Friday, September 28, 2012

The Growing Culture of Hostile Dependency Toward Caregivers

Not long ago in this blog, I wrote about one of my colleague's tears as she hung up the phone after a bitter patient  berated her for making a surgical schedule change.   Tired and exhausted and still with consults and pacemaker checks to perform, she was returning a series of phone calls at the end of the day long after most people had already headed home.  She tried to maintain control, but after that call, the damage was done.
I have seen this happening over and over again recently.  The stress is palpable in our profession that cares for people's most prescious commodity, their health, while under extreme pressure to do more with less.

For businesses everywhere, the balance of costs with productivity to assure profit is nothing new. But in health care where people's lives are in the balance, the stress to health professional personnel is particularly palpable, especially now as huge transformative shifts are underway in how health care is being delivered in America.

So it was from this background that I struggled to understand why an exerpt from a heavily promoted book on patient safety appeared recently in the Wall Street Journal.  Why should an article about five simple steps to "keep hospitals from killing us" bother me so?  After all on the surface, it's such an important concept.
Perhaps I was bothered that "killing" was used in the byline when there are so many of us trying to prevent harm or do good for patients.  Perhaps it was because some of the insinuations made in the book lacked a national perspective.  Perhaps it was because some of the suggestions made were just more top-down Big Brother ideas that detract from actual patient care.  Perhaps it was all of these.  But after considerable reflection, I realized there was something else: a another overriding phenomenon that I was having a hard time putting my finger on. 
I submitted the following letter to the Wall Street Journal Wednesday.  They elected not to publish it.  This really did not come as a surprise since it was quite critical of their coverage of the patient safety issue.   But after showing the letter to a number of well-respected colleagues, they all encouraged me to publish it here.   Hopefully it will make people think about the complicated psychology of what's happening on the front line of health care these days.

Holding the Wall Street Journal Accountable

Since when does a book promotion get a full page and a half of prime news print in one of the most respected business newspapers in the world?  Usually a story that commands that much newsprint in the Wall Street Journal is written by one or more seasoned journalists to make sure all sides of the story are reported.

Full-page WSJ Story 21 Sep 2012
 So why the Wall Street Journal's recent coverage of Marty Makary's newly released book "Unaccountable?"   Not only has the Wall Street Journal devoted a full page-and-a-half article by Dr. Makary (who we find on Twitter describes himself first as a "medical commentator and author" and second as an Associate Professor of Medicine at Johns Hopkins School of Medicine), but they have now allowed him to host a special electronic blog platform called an "Ideas Market" on their website.   As news coverage of Dr. Makary's book spread this week, we learned from CNN that this same doctor described his fellow surgical colleagues as "Fred Flintstones" in his book because they don't use the latest laparoscopic techniques. 

Doctor versus doctor: it just doesn't get any better for Main Stream Media. 

But did anyone think to ask Dr. Makary if maybe the reason those older doctors don't use laparoscopic techniques is because they work at an inner city hospital with a limited budget without all the trappings of an academic medical center? 

No.  That would be reporting.

I am trying to understand the Wall Street Journal's motivation for their recent move.  It is both puzzling and concerning.  But at its core, it's probably quite simple to understand.  I should probably follow the money.  After all, we're all aware of the problems print media is having these days.

My bet is there's Big Business behind the Wall Street Journal's journalistic move. 

And who's Bigger Business or Bigger Money than the insurance industry or the hospital industry?  After all, medicine is the Biggest of Businesses in America.

Now before you go laughing at my conspiracy theory, ask yourself if there might be a problem with the perfectly even 98,000 number of deaths caused by medical errors touted by the Institute of Medicine in 1999 and highlighted in the Wall Street Journal's patient safety piece.  Ask yourself why a professionally-produced book trailer promoting Dr, Makary's book that HAD to cost upwards of a quarter million dollars to produce winds its way on to the Internet.  Ask yourself why no one would research the background of the players in that video and their motivations to appear in it.  Was their motivation truly altruistic?  Or in this era of the creation of Big Box medical care delivery, might there be another reason?

These days, the majority of today's American doctors are in the unenviable position of trying to be true patient advocates while promoting a Big Box medical model that has been foisted upon them and, for the majority of us, serves as our employer.  The world loves idealists and none more so that Big Box Medical Center administrators and thought-leaders.  Getting a physician leader spokesperson to forward a business agenda that serves the interest of its cash-paying customers is about as sweet as it gets.  Better yet, using patient safety as a means to influence doctors' behavior is ideal because it is professionally unassailable.  What doctor in his right mind would ever dare to think, let alone put in writing, that there could ever be a down-side to assuring perfect patient safety?

But is this new paradigm of journalistic reporting and wholesale promotion of one doctor's five ideas for patient safety without consequences? Can we afford perfect safety and all of the costs it entails while throwing our doctors under the documentation bus (or Big Brother camera) as they are asked to take incredible risks on behalf of their patients, be omnipresent, omni-available, impeccably skilled, omni-credentialed, omni-sympathetic all while seeing more patients in less time?  Must we be made to believe, without reservation, that doctors (or any of the hundreds of people who work on each doctor's behalf) aren't human and subject to error?

I am seeing a culture of hostile dependency growing toward caregivers.  The theme is like an adolescent who realizes his parents have feet of clay.  He comes out of his childhood bubble and realizes his parents have failures and limitations because they are human beings.  This results in the adolescent feeling unsafe, unprotected and vulnerable.  Since this is not a pleasant feeling, narcissistic rage is triggered toward the people he needs and depends on the most.  None of this occurs at a conscious level.  Most of us understand this behavior simply as "adolescent rebellion," not understanding the powerful issues at play.  So when we spotlight one side of the patient safety story without acknowledging the realities health care workers face like looming staffing shortages and pay cuts, we risk fanning the flames of narcissistic rage against the very caregivers whom we depend on the most - the very caregivers who are striving to do more with less, check boxes while still looking in the patient's eyes, meet productivity ratios, all while working in a highly litigious environment.  Why would we do this and why would we allocated money as Dr. Makary suggests, for punitive top-down solutions instead of spending that same money on supporting and educating our frontline providers?

A good journalist would investigate all sides of the story and understand its impact.  A one-sided full-page book promotion by a non-journalist in the well-respected Wall Street Journal that reduces the serious patient safety issues in today's Big Box medical organizations to "5 simple steps" is nothing more than a cheap shot at the majority of  doctors who choose to carefully and tirelessly treat their patients as safely as they can without basking in the glow of Main Stream Media.



Dennis said...

Dr. Wes... There are two important viewpoints when trying to understand how doctors and patients treat one another and that is simply the doctors view and the patients view. As a patient I can give you a thumbnail of how I feel about patient care. In general I view the doctor like I would a mechanic. I take my car or body in for a checkup or repair and I a m concerned as to the quality that I will receive and the cost... time is money as you are aware. I worry that the mechanic or doctor has so many check ups and repairs to accomplish in a given time frame that there may be a tendency to rush things along and miss something important or in the worse case scenario, turn out shoddy work. Governments are always lurking in the background, turning out new rules and regulation for the good of the consumers we are told, however this puts an undue stress on both mechanic and doctor who now spend more and more time worrying about things that interfere with their chosen profession and of course the result in passed on to the consumer... ie. the patient. I sometimes feel like the sheep waiting to be sheared and once that is accomplished and the cash trades hands, I am no longer useful until the next shearing time or ER or office visit. I also believe that people who enter the medical professions (plural) no longer are motivated by the same desires that their predecessors were and of course now it is segregated by ‘specialties’ and it is not common for those to cross paths other than results projected on a tablet at rounds or prior to a face to face with the customer who has lost most of his or her identity.

So in some ways it may be a monkey see, monkey do situation. I am aware that patient and customers can be demanding or rude, however those same people might feel the same toward the doctors, nurses, office personnel, specialists and all those caught up in the gauntlet of the medical maze. Feelings wear thin when the sense of intimacy no longer exists and both sides feel like a worn out old shoe that has no further meaning or use . And then the bill comes and the medical teams charge like they were funding a mission to Mars and the consumer has a heart attack trying to put it into perspective against his or her $15-20 dollar an hour job...

Not the best of analogies but one man's viewpoint.

Anonymous said...

Great points. The WSJ should have published it. Their loss. Keep up the good advocate work. : )

Anonymous said...

Thank you for your advocacy.

This is not the first time the WSJ has turned on docs. They did another hatchet piece years ago about aortic dissection when John Ritter died with the condition. They basically implied that everyone with chest pain should have a CT scan. It was so biased and one-sided that I stopped reading the paper.

Carolyn Thomas said...

Dear Dr. Wes,

I'm guessing that you haven't yet read Makary's book, which would be unfortunate given that his focus is on addressing five important ways that hospitals can become safer for patients. This message is important, however offended you may be personally by the unprecedented media hype his publishers have arranged for the book launch. Such hype reflects the very real concern of those who are being harmed: patients and their families.

Your post reminds me of the online outrage expressed recently on a surgeon's blog about handwashing cameras being installed in a New York hospital's ICU because of disturbingly low staff handwashing rates (as low as 10%). But after cameras were installed, handwashing adherence went up to 90%. This surgeon, however, was upset by this report because aiming cameras at doctors and nurses somehow implies an insulting lack of trust in them.

Talk about your "narcissistic rage"!

As a heart attack survivor who has had both the very best and worst of experiences with my doctors, I do share your concerns about doctor-bashing. I just attended the Medicine X conference at Stanford this weekend where we learned of a 2012 Merrit Hawkings study showing that 47% of physicians under 40 would retire today if given the opportunity.

That's a catastrophic number. We have a lot of unhappy, under-appreciated doctors out there who are genuinely doing their best under very challenging circumstances. I met hundreds of them at MedX.

But we are not going to stuff this genie back into its bottle: patients, family members and their doctors are asking questions and demanding answers, just as they should.

And let's face it: like the ICU handwashing cams, a sharp lens is now being focused on a profession that has until now had very little experience with being questioned by anybody.

Carolyn Thomas

Anonymous said...


Anonymous said...

I agree entirely, Dr. Wes. We get it in the pharmacy profession as well. Plus we get it from older pharmacists that may have been stuck in an different paradigm such as one of the passing fads or remain 'unenlightened' in comparison to us younger pups (Yes, I'm 54 but I went back for my doctorate and have been taking class one after another for 20 I have the benefit of a study of modern pharmacy history as well!)

I will agree that the mindset has had to change from 'pharmacists' never make a mistake (or admit that they could) to pro-active elimination of the situation that could cause an inevitable error.

But, it's throwing the baby out with the bathwater when a supposed 'expert' professional gets a burr up the wrong orifice and demeans the job that co-workers are striving to perform each and every minute of every day, which prevailing work conditions thwart!

Skeptical Scalpel said...

I'm the outraged surgeon Ms. Thomas referred to. While supporting her point of view, she omitted many facts that I blogged about. The hospital admitted it had no data on the actual percentage of compliance since the cameras were installed. I pointed out some instances where false accusations of not washing hands could be leveled at doctors. There was no mention in the article of the cost of the 27 cameras and the outsourced monitoring of them to India. Could that money have been better spent elsewhere?

To her credit, she mentions yet another study that shows how many doctors are unhappy. As for me, I'm quitting.

Anonymous said...

Skeptical Scalpel,

I agree with the assessment, plus the study itself is pretty uninteresting. In their own words, the starting point, pre camera's were "6.5 percent of workers on average washed their hands within 10 seconds of entering or leaving a room."

Big deal. I'll admit I rarely wash my hands within 10 seconds of entering/leaving a room. I do however wash them before touching anything in the room or after touching anything in the room (patient, objects, etc.). Heck, as a medical student sometimes I won't wash my hands at all if I am rounding with a team and know I won't be doing anything other than standing in the corner, observing and occasionally getting pimped. Why dry out my hands more than they already are for no good reason?

Of course if I am entering the room of a patient who is ill or immune suppressed I not only wash my hands but glove/mask up as well, even if there aren't isolation precautions posted. It's just common sense, which is lost by bureaucrats making dumb rules like "everyone must wash their hands within 10 seconds of entering/leaving a patient's room."

People might argue well "everyone in the ICU is really sick!" you should always be in hypervigilant mode. Such people have never worked in an ICU. While I haven't done a rotation in an adult ICU, I spent a lot of time in the PICU. For every patient with some horrible infection, there is another there because they have DKA, status asthmatics, status epilepticus or a variety of other conditions that are neither contagious nor imunosuppressive.

Anonymous said...

As a public health professional, scientist and biostatistician, I have long been appalled by the lack of appropriate medical systems that could prevent medical errors in the US. I have been a patient and a colleague of MDs for decades and have had many poor experiences with MDs and only a few good ones. The blog post provided above further cements the prevailing stereotype about MDs, namely, that they are more concerned about themselves and their reputations than they are about patient care. Perhaps a little humility will be needed by medical professionals before patient care can truly improve. Why are MDs getting offended by the mere suggestion that they should wash their hands systematically in order to save lives? Why is this offense taken particularly in light of solid scientific evidence? It suggests motives other than the search for truth and good public heath.