The 80-20 Rule and Disruptive Healthcare Professionals

80_20_Rule_ImageA colleague forwarded on a momentarily disheartening clip from the Washington Post last week. The article, entitled Anesthesiologist trashes sedated patient–and it ends up costing her, included an audio clip from the patient’s cell phone that he had inadvertently left running during a colonoscopy in which healthcare professionals charged to care for him instead chose to act like grade school bullies. The anesthesiologist, who was one of two physicians named in a lawsuit for medical malpractice and defamation, is clearly heard on the audio clip belittling and taunting the patient while sedated. Additional staff is heard laughing as the proceduralist and anesthesiologist continue their disturbing banter. No one in the room, or at least no one on the audio clip included in the Post article, told them to stop. I will bet, however, there was at least one person in the room who wanted to say something.

I say momentarily disheartening because as I sat listening and briefly wondering how any of the work we do educating the young–teaching them to stand up to bullies and disruptive healthcare “professionals” like this in the workplace–was going to overcome the still so well-ensconced medical culture, I quickly found solace in the fact that we like to elevate the train wrecks in all walks of life. And the Post was most definitely covering the story of a train wreck.

Knowing that our culture is comprised of the stories we share, I just as quickly recalled multiple stories of the great work being done in my small corner of healthcare alone. Take, for example, the weekly Good Catch stories shared throughout the MedStar Health system showing exactly how the 80-20 rule can be applied to the prevalence of healthcare bullies. I was comforted by the fact that for the 2 physicians mentioned in the Post story, I knew of at least 8 good people protecting patients in just one health system. Stories of visiting nurses who ensure the safety of those in the home, or of the local security guard who sits with a soon-to-be patient until help arrives. Stories of nurses who speak up when care does not seem to be going in the needed direction, and stories of physician leaders who actually lead, setting the stage for those often silenced to share their voice. Yes, the 80% is alive and well!

Those who aren’t convinced it is just good form or good karma to treat patients and/or colleagues with dignity and respect can turn to a growing body of formal research that contends bullying and incivility in the workplace has many costs, including patient safety and workforce overall well-being. An opinion piece in the New York Times on June 19th entitled, No Time to Be Nice At Work, by Christine Porath refers to a survey of more than 4,500 doctors, nurses and other hospital personnel of which “…71 percent tied disruptive behavior, such as abusive, condescending or insulting personal conduct, to medical errors, and 27 percent tied such behavior to patient deaths.”  Porath also references work recently published in the American Journal of Management, Does Rudeness Really Matter? The Effects of Rudeness on Task Performance and Helpfulnesswhich showed people working in an environment that lacked civility missed information directly in front of them and offered fewer creative solutions to tasks before them. The same was true if individuals simply witnessed an exchange of rudeness.

It matters not whether it ends up being the data or the stories that drives us to treat one another, especially patients, with dignity and respect in the healthcare environment. And maybe stories like the one in the Post last week are needed in some strange way, if only so that they might discourage the next bad actor who has failed to mature themselves from lashing out at the vulnerable. I do know, however, that we need to add at least five stories of the good work healthcare professionals are doing each day to counteract the negative force a story like this carries into the mainstream. In the meantime, we need to continue to empower those healthcare professionals who want to do better, especially young healthcare trainees. There are many within healthcare who look at the Post story and are embarrassed to be part of a profession that would allow this to continue but have yet to find their voice or platform. Here’s to the good guys and gals–the 80%–we know you’re out there. It is up to healthcare leaders to give them a pen…or a mic!


A More Realistic Perspective on a Career in Medicine

Artesa_View_NapaDanielle Ofri, MD, physician, writer and editor, often turns her pen along with her focus to the emotional complexities that accompany a career in medicine. Her book, What Doctors Feel: How Emotions Affect the Practice of Medicine, is an honest sharing of what many healthcare professionals are often processing behind a mask of false bravado and confidence. The book, a must read for every medical education program in the country, can prepare and provide a realistic perspective of the road medical students can travel, to know they are not alone when doubt or disillusionment creeps in. It also can serve as an instruction manual of sorts for patients to better understand the person who provides the care. In just the Introduction, she writes:

There has been a steady stream of research into how doctors think…In…How Doctors Think, Jerome Groopman explored various styles and strategies that doctors use to guide diagnosis and treatment, pointing out the flaws and strengths along the way. He studied cognitive processes that doctors use and observed that emotions can strongly influence these thought patterns, sometimes in ways that gravely damage our patients. “Most [medical] errors are mistakes in thinking,” Groopman writes. “And part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don’t even recognize…

…The emotional layers in medicine…are far more nuanced and pervasive than we may like to believe…they can often be the dominant players in medical decision-making, handily overshadowing evidenced-based medicine, clinical algorithms, quality-control measures, even medical experience. And this can occur without anyone’s conscious awareness…

…This book is intended to shed light on the vast emotional vocabulary of medicine…how it affects the practice of medicine at all levels.

It was the recent reporting of two young physicians taking their own lives at a time they should be celebrating academic and professional milestones that prompted this post. While we are not privy to what contributed to these terrible losses, the frequency with which similar lives are lost among the healthcare ranks speaks to what can often be a Grand Canyon-sized gap in the expectations and the reality of a career in medicine–as well as what is often left untreated or acknowledged within the profession: mental health and wellness of the healthcare professional. As Ofri writes in a recent article for Slate Magazine, The Tyranny of Perfection:

…it is clear that a career in medicine also brings on tidal waves of pain, confusion, stress, self-doubt, and fear. The eddies nip at our ankles from our first step into anatomy lab, gathering in force and ferocity over the years of training and practice. During medical school, at least half of students experience burnout, and some 10 percent contemplate suicide.

So much of medicine is a tyranny of perfection. Medical students are asked to absorb an immense body of knowledge…Yet, we act as though this perfection of knowledge is a realistic possibility.  No wonder nearly every student feels like an imposter during his or her training….We’ve been asked for a perfection that is unachievable, yet the system acts as though the expectation is eminently reasonable. It’s no surprise that disillusionment is a prominent feature in the medical landscape today. It’s also no surprise that such burnout is associated with unprofessional behavior and more frequent errors.

Each year (since 2010) we gather medical, nursing and health science students, and resident physicians together for the Telluride Patient Safety Summer Camps in Telluride, CO (now Napa, CA and the Washington DC area as well) for week-long educational sessions, discussing patient safety related topics such as the need for open, honest communication in medicine, the need to honor the patient’s voice, and in the past, the bullying that goes on in the healthcare culture. The hope is that we can empower young change agents that will put a more realistic, positive spin to a culture that seeks to heal versus harm one another, or patients, yet continues to fail on both accounts far too often. The students and residents that take time out of their ever-increasing busy schedules to spend a week of vacation focused on making care safer are some of the most interesting, well-intended and accomplished young people. They have big hearts and the energy to climb the healthcare administrative and cultural mountains required when choosing to open their eyes to the challenges that lie within the healthcare culture. What steps can be taken by those leading today, to clear a safer, more well-rounded path, for their training and well-being? The thought of any one of our Telluride alum experiencing what Ofri and others describe is untenable–as is the thought that there are people posing as healthcare leaders that would allow this to continue.

Today is the day to commit to do things differently. To act upon what your gut is telling you. Today is the day to protect those you lead as they learn!


Culture of Disrespect in Medicine Affects Patient Safety

Lucian Leape’s words from the 2009 Telluride Patient Safety Educational Roundtable and Student/Resident Summer Camps tend to come back to me at random times. Not only was it amazing to sit in small group breakout sessions with him, discussing patient safety topics like a culture of disrespect in medicine, but to be in the classroom as he taught was something I’ll never forget.

Recently, his words on bullying in the healthcare workplace rang true and clear. In Danielle Ofri’s July 18 NYTimes Well blog piece, In a Culture of Disrespect Patients Lose Out, the topic was highlighted yet again. Unfortunately, this healthcare challenge remains alive and well. (See also ETY posts What Doctors Feel, and Bullying: Just Say No).

What struck me about Ofri’s NYTimes piece wasn’t that disrespect in the medical workplace was being linked directly to patient safety. That is just common sense. If your workforce is being bullied or treated poorly, how will those same individuals feel when going to do their job — which in this case, is care for patients? It was the following that was a reminder of the responsibility we all have to stop disrespectful behavior:

…This shift in perspective was a shock to the system. When we tolerate a culture of disrespect, we aren’t just being insensitive, or obtuse, or lazy, or enabling. We’re in fact violating the first commandment of medicine. How can we stand idly by when our casual acceptance of disrespect is causing the same harm to our patients as medication errors…

How can we continue to stand idly by? Bullies need to be called out. Period.

As we embark on yet another wonderful week of “Educating the Young” and move Telluride east to the Georgetown University campus for the first time, I hope that those of us able to stand up for students, residents and those we are charged with leading, continue to do just that — to stand up, to not stand idly by, and as Ofri says, view respect for one another…as common decency, something we should do because it’s simply the right thing to do.

For more information, see Leape et al in Academic Medicine July 2012.


What Doctors Feel

Screen Shot 2013-06-07 at 9.49.58 AMI came across a post last week on Slate, The Darkest Year of Medical School, revisiting the idea that medical students lose not only empathy during their medical education, but according to author and NYU physician, Danielle Ofri, “altruism…generosity of spirit, love of learning, high ethical standards—are eroded by the end of medical training.” On June 4th, Ofri also published What Doctors Feel: How Emotions Affect the Practice of Medicine, having performed numerous interviews to draw her conclusions. I read some of the comments on her blog post above–many sharing “medical school was great”. Yet research–past and present– shows many students are not having that experience.

Ofri’s post and newest publication caught my eye as we embark upon the 9th year of the Telluride Patient Safety Educational Roundtable and Resident/Student Summer Camps. This will be my third year in Telluride. The first year I attended, I had the privilege to share a breakout discussion with Lucian Leape and a group of students in the shadows of the San Juan mountains. Throughout that week, Lucian emphasized the need to get a handle on the bullying that occurs in medicine, and instead, instill a greater respect for all in the medical workplace. He shared that unless we are able to do this — treat one another with respect — patients would pay the price, as well as healthcare providers and students.

Having not yet read Ofri’s book, I wonder if medical students who report enjoying medical school overall, were safely ensconced within a workplace with the culture of respect that Dr. Leape refers to as being so very important to patient well-being. It is safe to assume just how empowering a culture of respect would be for students, making them feel competent, part of a team and confident in their newly acquired skills. It’s also safe to assume how students who were bullied might feel (see Bullying in Medicine: Just Say No).

For more information on a culture of respect, and how to create one, see Lucian’s papers:

Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians
Perspective: A Culture of Respect, Part 2: Creating a Culture of Respect

Teamwork + #SXSW + #Minecraft + #Healthcare = Sum Greater Than Parts

There is a call in healthcare for all stakeholders to move toward a culture where team-based care is the norm. Where patients are welcomed into the care team as equal partners, moving away from the traditional, hierarchical approach. To make this shift, new skills will need to be embraced by those accustomed to old ways of delivering care. Many of the younger learners, in medicine and elsewhere, are great resources to turn to as role models for these team-based skills, as their play environments have proven to be wonderful training grounds for the same. For example, teamwork is thriving in video gaming environments — environments that may seem an unconventional place for medical training, but are proving to hold promise for more than just acquisition of surgical skills.

It was this knowledge I carried while attending SXSW in Austin, TX two weeks ago, during which I had the pleasure of sitting in on the Mindful Minecraft session in the Gaming and Interactive track. For those who aren’t familiar, the video game, Minecraft, has sold over 20 million copies across all gaming platforms (PC, Xbox, iOS, mobile), and is played by both kids and adults, alone or in a multiplayer environment. Servers across the country house multiplayer Minecraft sessions, where players work together to build worlds limited only by their imaginations. My own Minecraft knowledge is nascent, and I hope to convince my niece or nephew to slow down when they play and explain it further. Until then, I’m left to appreciate the artistry and the opportunity this gaming environment offers young and old. Following is a video shared by the #SXSW Mindful Minecraft presenter, Mike Langlois, a social worker who uses the video game as a tool to better understand his young patients, and redefine the way gaming addiction is perceived and approached.

Langlois also shared a number of interesting facts about both the single-player and multiplayer Minecraft environments that could be directly applicable to our healthcare learning environments. Mindfulness and teamwork were the two components of this game mentioned that really hit home for me. If you watched the video above, and understand just the basics about the game, the creation of such a work of art by a team of individuals located around the world is amazing in and of itself, and speaks to the coordination and teamwork developed in order to be successful. Langlois reported on additional findings from these gaming environments which could also show promise for learning emotional intelligence not taught through traditional healthcare curriculum, such as:

  1. Mindfulness — The game requires intentional, focused attention and keeps players in the moment. By taking a non-judgmental approach to the game, players learn to experience “what is”.
  2. Bullies in a the multiplayer gaming environments are soon marginalized. According to research on bullying, video game environments are ahead of schools in how bullies are managed.
  3. Kids eventually work out issues that arise on their own, before their Minecraft-playing parents have to intervene.
  4. Mode of play (i.e. single-player, multiplayer, creative, survival) changes the way players interact with, and within the game, allowing them to practice different social skills accordingly.
  5. Through different modes of play, autistic learners may be able to learn empathy.

Research has shown that surgeons who play video games were 27% faster at advanced surgical procedures and made 37% fewer errors than those who did not play video games. Additional studies have shown that scientific reasoning is improved through certain video game environments. Wouldn’t it be reasonable to think that care providers who practice mindfulness and team-based play in a video gaming environment might have better outcomes related to both? This is a study I would like to see funded!


Bullying In Medicine: Just Say No

The internationally award-winning documentary film, Bully, tells the story of four kids who were victims of bullying in their respective schools. Tyler Long, who committed suicide because of the unrelenting physical and mental abuse he endured each day in school, was one of the kids whose stories was shared in the making of the film.  A short trailer for the film follows.

While filmmaker Lee Hirsch focused on school age children, physician and author Pauline Chen MD recently wrote about the bullying that goes on in medical schools in the NYTimes Well blog (see The Bullying Culture of Medical School.) Bullies, and the pain they inflict upon others, does not stop in middle school, and according to Chen:

…For 30 years, medical educators have known that becoming a doctor requires more than an endless array of standardized exams, long hours on the wards and years spent in training. For many medical students, verbal and physical harassment and intimidation are part of the exhausting process, too…early studies found that abuse of medical students was most pronounced in the third year of medical school, when students began working one on one or in small teams with senior physicians and residents in the hospital. The first surveys found that as many as 85 percent of students felt they had been abused during their third year…

Lucian Leape MD published two papers this past July in Academic Medicine on the disrespectful behavior that continues to occur in medicine, further confirming Chen’s assertions. A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians, and A Culture of Respect, Part 2: Creating a Culture of Respect both address this problem, and share that patients, as well as medical professionals, suffer when bullies are allowed to reign. Lucian says:

Students and residents suffer from disrespectful treatment. “Education by humiliation” had long been a tradition in medical education and still persists. Patients suffer when physicians do not listen, show disdain for their questions, or fail to explain alternative approaches and fully involve them in the decision-making process…

We have talked often in this blog about creating high reliability organizations (HROs) in healthcare. Other high risk industries do not tolerate bullying like healthcare does. Why is that? Does healthcare lack the strong leadership needed to eliminate it? Bullying does not belong in healthcare period, or anywhere else in learning cultures for that matter. While it is allowed to persist in any given health system, it will be almost impossible to achieve high reliability.