More on Pronovost

I have been continuing to read Peter Pronovost’s new book.  He has some great things to say about changing hospital culture that everybody should read.  His book also highlights some serious problems in the medical hierarchy not only between doctors and nurses but between physicians.  This is another area where we could easily learn something from the airline industry.

When the aviation industry began to move from an autocratically reckless culture, with hot sticks (i.e. captains and sometimes other pilots) – the ones who had the right stuff – dominating all of those who didn’t (first officers, flight engineers, flight attendants etc.) they quickly and cleverly challenged the dominant mode of what I call toxic hierarchy. We all live in hierarchies. Some people know more about some things than others. Some people have more money. Some people are actors and some super stars. Hierarchy, however, doesn’t mean you don’t have to listen to others or treat them abusively. In a hierarchy you can assert differences while still insisting on the need to be civil and respectful to others. In a hierarchy, you can still recognize that other people may have useful information to share, that you can learn from and that they represent a potential resource.

In a toxic hierarchy, however, what Paolo Friere describes is the prevailing mode of being. “We have a strong tendency to affirm that what is different from us is inferior. We start from the belief that our way of being is not only good but better than that of others who are different from us. This is intolerance. It is the irresistible preference to reject differences.”

This kind of intolerance prevailed in the cockpit where as one aviation expert, Robert T. Francis, explained, the captain, in one way or another, informed the co-pilots, “I’m the captain, I’m king, don’t do anything, don’t say anything, don’t touch anything, shut up.” Once the captain entered the cockpit, it was as though he, not the airline company, owned the plane, as well as all the passengers. To protect not his judgment, but his authority, he could and sometimes did, make any call, no matter whom or what it jeopardized. All that changed with the advent of Crew Resource Management and the aviation safety movement. Now, as Francis explains, there is still a hierarchy in aviation, but it is no longer toxic. So, as he told me, the captain is still king, but when he enters the airplane and cockpit, the new mantra is “I’m the captain. I’m king, please tell me if you see me making a mistake.”

One of the ways hierarchy is maintained while safety enforced is through the empowerment of the crew and first officer to challenge the captain. As team leaders captains are taught that their job is to make decisions based on all available information and resources. Their job is also to make sure team members can do their jobs efficiently and effectively. Team members are taught that their role is IAA –Inquiry, Advocacy and Assertion. In other words, if a captain says “jump, “ they don’t just reactively say “how high.” Instead, if they are not completely clear on the whole jumping thing, they are trained to “inquire” to clarify the order, if necessary. Keeping in mind that the captain is still in charge, crews learn that if subordinates see that jumping, in this case, may not be the best course of action for the circumstances, they are expected to seek clarity through IQA. Crew members are taught about the two challenge rule: If the captain is about to make a critical mistake –flying into a mountain, for example — you urgently warn him about the situation. If he doesn’t listen, you tell him again, and if he still doesn’t listen, you have a serious decision to make, and if the safety of the flight is clearly at risk, you need to consider taking control of the aircraft. Obviously a first officer is in a position to do this and sometimes does. This is a situation that must only happen with a great deal of forethought, consideration and commitment, for obvious reasons. The point is, the captain is no longer allowed to fly the $70 million plus plane “solo” into the mountain – unchallenged – taking with him the passengers and crew members.

Well, doctors are still flying the health care equivalent of the plane into the mountain and those who are crew members seem to have little leeway to do anything about it. Patients, if they’re alive, their families, if they’re not, can always try to sue. But lawsuits are a very poor and cumbersome way to change a culture.

Just how much the culture needs to change and how much health care needs to learn from aviation is evident in several stories Pronovost recounts in his book. I will only talk about one of them. But it’s a doozie.

Pronovost is a superstar doctor, and head of the Intensive Care Unit at Johns Hopkins. Yet the fact that he’s a physician – and a superstar one at that – doesn’t seem to matter much in the toxic hierarchy of his hospital. In the medical hierarchy, the surgeon, not the intensivist – owns the patient. What he wants to do – or not do, in this case – gets done, or not.

So a 29 -year -old woman comes to Hopkins to have a kidney removed. Apart from her kidney problem, she is otherwise in good health. She comes out of the OR after a laparoscopic procedure and the surgeon insists all is well. But she starts to go down hill quickly. At 10 PMPronovost is paged and talks to the resident, who insists the surgeon says all is well. He nonetheless wants the patient to be taken to an Intermediate Care Unit, which involves Pronovost and a CT scan is done. The CT shows no signs of a surgical complication. The surgeon insists there was none, but the patient has rapidly deteriorated and Pronovost thinks the surgeon has made a “classic diagnostic error” and that the patient needs to be taken to the OR. But the surgeon owns the patient. Four hours later, Pronovost gets a second call. The patient is clearly dying. He knows her condition can’t possibly be due to anything other than a surgical complication. He calls the surgeon –it’s now 2 A.M. – and the surgeon refuses to listen. In fact, he screams at Pronovost, who with difficulty, maintains his cool. Finally the surgeon says or rather yells, “I am not going to the OR. I have to leave town. From now on, talk to the surgeon on call.”

Pronovost does. They take the patient to the OR, open her up and guess what, he was right. The surgeon had accidentally “punctured her intestine and pancreas.” The patient lived. Just. She lost her other kidney, spent six months in the hospital instead of three days, and was in rehab for a year. “This healthy woman,” Pronovost writes,” who had come to Hopkins at 110 pounds, now weighed 80 pounds, had had a tracheotomy, could barely speak or walk, and was on dialysis and needed a kidney transplant, all needlessly.”

Reading this, as I did, you might be tempted to say, hope that surgeon got sued for everything, lost his license, is flipping burgers at McDonalds. Pronovost doesn’t tell us what happened to him, but even if he is dishing out fast food to teenagers, how would that help the next patient and the next? Doctors who are sued get defensive and resentful. Their stories become part of the lore of the malpractice legions ready to storm the gates. People don’t learn from lawsuits and while chasing one doctor out of the elite club may hurt his ego, it doesn’t change the behavior or attitudes of those who remain members in good standing.

Now if this were aviation what would have happened? In the CRM culture, Pronovost as first officer, would have challenged that surgeon on the very first page. In a reformed health care culture, where the patient not the doctor, owns her own body, and the hospital, not the surgeon, owns the facility, the two challenge rule would be immediately put into play. At 10 PM at night when he got the first call from the resident, Pronovost would have called the surgeon, as he did at 2P.M. When the surgeon refused to take the patient to the OR, the intensivist would have urgently and firmly repeated the concern (as Pronovost in fact did) and then, when the surgeon refused, he would have taken the patient out of the surgeon’s control and called the on-call surgeon. Would that have saved the patient’s good kidney, and restored her health, from the book I can’t tell. But I can tell you that without a model in which doctors and nurses can act immediately and urgently to prevent those physicians (or nurses or anyone else) more concerned with their status and authority than patient care from jeopardizing patient safety, patients like myself will always be in danger.

In the airline industry that kind of challenge to the captain’s authority is rare. People don’t do it lightly. But they do it and they are protected when they do. In fact, in aviation today, if a first officer allowed a captain to put the plane and passengers in jeopardy without challenging that captain, he or she would be in a lot of trouble. It’s kind of like being a mandated reporter for child abuse. If you suspect abuse and don’t report it and abuse is later discovered, the direct abuser isn’t the only one in trouble. Maybe that’s what we need in health care. Everyone in the hospital needs to become a mandated reporter for patient abuse – a kind of deputy sheriff empowered by government and the company to protect us when there is absolutely no way we can protect ourselves.

  • Colleen


    I am an RN and I just finished reading Provonost’s book. Absolutely amazing. I also liked Gawande’s checklist manifesto.

    People haven’t a clue airlines use checklists, but they are so important to them, why not for us on the floor? I am a newer nurse so the hierarchy thing was very alien to me, especially since I escaped a 15 year business/IT career to become a nurse.

    I really have enjoyed your work and look forward to reading your latest book as well.


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