "Afraid to Speak Up to Medical Power", Pauline Chen, MD discussed her personal experience in dealing with the all too common unsafe medical hierarchy that is endemic of our current healthcare culture. I'm glad to see such well respected physicians confronting these "old rules" that have such a profound impact on patient safety.

Dr. Chen shared how when the hospital where she worked, hired a "Rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital's then lackluster cancer center...", none of the incumbent medical staff felt comfortable challenging anything he said. Even the "Number 2" doctor on staff was afraid to throw in his two cents when he felt we was witnessing the wrong treatment for a patient. Long story short, due to an invisible, unspoken, fear driven medical hierarchy, two physicians who had more intimate knowledge of the patient than the new "superstar" kept quiet while suboptimal treatment was given causing a patient to die.

Dr. Chen cited a recent New England Journal of Medicine article, "Speaking Up — When Doctors Navigate Medical Hierarchy" by Ranjana Srivastava, F.R.A.C.P. which equally demonstrated this fear-based hierarchy through the eyes of a Medical Oncologist who was handed a patient from a resident. The patient was scheduled for surgery just a few hours after the physician made his courtesy call. He found the patient, "Scrunched up in bed, tossing and turning, his sheets tangled between his legs. He's pale and uncomfortable, licking his lips, his IV fluids having run out. My immediate impression is that he's dying. But I remind myself that he's scheduled for surgery." After conversing with the patient, the Oncologist felt sure that the patient wouldn't survive a surgery. But in this particular hierarchy, the surgeon was king and very few (if any) would question him. So when the surgeon showed up ready to proceed, the Oncologist figured he knew what he was doing, so he kept his mouth shut. And although the patient survived the surgery, he died shortly after. 

Afterward, (better late than never), he spoke to the surgeon about it, and the surgeon admitted that he would like to be told if he was perceived as inadvertently harming his patient. But the Oncologist couldn't have known that since the medical hierarchy has always been there... and has always been present in every hospital he'd worked in.

The two agreed to be more open and sharing in the future... just not soon enough for this patient.

You would think that physicians intervening with each other to help treat a patient, and especially to save a life, would be a given. Sadly it's the exception and medical hierarchies like these have proven to be a significant contributor to unsafe cultures. Almost all physician you and I know have experienced similar situations. I rarely meet a physician who doesn't have his or her own poignant story to tell me about an unsafe conversation with another doctor that led to suboptimal care.

It's the right time for Dr. Chen and Dr. Srivastava to be voicing their concern on the issue as many suggest the symptoms are getting worse. When I began writing my book, "Heroes Need Not Apply", two years ago, it was clear that this challenge was becoming more pronounced, as healthcare reform places greater emphasis on providers working as integrated teams to improve quality, create efficiencies and reduce cost. Understanding that the severity and frequency of these unsafe exchanges has nowhere to go but up, my book takes a close look at the key factors that produce unsafe medical hierarchies and what we as medical community must do about it. Now that the book is set to be published this Summer, I'm hoping that this story and the leadership of physicians like Dr. Chen and Dr. Srivastava, can offer a new template for how we physicians interact, as there is no room for these medical hierarchies in these new care models.

Like most cultural challenges we face, medical hierarchies and the "old rules" that follow are steeped in medical training and can't be resolved with a checklist or confronted with punitive approaches. If we physicians are to prevent unsafe conversations, we're going to need to replace the template for how we interact. Consider our current context, a template for interaction that celebrates individual expertise, credentials and honors. In other words, a culture that rewards and recognizes individual heroic effort with little emphasis on peer coaching, physician collaboration,and clinical teamwork.

18 Tip: How to defuse a medical hierarchy in 5 seconds or less.

Medical hierarchies often create conditions that allow extraordinary power to be given to extraordinary physicians. These physicians are highly accomplished, have numerous credits to their name, and get excellent results. Physicians like Dr. Chen and myself operate within this hierarchical context, assuming that because they are the best at what they do, they must know what's best for the patient. This is the most costly (and incorrect) assumption we make,and it's ultimately shortchanging our patients. As we formulate assumptions like these, our "superstar physicians" become dangerously unapproachable, resulting in a system with fewer checks and balances. Simply said, we begin to rely too heavily on the smartest person in the room and minimize collaboration, which hinders patent-centered exchanges.

Keep in mind that incompetence is rarely the issue, as in most cases, our "superstar" specialist in question is often administering the right treatment for the condition. However, in many of the cases I've consulted on, similar to that of Dr. Chen and Dr. Srivastava, the lead physicians often become too focused on treating the disease without considering the human factors that matter most to the patient and influence outcomes. These physicians report getting fixated on the medical response while minimizing the concerns of the patient and/or another physician.

So what is the answer to defusing medical hierarchy? And how do we create a zone of safety and improve physician collaboration?The answer to this safety challenge is simpler than the average checklist and resides with just one question: "What matters most to the patient?"

I can tell you from the experience of working with hundreds of physicians, this question is 99 percent effective at disabling and preventing harmful conversations. Why is it such an effective coaching tool? Patient-centered questions like this help physicians navigate the power differential by putting the focus on patient concerns and helping the team review the medical response in a more thoughtful way. It sends the signal to all those "superstars" out there that your not competing for the smartest guy in the room award or telling the other guy, "I know something you don't".
We don't need hero physicians. We need team players and coaches.

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Brian WongDr. Brian Wong's highly anticipated book,'HEROES NEED NOT APPLY' releases this spring.

Listen to Dr. Wong as he discusses Heroes Need Not Apply: A Unique View on Accountable Culture Click here to listen>>

Brian WongCheck out the new video interview with Brian Wong, M.D.
to access Dr. Wong's Q&A as he discusses "Heroes Need Not Apply," Click here>>

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