Why Aren't More Hospitals Protecting Patients from Abusive MDs?
For the past fifteen years, since the Institute of Medicine published its report To Err Is Human, patient safety has become the watchword of the day. Money has been spent. Initiatives have been launched. Champions have been recruited. Whether it is the hospital CEO, the Chief of Medicine, the Vice President of Nursing, everyone is on board when it comes to patient safety. And yet, the numbers of patient deaths and injuries are barely budging. In fact, the only progress we seem to be making is in adjusting the statistics on patient deaths upward. When the Institute of Medicine report came out in 1999, the public was informed that 98,000 patients were dying of preventable medical mistakes every year – the equivalent of a jumbo jet crashing every three days. In 2013, we learned that that figure was probably a radical underestimation. The correct figure is over 400,000 a year – making deaths due to preventable medical errors the third leading cause of death in the US.
Why are patients still needlessly dying from medical treatment? Why are hospitals – (the word, remember comes from the Latin hospice, which means guest and hospitality, not as in industry but as in acts of kindness,welcome and generosity), still so inhospitable? One reason is that hospital and healthcare leaders are not acting to curb the kind of bad –even disruptive – behavior that we now know is one of the leading causes of medical harm. More than 75% of medical errors and injuries stem from failures of communication and teamwork. Yet one of the primary barriers to teamwork and communication is tolerated in our healthcare system everyday. The sorry fact is that people in power are allowed to act in ways that humiliate, intimidate, even abuse, and ultimately silence, their patients and the people whom they manage, supervise and ostensibly lead. These actions create climates of fear and anxiety which make it almost impossible for people – particularly those lower down on the medical totem pole — to speak up when they notice a patient safety problem that begs to be remedied, or even more worrisome, when they see someone about to make a potentially serious or even fatal mistake.
I have spent the last decade interviewing nurses, residents, housekeepers, nursing assistants, chiefs of medical executive committees in hospitals as well as hospital CEOS, and chief nursing officers. What has become clear to me is that at all levels of the hospital hierarchy, there is an astonishing and pervasive tolerance for bad behavior and a refusal to exert leverage to engage, encourage, and yes mandate behaviors that protect patients and staff. This was confirmed once again in a recent article discussing the fact that hospital executives tolerate an astonishing amount of bad behavior in healthcare professionals deemed to be revenue generators.
This is no surprise to me. I sat in one recent meeting of a medical executive committee, where a group of the hospital’s top physicians casually admitted that they do almost nothing to rein in a colleague who is routinely abusive to nursing and other lower level staff. At another meeting, a CEO of a large teaching hospital, himself a physician, complained that nursing staff do not report physicians who engage in dangerous behavior, behavior they know jeopardizes patients. He never informed the nursing staff that he was there, standing behind them, ready to support them if there was a problem with an intractable physician. In fact, when I asked him what he and his executive staff were doing to deal with the minority of physicians in his hospital who were disruptive or abusive, he threw up his hands and looked skyward, as if the heavens would provide me with my answer. “We are talking a lot about it,” he lamely ventured.
When I recently talked to a dean of a nursing school who was also a board member of his local hospital, he told me about a physician who’d finally been disciplined because of her bad behavior. The dean told me that this particular physician had been abusing nurses and other staff for years. What finally tipped the balance was a complaint from a patient. Why, I asked, hadn’t the hospital administration and board done something years earlier to stem this woman’s unrelenting attacks on her subordinates. Why did it take a patient complaint to spur the board to action? “Well, she’s such a good clinician,” the dean said, adding of course that she was also a revenue generator. No, I thought, this person is not a good clinician. She may be a good technician, but since clinicians deal with human beings and should work on teams, the term “good clinician” does not apply to anyone — whether nurse, doctor, pharmacist, PT, etc — who ill treats colleagues and co-workers.
The problem is that hospital leaders have leverage over physicians — just as much leverage as they have over RNs and other employees. But in too many instances they fail to exercise it to protect patients. It is indeed true that many physicians are not actually employed by the hospital (although more and more are hospital employees). They are, however, granted admitting privileges that allow them to practice in a particular hospital. Those admitting privileges can be suspended or rescinded. The question hospital executives and hospital boards must ask is why are so many badly behaving people allowed to continue behaving badly? Misbehaving physicians are often considered to be the golden geese that lay the golden eggs. In our book Beyond the Checklist we asked “What, precisely, is so golden about surgeons who refuse to complete a checklist or time-out because they are in a hurry or are personally annoyed by the protocol? Why reward the medical and nursing staff on units where there is no genuine communication about a patient’s status or about staff safety concerns? Why does a hospital continue to employ a nurse manager who’s great at making OR schedules but can’t deal effectively with her staff?” Our argument in that book was that “leaders must lead,” which means making tough decisions about people who are good technicians, and who may have excellent reputations but who are abusive and create a climate of fear and anxiety that stops people from speaking up to protect patients from harm.
Excellent blog. Found this on Nurseup.com. I left traditional nursing 13 years ago and this was part of why. I see it hasn’t changed. I applaud you for speaking out on this important matter! Blessings!
I wrote you three or four years ago and never heard back.I have read hundreds of journal articles and books on related subjects. I have tirelessly advocated to change such behaviors. I do write CEO’s, policy people,academics. I do surveys, public comment and have written dozens of journalists. I have written Magnet,AORN,ANA,Leapfrog,Joint Commission, Congress. Like you say, many are on the bandwagon. I say they can’t look within. They are elite and omnipitant.
I have written scholars,policy makers,Congress,journalists,Joint Commission,Magnet,Leapfrog,ANA,AORN, Did surveys and public comment. Read everything I can get my hands on related to this.The problem is even with all these people there is an omnipotence and elitism that discounts us as not reliant.I wrote you three or four years ago and you never wrote back. Even left a message with your office. I have been thrown under the bus more times than you can can’t for speaking up. I have lived it.
I am a retired RN with a chronic Primary Immune Disorder and have had great difficulty getting the doctor here in a small Florida town first to believe me,then to treat me. IV Gamma Globulin is the only treatment and I have had to put up with so much abuse,humiliation. And after all that I am still not receiving my medication which means I have no functioning immune system.
I have found that the RNs are equally as abusive here as the doctors and no one,NO ONE,reins them in. I hope I can last long enough to move somewhere where I can get treated before I die,but where?
My depression has gotten worse as I can find no one to help me.
Your article definitely resounds with me.
Terrific blog as always Suzanne. This ‘issue’ of tolerating appalling staff whether doctors, nurses or execs is almost universal. Every audience of nurses in every country that I ask about this says, “Yes, we have them in our place”., “Yes, everybody knows them and knows about them but there’s “nothing we can do” because “you can’t get rid of them”. In big public sector bureaucracies staff say that they are simply not willing to put themselves through several years of the HR Hell that is: ‘Performance Management’ with associated accusations of bullying & harassment, inquiries, industrial tribunals, additional ‘supervision’ and ‘education’ for the perpetrators, only to see them at the end of the day being simply ‘redeployed’ somewhere else since it is almost impossible to fire anyone. This may sound harsh but the problem is endemic. One UK report, responding to the UK’s ‘Crisis in Care’ named the ‘elephant in the room’:
“A particular frustration reported by the participants was the difficulty in managing poorly performing staff. They all reported making judgement calls which led to the sacking of staff, which then resulted in Industrial Tribunals which were both time consuming and stressful. Whilst not seeking to remove the rights of workers, they did express views about the ease with which staff can seek a Tribunal, even when it seems a prima facie case for dismissal has been established. One focus group member said “being brave costs time”.
Rudeness, abusiveness, incivility, a ‘couldn’t care less’ attitude and the like would not be tolerated for a nanosecond by a business selling burgers or pizzas and yet we tolerate and enable that in the places where people come for care at some of the most terrifying, distressing and vulnerable times of their lives.
Shame on us.
Philip Darbyshire, Adelaide, Australia
Re: The Fierce healthcare article you linked to citing the doctor in Syracuse, NY who was slapping patients’ buttocks and calling them names. Just appalling…
This article was published about 10 days ago… http://www.syracuse.com/news/index.ssf/2014/08/post_1116.html
highlighting a $4.1 million loss (in six months!) to the hospital after letting him go.
Unfortunately all those “leaders” are really followers of the “follow the money” gospel too. The CEO of that hospital in Syracuse found out just how expensive such a “follow” can be when her hospital’s name was publicly dragged through the mud when she took no action after many reports of his bad behavior.
At least the mud-dragging resulted in the surgeon being kicked to the curb – but he is now, almost literally, operating across the street. We can only hope he is a bit smarter about who he slaps and calls names.
If it takes public shaming of these “leaders” to make them pay attention – well then – so be it.
Every Patient’s Advocate
Thank you Suzanne. Once again you hit the nail on the head. I have come the sad conclusions that hospital leadership are encrusted in the past and are afraid to empower, or even respect, the largest workforce in their organizations, NURSES. When one speaks of collaboration, shared communication, mutual respect, calling MDs by their first name, they tend to look at one funny. It’s no wonder the patent safety alarms are still ringing!
Kaiser, one of the leading and considered “progressive” hearth care organizations in the nation, especially CA, is blatantly guilty of this behavior with countless unit managers (our so called “leaders”) constantly placing every physician on a throne, modeling subservient behavior, calling MDs they’ve worked with for years, “Dr. Jones” and “Dr. Smith.”
Yet, I call every on them by their first names (from our first meeting), with virtually never an objection (there was one–another story). And it is “I” who thwart the medical errors, suggest alternate therapies, questions treatment plans, and act as the pt’s advocate. And it is “I” who is respected, endeared, and listened to by those very physicians. It is so hard and frustration to level the playing field, when the out umpires are weak and ignorant to the real game, pt safety and mutual respect.