Julie Salamon has been guest posting here on the themes covered in her new book, Hospital. This is her last post.
Rudeness isn’t new to the medical profession. In the original charter of the American Medical Association, approved more than 150 years ago, physicians were warned to “avoid all contumelious and sarcastic remarks.”
But now the medical community acknowledges that bad behavior isn’t just about manners. It can harm patients and result in serious financial consequences for hospitals through loss of efficiency and decreased productivity.
Last week the Joint Commission on Accreditation of Hospitals issued a “sentinel event alert,” which warned that “rude language and hostile behavior among health care professionals goes beyond being unpleasant and poses a serious threat to patient safety and the overall quality of care.” By January 1, 2009, the 15,000 hospitals, nursing homes, and other health agencies monitored by the Joint Commission will be required “to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior.”
This week the American Hospital Association’s Hospital and Health Networks published an article on the subject under this headline: “The right culture can result in the right outcomes and help avoid costly litigation.”
The New York Times recently reported that doctors are being advised to apologize to patients as a way to fend off malpractice suits.
Momentum has been building. Three years ago a publication from the National Institutes of Health reported, “Dysfunctional nurse-physician communication has been linked to medication errors, patient injuries, and patient deaths.”
About that time, Maimonides Medical Center in Brooklyn began a program to encourage employees to follow the hospital’s Code of Mutual Respect, whose provisions include this one: “The Medical Staff agrees to refrain from any behavior that is deemed to be intimidating, including but not limited to using foul language or shouting, physical throwing of objects …”
The program coincided with the year I spent immersed at the hospital to write a book. During that time, a senior nurse explained,
Think about it. You can’t do surgery without your instruments. Our instrument techs make thirty thousand dollars a year, and we expect them to be these highly skilled, ambitious people who are going to make sure the tray is going to be built exactly the way the surgeon wants it. But they don’t have the same drive the surgeon has. It’s not the same drive even a nurse may have.
How do you motivate someone who makes twelve dollars an hour? By saying, “Your next raise you’re getting another twelve cents?” I think what beats them down is the hierarchy — the respect they’re given or not given. Everyone beats down on the one below.
Here is the hospital’s “respect survey” and how people have responded over the past three years:
The Joint Commission might urge medical people to follow the advice of Maimonides, the 12th century philosopher and physician who wrote: “The perfect man needs to inspect his moral habits continually, weigh his actions, and reflect upon the state of his soul every single day.”
Will more self-scrutiny help avoid litigation and improve patient care?
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What tosh. Doctors need to act MORE like real people, not less. The stress and inumerable auxiliary problems restrictions on how doctors can behave as human beings should not be underestimated. If you want them to be good people, you should have started on them while they were in kindergarten.
As typical, JCAH ( a for profit entity that derives revenue from charging it’s hospital subscribers) is decades late with this. Twenty years ago, this would have had a real impact.
The culture has already changed via work-place and sexual harassment law.
My Dad is dentist. Many years ago my parents went through an ugly divorce. During that time my
Dad lost a malpractice suit. He told me that usually, when dealing with unreasonable patients who blamed him for things he had no control over, he would apologize and offer freebies if necessary to calm them down. But during the divorce my normally mild-mannered Dad was angry and kind of crazy. When dealing with this patient who was upset he was dismissive and rude. This resulted in a malpractice lawsuit that my Dad lost in arbitration. The amount of money involved was small but it affected his insurance rates for years.
What would potentially lessen malpractice litigation is for doctors to speak in a kind and direct manner and to admit when they do not know what is going on.And to do so not as they are rushing out of the room. My wife was in for a TIA recently and they ordered every test under the sun…with very little communication from the doctor other than “well, we are going to do this test next”. It became clear they were fishing. Admitting it would be nice. A TIA is more complex than setting a broken arm. Some honesty would have been appreciated.
We did get the honesty we needed, but it was from the nurses. Seems a little backwards.
to Scott:
You may have preferred: “I do not know the cause of the TIA at this time, but I am looking for a carotid or aortic atheroembolism, a clot from the heart, or a
in-situ thrombus.” The physician was fishing,…..appropriately so.
However, many patients/families can not deal with ambiguities or uncertainties. They want concrete statements only. They freak-out to hear, “I don’t know.” You were scared and likely may have been upset with anything the physician would have said. It is rare to work with a family that stays calm and patient in that setting.
It is not just in the medical profession. It ranges everywhere from medical to law to business all the way down to food making industry. As a teenager making nine dollars per hour at a deli, I have to say that I’ve encountered more rude people than I have when I was interning at a hospital. It really just gets down to how people are deep down inside. I believe we are all sometimes selfish and rude creatures, especially on a bad day.
At the hospital, I hear people try to say that doing your job with compassion doesn’t take any longer than doing it without. Unfortunately, that’s about the dumbest thing I’ve ever heard. But I’m glad when those are the people I’m taking care of patients with (because apparently we’re going to be at the hospital later than everybody else!).
The only incentive doctors have to treat others with respect is the maintenance of their own self-respect. And most docs over about 50 lost their self-respect a long time ago. Us younger folk have been promised that our salaries are only going to plummet over the course of our careers, so our self-respect is all we’re going to have left.
Yesterday at a local pharmacy (Florida) a pharm technologist informed me of an unpleasant incident with a physician. It appears that this physician became upset when she didn’t recognize him; “Don’t you know who I am?” The double irony is that she was new to the job (six weeks) and the doctor is new to the area (one year.)
As physicians we’re taught to keep our mouths closed in the unfortunate case of a medical error, as this admission of guilt can lead to an adverse result in case of a lawsuit. However, we are human and subject to errors, and when committed, many of us feel badly (and embarrassed) and would like to apologize, not necessarily to try to avoid litigation, but because it is the right thing to do.
Health care has revolved around physicians since time immemorial, and they (we) have grown accustomed to being in the drivers seat for the most part. With this comes power and, as we all know, power inevitably corrupts. With this power sometimes comes a perceived “exemption” from normative behavior including treating fellow human beings with respect.
Regarding the example of the salary issue mentioned above the difference is that the employed person’s salary is set by the hospital, basically by supply and demand. As a parallel example, due to the nursing shortages nursing salaries have significantly increased. Also, at least in Florida, as of 2006, some 30% of hospitals were losing money and similar data may be present in NY. http://www.fha.org/facts.html
There is downward pressure on non-scarce employees.
On the other hand a self-employed physician’s salary is less dependent upon market forces (though it should be in part) and more dependent on issues of self-sufficiency and initiative.
Malpractice is a tough nut. There are probably 10 times as many incident of malpractice, both minor and major, than lead to a lawsuit. When you have so many different players in the mix such as physicians, nurses, pharmacists, lab techs, orderlies and so many different systems in place something is bound to occur. Our system basically sucks because the attorney’s cut of the deal is usually 51% of the settlement (Florida) counting fees, expenses etc. A better system would be a 3-member panel of unbiased experts that any patient could bring a complaint to to seek redress for injuries. More people would seek help and they would get more of the money than the attorneys.
Regarding saying “I don’t know” it is difficult for most physicians to say, and is probably hard for everyone to admit ignorance. What I say when I’m faced with a difficult clinical issue, and don’t know the answer or the diagnosis, I routinely tell the patient “I don’t know but I will find out or send you to someone who will be able to help you.”
This communicates to the patient that you will do your best for them and also act as their advocate even when your roll in his/her care will be limited.