A survey of health care workers at 102 nonprofit hospitals from 2004 to 2007 found that 67 percent of respondents said they thought there was a link between disruptive behavior and medical mistakes, and 18 percent said they knew of a mistake that occurred because of an obnoxious doctor. (The author was Dr. Alan Rosenstein, medical director for the West Coast region of VHA Inc., an alliance of nonprofit hospitals.)
The observation that some people are jerks, and that jerkiness does not enhance performance, is not exactly surprising. What I want to know is whether disruptive doctors actually account for a notable percentage of medical errors. I'm sure if you surveyed doctors, 20% or so could report an error caused by a lazy LPN, incompetent PA, or pigheaded nurse. But I'm skeptical that "nurse pigheadedness" is actually a major problem that America's healthcare system needs to address.
I don't believe this result as it runs contrary to everything I know about modern medicine.
On the other hand, everything I know about modern medicine I learned on House.
I think the opening anecdote points to the problem, Megan: nurses are the eyes and ears of the doctor, OR as my RN wife says, "nurses are an advocate for the patient."
When MDs don't want to be bothered with incoming data from RNs because they think that it isn't relevant, that's fine and their clinical judgment. But if RNs don't feel like picking up the phone because they don't want to get yelled at again, I suspect that will, over time, result in detriment to the patient.
Ultimately, though, I suspect you are right and that medical errors are just plain human error and not so easily remedied by having doctors act nicer (as much I think that's a good idea.)
what do they mean by "disruptive" behavior?
Sounds like there might be some availability heuristics going on there. There's also the issue of one case polluting a bunch of nurses - if there's a single case of a doctor error in any one of those hospitals, all of the nurses in that hospital are likely to know about it. How do they know that seventeen nurses aren't talking about the same case?
thanks megan for bringing this up. this article just seemed like a big doctor bash. while it is true that a lot of us can be jerks the article doesn't even talk about nurse error. if there was a survey of doctors 100% of them could point to an error cause by any number of support staff.
that said, the culture is changing, pig headed surgeons screaming and throwing stuff are not tolerated anymore.
The thing about clinical medicine is that there is actually a lot of data cheaply available, and a lot of incentive to analyze and act on it. That's how we learned that fairly simple cleanliness procedures would save X thousands lives from MRSA recently, and hospitals fairly quickly put those procedures into place. Now I'm not suggesting that the article cited was pulled out of the air by a reporter with deadline issues, but there's a whole lot of anecdote there, and not much actual data. Indeed, the only hard data was a survey, where what you would need to actually show the effect implied is several clinical studies.
The larger problem with doctor arrogance is not so much that it is a direct cause of error, but that it is a major barrier to the health care quality movement. The US hospital error rate is something like %10, to a large extent because we’ve built a system based on the god like ability of doctors to not make mistakes. They do, and people get sick and die.
http://www.nap.edu/openbook.php?record_id=9728&page=R24
dude, you know what a real medical problem is? I am an army medic and no matter how badly I do my job I still get paid. Malpractice, who cares? I hope we nationalize medicine so the rest of the nation can experience the "free health care" my recruiter got me.
reminds me of the old joke:
"What do you call the guy who finished last in his medical school class?"
"Doctor."
Maybe if nurses were competent enough to not bother on call docs with minutiae, it would prevent pissed off docs from making mistakes. There are many nurses who not only lack medical knowledge, but the common sense to know what information needs to be dealt with by a doctor, and what they can handle themselves if they take two seconds to think about it.
"I hope we nationalize medicine so the rest of the nation can experience the "free health care" my recruiter got me."
Thank you, Medic McFadden, for reminding me how wise a choice it was to make Hillary Secretary of State.......she could've been so much more.......and less.......
Doctors work long, stressful hours. So yeah, I think it's natural that they don't necessarily come across as likable (Ha, as angry doc certainly shows us).
Bob Sutton is a Stanford researcher who's done a lot of academic work in this area, as well as some popular books. Here's his take:
http://bobsutton.typepad.com/my_weblog/2008/12/how-and-why-asshole-doctors-harm-patients.html
There's pretty clear evidence that normal people given authority have a tendency to become jerks. It's not that nurses are inherently nicer people than doctors, they just don't have that sort of power, and so don't suffer from the same decision-making handicap.
Maybe if nurses were competent enough to not bother on call docs with minutiae, it would prevent pissed off docs from making mistakes.
Lawyers, like doctors, rely heavily on paralegals and secretaries. But when something goes out over your signature, you own it. Attempts to blame it on anyone else are 1) lame, and 2) totally ineffective.
Disclosure: My father and grandfather were doctors. I'm married to one, so this may color my perceptions some.
My wife does anesthesia and has observed a lot of doctors under stress. Some of the most obnoxious are great surgeons. I know of one that she referred a family member to for surgery. She's said that she would use him if needed. Some of the nicest are not fit to carve a roast - they are indecisive and take way too long to do simple procedures.
I agree with Dave above that with some good data mining, clinical outcomes could be improved. There is a recent study that showed that using checklists for routine procedures could help outcomes quite a bit. (IIRC, Megan had a post on it.) The anesthesia community is big on data mining (see the ongoing Closed Claim study, where they look at malpractice claims to find common causes and have greatly improved standards of care) and checklists - but anesthesia is one of the fields that attracts people with personalities associated with engineering, which is big on procedures and process.
There is no good data on what percentage of medical errors are attributable to disruptive behavior. About half of medical errors are due to "communication failures," though that includes everything from poor doctor-nurse communication to misreading the drug label. Anyhow, while physicians are the ones usually tagged as being disruptive, any member of the health care team -- from the hospital's CEO to the maintenance man -- can be disruptive in a way that harms patients. That said, freaktown's question -- what is disruptive behavior? -- is one that many doctors share.
See my recent story on this:
http://tinyurl.com/6d4a7j
But I'm skeptical that "nurse pigheadedness" is actually a major problem that America's healthcare system needs to address.
Oh, well. It must not be true, then - McFacty knows better!
As a doctor this post certainly attracted by attention, but my response is a bit long for a blog comment. I have posted my response here:
http://liberalvaluesblog.com/?p=6060
Rob Lyman:
I don't agree with angrydoc's comment which you are responding to, but you do miss the point in writing "Lawyers, like doctors, rely heavily on paralegals and secretaries. But when something goes out over your signature, you own it. Attempts to blame it on anyone else are 1) lame, and 2) totally ineffective."
The problem is that doctors are not just signing their signature to what a nurse does in a manner analogous to a lawyer signing off on the work of a paralegal. Hospital nurses are not employees of the doctors and are not under the direct control of doctors in the way that a secretary or paralegal is.
Doctors write orders when doing hospital rounds. When nurses fail to correctly carry out the physician orders this is not something which a doctor can control in the same way a normal employer could respond to a secretary making an error. Errors made by nurses are totally separate actions from the actions of the doctors. Doctors do not "own" the actions of nurses or other hospital employees. We cannot fire or discipline nurses who screw up, and we are not there around the clock to make sure they follow orders correctly.
Complaining about nursing errors is not lame--it is often necessary to bring about change at hospitals. Whether it is effective is a different matter. In my experience, sometimes complaining about patterns of nursing errors has brought about changes in hospital procedure. Other complaints have been ignored, or received insufficient response to solve the problem. Complaining about nursing errors is not totally ineffective, but it is far less effective than it should be in reducing systems errors at hospitals.
I couldn't imagine a more appropriate subject from an MBA with PhD envy. 2X4, you don't have the chops. Pathos distilled.
i'm related to a RN who is practically certifiable (as in, cuckoo for cocoa puffs) , and has been relieved from multiple positions. I wouldn't be surprised if her arrogance caused some major medical mistakes, all of which I presume are connected now forever to the doctor whose patient she was caring for.
also, I would assume that the degree to which asshole-ness negatively impacts job performance depends on the type of doctor.
It's worth noting in Malcolm Gladwell's Blink that patients are less likely to sue doctors they like, even if they make mistakes, and more likely to want to sue doctors who are assholes even if they didn't make one.
Nurses are unionized. Unions require promotions based on seniority, not competence (may merit pay never happen). Errors by union member are always blaimed on non-union scabs (eg Doctors) or on management.
Soon our hospitals will go the way of the Big 3.
Good riddence.
My wife, a Labor and Delivery RN, spoke up during a C-section when the gauze count was incorrect and the missing gauze could not be accounted for. The doctor dismissed her. My wife spoke up a second time. The doctor dismissed her again. The surgery was completed and incision closed. An xray confirmed that the missing gauze was inside the patient.
Situations like this along with verbal abuse, usually from the same couple of doctors, have led my wife to rethink her career. She is leaving the hospital for another position next week.
Hospital nurses are not employees of the doctors and are not under the direct control of doctors in the way that a secretary or paralegal is.
That is a good point, and I agree we can't blame doctors if their orders are improperly carried out.However, angrydoc's point was that doctors screw up because nurses bother them with too many questions. That's both ridiculous and lame.
Rob,
I did start my comment by noting that I also did not agree with angrydoc's point.
Yes, it is true that some of the calls made by nurses ideally should not have been made, but many others are. Angrydoc's attitude is more likely to lead to medical errors because of nurses who become reluctant to call due to the handful of doctors who do yell at them for doing so. I am willing to put up with some calls which are unnecessary in order to receive the calls when there really is a change in the patient's condition.
Re: Klug's comment:
This is old news in the aviation business. "Relationship" issues between Captains and lowly first officers / flight engineers were found to have restricted effective communication of problems in the cockpit. Many accidents were blamed on this.
The industry and NTSB invented CRM (Cockpit Resource Management), a package of procedure changes and training, aimed at solving this problem.
AFAIK it was widely successful, but I'd be interested in comments from any flight crews.
I think the analogy to doctors, nurses, and hospitals is obvious.
Funny, Fred, I was actually thinking about the relationship between the captain of a ship and his officer of the deck, actually. I think there's lots to learn in terms of management relationships from other parts of our world.
Yeah, docs can be jerks and it ain't good for them, their patients, or anyone.
Still, it's the, as our blog host states, the thinness of the data in this NYT 'doctorz sux' series that is amusing. I'm sure I could come up with a survey, distribute it to physicians, and come up with almost the exact same data that says that nurses' behavior contributes to poor patient outcomes. (I know of one instance - okay, I heard about it once which is on par with the data they had in their last docs-are-bad article, in a VA hospital where nurses were making up vitals.....see anecdotes run both ways!)
Who the heck is the science editor for the NYT anyway? Wobbly data....wobbly, wobbly.
Oh, duh, you just made my point in your post, didn't you?
Actually, pigheadedness in any employee of a hospital can cause a big problem. It's a team effort to get it right - that's another problem with these 'turn the team against each other' articles.
*Oh, I have MS, too, so I'm not just a cold-hearted doctor that doesn't get how it is for a patient. I get it. And, as a patient, trust me, nurses and techs who make mistakes cause a lot of problems, too. Before my last scan, a nurse almost gave me contrast when it explicitly said not to give me contrast on my paperwork. Everyone has to get it right for the system to work for the patients. We should hold doctors to a higher standard of behavior, to be sure, but they aren't the only problem....
Peter Warden - you make the most salient point, I think. People given power, particularly in stressful situations, can abuse that power. Not good.
(to keep up with my it's not only docs who behave badly theme - that might explain teaching hospital nursing behavior toward rotating residents. I'm not nurse bashing! It's just that, again, everyone on the team has to be good for the system to work. Singling out one part of it doesn't help as much as paying attention to the whole system).
Some doctors do have the god-complex. This is a necessary feature of the system.
OK, so House really is a terrible doctor after all.
But he used to be a very entertaining defense lawyer.
Blogger arrogance is a leading cause of misinformation on the internet. Evidence? I give you... Megan M. Exhibit 1!
Megan - you REALLY don't know anything about hospitals, doctors, or medicine, do you?
I'm a doctor, and I'm married to one, so there's plenty of talk about this sort of thing around our dinner table. The anesthesiologists are right: we should use more checklists, more standardization of practice, more data-driven decision support, and more peer revue.
But, as much as I appreciate the nursing role and totally depend on the nurses I work with, they shouldn't be casting the first stone. For example, most of the OR nurses at the hospital where my wife is a resident refuse to answer resident's pagers. God forbid some patient is dying up on the ward; those OR nurses are never going to demean themselves by answering a lowly resident's pager.
Hi Megan,
Thank you for your interest in my research. I'm glad to see that it has opened up a conversation about relationships between physicians and nurses and the impact on patient care.
You're right to ask about the volume of errors caused by disruptive behavior. It is often difficult to pinpoint a direct cause-and-effect relationship between disruptive behavior and poor patient care because outcomes are a result of many contributing factors.
However, comments from hospital staff certainly attest to the reality of the issue. While it's true that 18 percent of the nurses can think of a specific instance where patients have been harmed because of disruptive behavior, there are many more instances where disruptive behavior causes miscommunication and lack of concentration which result in a downstream negative effect. In these cases, the patient is the one ultimately affected, but the relationship with disruptive behavior may be difficult to trace.
Addressing the human factor issues is a key component of addressing circumstances that affect patient safety. Hospitals can potentially avoid preventable errors by raising awareness and building in an on-going discussion about this topic around policies and procedures, accountability, a better understanding of roles and responsibilities, communication and team collaboration training, and promoting a supportive organizational culture. I hope the new Joint Commission standards will stimulate positive actions in this area.
Thanks again,
Alan Rosenstein
Medical Director, VHA West Coast