Dr. Gooser and Asshole Poisoning in Hospitals

A longitudinal study of nearly 3000 medical students from 16 medical schools was just published the British Medical Journal. Dr. Erica Frank and her colleagues at the Emory Medical School found that 42 percent of seniors reported being harassed by fellow students, professors, physicians, or patients; 84 percent reported they had been belittled and 40 percent reported being both harassed and belittled. You can see a nice summary on Yahoo! or can download the study at the BMJ website.

Dr. Frank’s study is unusually careful, but the finding that hospitals are nasty places to work – especially for nurses, medical students, and residents – has been replicated again and again.  An earlier study of  594 “junior physicians” (similar to “residents” in the U.S.) in the United Kingdom found that 37% had been bullied in the prior year (especially by more senior physicians) and 84% indicated they had witnessed bullying that was aimed at fellow junior physicians. Nurses appear to have it especially bad, and unlike these medical students or residents, they don’t graduate to positions as doctors where they are relatively free from getting abuse, and apparently, also relatively free to dish it out.

I first saw the abuse that nurses face in the 1980s, when I was a PhD. student at The University of Michigan. My colleague Daniel Denison and I spent a week interviewing and observing a team of surgical nurses, and we were appalled by how rude, oppressive, and downright abusive the male doctors were to the (largely) female nurses. Take the surgeon that we dubbed “Dr Gooser,” after we saw him chasing a female nurse down the hall while trying to pinch her behind. The nurses we interviewed bitterly complained that it was useless to report him to administrators because they would be labeled as troublemakers and be told “he is just joking.” The told us that all they could do was to avoid him as much as possible.

Indeed, study after study shows that too many hospitals let people like Dr. Gooser get away with their dirty work. A 1997 study of 130 U.S. nurses in the Journal of Professional Nursing found that 90% reported being victims of verbal abuse by physicians during the past year; the average respondent reported 6 to 12 incidents of abusive anger, being ignored, and treated in a condescending fashion. Similarly, a 2003 study of 461 nurses published in the journal of Orthopaedic Nursing found that 91% had experienced verbal abuse in the past month, defined as mistreatment that left them feeling attacked, devalued, or humiliated. Physicians were the most frequent source of such nastiness, but it also came from patients and their families, fellow nurses, and supervisors.

The author of this most recent study, Dr. Frank, was quoted as saying, "This kind of culture change is not going to happen with any particular rapidity." And that, "We give a lot of lip-service to teaching professionalism [and] to reducing the prevalence of disruptive physicians, but unless we train physicians not to do this, it still falls into the action-speaks-louder-than-words category." Her comments raise the question of how to start such a process of cultural change. I agree it wouldn’t be easy, but at the same time, this attitude is dangerous because of the power of the self-fulfilling prophecy. If you believe that cultural change is difficult and takes a long-time, then it will be difficult and take a long time.

Hospitals operate under severe cost pressures, especially since the rise of HMOs. So the first thing that comes  is start with a serious effort to calculate the total cost of assholes in hospitals (or TCA), to calculate the amount of money lost on turnover, absenteeism, additional health care costs and so on. I provide some examples and a list of possible costs in The No Asshole Rule, but one cost that I left out for hospitals is the failure to learn from and report medical errors. There is a fascinating study by Harvard Business School's Amy Edmondson of eight nursing units that sheds light on the human and financial costs. She found that when nurses worked in units with demeaning and critical co-workers and supervisors, they were less likely (as much as 10 times less likely) to report drug treatment errors.  Edmondson’s research suggests to me that, when asshole poisoning runs rampant in a nursing unit, the fear of being demeaned and belittled can increase the chances that patients will get sicker and die, because people are so afraid to admit and talk about mistakes. 

Of course, there are no magical cures for organizational problems, but they only way they get better is by taking one step at a time, and looking for intervention points that seem likely to get noticed. And confronting hospital and HMO administrators with the financial costs strikes me as a good place to start.

Comments

[DH]

The entire medical profession is so dysfunctional that it simply beggars belief. Meanwhile, health care costs continue to spiral out of control.

It is my view that there are several root-causes for the current situation:

- The artificial delineation between the roles of doctor and nurse in an increasingly technology / diagnostic driven medical environment (i.e. doctors "protecting their turf")

- Extremely poor HR and resource management practices

- Failure and unwillingness to introspect or admit mistakes - as medicine is supposed to be a "mistake-free profession". This culture is poisonous to the very concept of building a "learning organisation".

- Bureaucracy-laded health management practices

- A lack of systematic / engineering-mindset rigour to the treatment of patients and delivery of healthcare

and perhaps most importantly:

- The ongoing failure (and infact outright hostility) by doctors / the medical profession to seek lessons beyond their own sphere of practice and to apply those. A great example are the leaps-and-bounds advances made in the aviation sector with "Crew Resource Management" (CRM) training, that enables highly-skilled, well-trained (and often type-A personality) individuals to work cohesively and effectively in a multi-crew environment, with absolutely measurable reductions in error and failure rate as a result

If what passes for medicine in an operating theatre were to be translated into the cockpits of modern commuter aircraft, I suggest to you that we would be watching a spate of aircraft falling from the sky literally on a daily basis.

[health coaching]

Some doctors these days are very uncompassionate and dead to the world when it comes to there patients.It is true , money is the root of all evil

[Cecil Nixon]

I read this article with great interest. I changed professions about 5 years ago, from basically a desk job as a physician recruiter to a clinical job as an xray technologist, I've witnessed both sides of this particular problem. As a recruiter I was given respect by the doctors because I essentially controlled their income as I negotiated what they were going to be paid. As an Xray Tech, I have seen appalling behavior that I never would have witnessed as a recruiter...As an Xray Tech I do many surgery cases and as such I have seen tools thrown, temper tantrums thrown as if a two year old suddenly inhabited a fully grown "Intelligent" human body, the most egregious however is the constant "microagressions" the passive aggresive comments that wear and tear at ones well being statements like " oh you had 50% chance of getting that right" or "SHOW ME SOMETHING!!!" or DON'T TOUCH ANYTHING JUST STAND THERE AND PUNCH YOUR LITTLE BUTTON" These are the G rated experiences There have been some instances of outright profanity. I have worked in many different industries including the contruction trades, the US Military and Sales...I have never witnessed anything like surgeons in the Operating Room. Not to say they're all bad, but, More than half are... I think they like the money but, hate the responsiblity of good patient care...A very nerve racking experience, other people say you just can't take the comments personally, that's hard to do. Good luck to anyone who would pursue a career in a hospital. No wonder there's a shortage of Nurses and other relevant technical modalities. The hospitals are really in a bind, they can live without nurses and techs, but the show stops if there is no doctor, and the doctors know it!

[Mark Graban]

I haven't seen it first hand, but at one hospital I've heard stories of surgeons throwing things at nurses and staff, how they needed a new director to come in and "take charge" to clean up the culture of harassment. As a potential patient, I'd hate be taken into such a dysfunctional atmosphere.

Look at airlines, do the pilots throw stuff at the maintenance crew when they don't get their way?

This behavior wouldn't be tolerated in the "barbaric" manufacturing industries, even.

[Anne]

The rude, demeaning behavior extends to other hospital professionals, as well. I am a Physical Therapist. I have been ignored, belittled, and cussed out many times myself. I once suffered the wrath of a doctor because I refused to carry out an order that was clearly contraindicated for the patient's particular situation, and to follow his order I would be risking my own professional license. As a result, I no longer work in hospitals and will never again.