Friday, July 17, 2009

That's A Negative, Ghost Rider

A couple of months back I read the book "Outliers" by Malcolm Gladwell.

I have to say it didn't impress me as much as his book, "Blink", but there were a couple of interesting chapters. The one I found most fascinating was the one about Air Korea and their increasing number of deadly crashes. Forgive me if you've read it but I'll flesh it out a little for those who haven't...(and also forgive me/correct me if I recall some of this sloppily as I've already passed the book on to a friend and can't reference it now for complete accuracy).

In brief, Air Korea was having so many plane crashes that it was in danger of losing it's ability to fly in North American airspace and going under as an airline. Experts were brought in to look at why the crashes were happening. In reviewing the documented dialogue between pilots/flight engineers they found the language that was being used (both to air traffic controllers and colleagues) often did not convey the seriousness of problems early enough for them to be corrected. It was often vague or the seriousness of the situation was watered down.

Also compounding that, the deference that the 1st officer has toward the captain (as a cultural implication) does not really allow for him to a)take over the controls if the captain is screwing up or b) tell the captain that he is royally screwing up and get him to change his actions. Even in the face of imminent death these 1st mates could not or would not violate the cultural norms to do as they are instructed in emergency situations (i.e take over the controls if the captain is making a grave error). I have to say that reading the transcripts of the dialogue prior to the crashes was heart wrenching and fascinating.

So the company was re-vamped, retrained, and dissected to see how this behavior could be 'un-learned' when the pilots were at the controls. One of the changes that was implemented was that the crew were to address each other by first names, thus eliminating some of the power differential present in the language of titles. Once the 1st officers were trained to be assertive and see themselves on more equal footing with the captains, the company soared (literally and figuratively). The pilots were trained to communicate more effectively with all of the members of the team--the captains consulting with the flight engineers and first officers and vice versa.
Korean Air, as it is now called, is a top notch airline with a safety record better than most of the competition.

So this got me thinking about the dynamics that occur in health care. Pilot errors and physician errors (or health care related errors) are often compared. Pilots have very strict guidelines in terms of sleep and work related to job safety...most hospitals have nothing in place that is comparable for nurses and doctors. Look at the hours that residents pull!! Would a pilot ever have to be at the controls for an entire weekend on only a few hours of sleep here and there? Not on your life! (Ha!)

This thread then got me thinking about the 'safest' places I've ever worked. And by safest I mean...ER departments or outpost clinics that I felt their existed a harmony amongst the staff where one could ask questions, point out errors, admit to errors, ask for help, admit to being swamped, call attention to urgent needs...etc. versus places where none of the nurses would speak up if they didn't understand an order, or thought that maybe the physician was making a mistake, or noticed a patient deteriorating. Or where physicians would ask for input, feedback, collaboration from the rest of the staff (be it physios, R.T's, nurses, whatever).

Trust and mutual respect go an amazingly long way with regards to patient safety in my humble opinion. The more I reflected on examples of this the more glaringly obvious it was.

The parallels between the airline crew example and an ER department staff seemed pretty obvious. Right down to addressing one another by first names instead of titles.

I know these aren't new or groundbreaking thoughts on workplace dynamics in the ED but it got me thinking back to a post that Old MD Girl made on her blog* about being a doctor and being the "boss" of nurses.

Nurses (and other health professionals) certainly have a lot more respect in the workplace than they did 100 years ago when their duties included cleaning the doctors lounge and standing up whenever one walked in the room (I would have lasted about 5 mins as a nurse if I'd been born 120 years ago, BTW).

Today I see us as the 1st officers to a certain degree. I have had relationships with some docs where I have felt my opinion and input on a patient was seen as important information and I have worked with docs who made me feel like an annoying mosquito buzzing in their ear every time I opened my mouth.

I have had physician colleagues write "sedative analgesic" as an order and trust me enough to use my discretion with regards to what I am going to give a patient to make them relaxed and pain free. And I have worked with doctors who have angrily told me NOT to use the word "angina" when describing a patients symptoms to him because "angina" is a medical diagnosis and nurses do not make medical diagnoses. (Not even joking).

So what sort of utopian emergency department would it be if nurses and doctors could lose some of that power differential and see each other as colleagues instead of two very separate camps. I know that all work places are all about hierarchies and titles and posturing and inflated egos. But I have seen how these natural human tendencies can actually put patients lives in jeopardy and I think it is something worth reflecting (or ranting?) on a little.

*To my surprise I actually wasn't irked by this post. Overall I enjoy her blog and think that she has interesting and often funny anecdotes (which I can certainly relate to being 'old' myself).


Keet said...

There are some really good articles on exactly this topic, e-rock... When I was doing patient safety consulting, we did a bit of research on Crew Resource Management in healthcare, as it is the accepted safety norm used in air-travel. It is exactly about shared responsibility and power equalization to optimize safety. The problem lies is trying to reshape some if those dinosaur mindsets that many dr's and nurses share about power and responsibility. I still hear nurses saying, "I know, it doesn't seem right, but the dr. ordered it..." as the go ahead with questionable directions. I also still see Doc's saying to nurses things like, "I wouldn't have ordered it that way if I didn't want it done that way!" when asked a reasonable question. We have a long wayvto go to make this thing we call healthcare "safe", whatever that is. LOL... Good times...

OMDG said...

Thanks for the link.... I think. I hope I don't get additional hate comments from people who want to get pissed off.

It would be nice if a rational level-headed discussion could take place about this subject, since there is an actual hierarchy between doctors and nurses, though we're all supposed to pretend that there isn't. I'm sorry you have had negative experiences with some doctors, but I'd be lying if I said that I'm surprised. I hope I treat the nurses who take care of my patients with respect, and don't make them feel like a buzzing mosquito!

Glad you like my blog!

Albinoblackbear said...

<3K--I figured you'd have had some experience with looking at these similarities in your line of work (you do still work, right? hahahah).

Shared responsibility is an interesting concept right? Ultimately the MD's ass is on the line if things go south so we as nurses enjoy an interesting buffer zone that allows us to question (and sometimes criticize) an MD's decisions from our 'safer' vantage point.

This became very clear to me the first time I had a cardiac patient in the Arctic and had to decide if I was going to medevac him. I would have rolled my eyes in the south if the doc had been humming and hawing on this case...and once I realised that it was my call, oh let me tell you there was humming and hawing and much gnashing of teeth. :)

OMDG--hahaha, I also hope you don't get additional hate comments! :)

That is why I added that I wasn't irked by your post and that I enjoy your blog(...obvi, I have it on my blogroll)--I just figured if someone went to the link and read that post (and it was their first exposure to your blog) they might get the wrong idea.

Obviously you've given more sober thought to these concepts than most individuals...and your comments on the matter made me think about the white-elephant-in-the-room-hierarchy issue, which is why I wanted to link to it.

I think it is important to stir the pot and get people thinking and talking about it...

Rogue Medic said...

I liked the book, but I think that part of the solution was requiring them to communicate in English, rather than Korean, since the ability to get the crews to view each other as colleagues just was not going to work in Korean. Too much of their class structure is a part of the language.

Good patient care is about everyone working as colleagues. If you observe something and do not pass the information on to the doctor, you are not doing the doctor or the patient any favors.

If a doctor chooses to ignore information from nurses, or others, by definition that is ignorance. Pretending otherwise is just a way to maintain as much of a power differential as possible, no matter how harmful to the patient.

The same is true of nurses or doctors ignoring medics, and medics or nurses or doctors ignoring basic EMTs. Intelligent people have the ability to listen to alternative points of view without having to play psychological games.

Nurses have a responsibility to refuse to follow an order that they believe to be dangerous to the patient. So do paramedics. This has been upheld by courts. Following an order, just because a doctor gave the order, is not a valid defense against malpractice. All medical providers can be sued for malpractice.

One example is a patient with an endotracheal tube. HeThe patient was biting down on the tube, apparently due to a lack of sedation. The doctor ordered me to transport the patient without sedation. I refused, since there was no patent airway. Even on a 1 mile trip, an airway is essential. When the doctor realized that I could not be persuaded, short conversation. A polite, but adamant refusal to transport the patient until there was a patent airway. This is not something that is common, but the doctor's priorities were misplaced and that needed to be addressed. If I had transported, I would have been just as much at fault for any negative outcome as the doctor.

The hierarchy does exist, just as a hierarchy exists in the military. The military does not encourage encourage officers to ignore information. Some forget this. That does not make it right. The military also educates everyone about their duty to refuse to obey unlawful orders.

When someone is shooting at members of the military, their ability to discuss orders is going to be significantly restricted.

In the hospital, there are very few situations that actually require immediate obedience. Few doctors are actually being shot at, when they are dramatizing their position higher up in the hierarchy, but that is hardly a good thing. Remember, the doctors are not at the top of the hospital hierarchy, the administrators and others are. No doctor would ever be displeased when treated badly by someone higher up in the hierarchy. This is a part of the actual hierarchy.

The ultimate responsibility lies with the doctor, but if the doctor is giving orders that the nurses, medics, EMTs feel are dangerous, then the doctor had better be prepared to perform those orders himself/herself.

Doctors, who know how to communicate, do not seem to have this problem. Why is it that the shortcomings of the doctor are the responsibility of those lower on the hierarchy? That is the way caste systems work, not a hierarchy designed to improve the care of patients.

Why is expansion of this hierarchy, far beyond what is relevant to patient care, something that is defended? If we are defending hierarchies, maybe we should just keep it simple. Men are at the top and women exist for their cooking, cleaning, intercourse, and child rearing abilities. After all, there is a hierarchy.

WWWebb said...

MDCSR. What I said.