On September 18, 2014, the New York Times OpEd page published a wonderful commentary by physician Barron H. Lerner called When Medicine Is Futile. The physician argued that doctors are pursuing futile treatment and great cost both in expense and suffering to patients. Using the example of his own physician father, who was committed to stopping the needless suffering of such futile treatment, he argues that physicians have largely ceded decisions about futile treatment to patients, who too often demand what is not good for them. He blames much of futile treatment on the patients’ rights movement and of bioethics movements – movements that argued that patients have a right to choose treatment options. Lerner discusses the “futility movement” — those who argue against futile treatment. The problem, he writes, is that “physicians declaring things to be ‘futile’ sounded too much like the old system of medical paternalism, in which doctors had made life-and-death decisions for patients by themselves. It was this mind-set that bioethics, appropriately, had sought to correct. Patients (or their families) were supposed to be in charge.” Patients, however, may want things that are not at all good for them and merely cause them more suffering. Read more >>
Since writing my blog post on the Quality and Safety BMJ article on the Deaf Effect, I’ve been thinking a lot about what people concerned with patient safety and the impact of toxic hierarchy can do about it. In Britain, they are trying to reward people who speak up. Clearly that should be done in North America and all over the globe. But we can think even more about this issue. Jones and Kelly describe what happens when employees use their voices and are ignored. When they take risks and no one acts to prevent harm. . Silence not voice is encouraged by high level inaction. This encourages a sense of futility and risk aversion and then self-silencing becomes contagious and a cultural –not just an individual – habit. High level inaction in the face of voice – what Jones and Kelly call the Deaf Effect (we might think of this as the sounds of silence) – is thus one of the things that instills the habit of silence. There are other factors that encourage silence rather than voice.There are other factors that encourage silence rather than voice. (Anyone interested in this subject should read Albert O. Hirchsman’s classic Exit, Voice and Loyalty). Read more >>
It is now well recognized that the majority of avoidable patient deaths and injuries could be prevented by better teamwork and communication. What does this mean in practice? It means that in many instances, someone knew that patient harm was imminent but that someone didn’t speak up – or didn’t speak up with enough urgency – to stop harm from happening. In many instances that someone – as I have written elsewhere in this blog – was lower down on the healthcare ladder and was afraid or unable to alert someone higher up on the ladder that an error was about to occur. Sometimes, harm happens because someone lower down the power gradient knew something bad was about to happen and did, in fact, try to alert higher ups but no one listened. Harm occurred not only because no one acted on warnings in a particular case. Even greater harm was done because lower level staff now feel so frustrated and demoralized that they are convinced there is no point in taking future action to prevent patient harm. People who may have taken huge risks to alert higher ups to problems are now absolutely certain there is no point in taking any risk in the future.
A recent article in Quality and Safety BMJ entitled “Deafening Silence? Time To Reconsider Whether Organisations Are Silent or Deaf When Things Go Wrong,” explores how silence begins and becomes a cultural habit because organizational higher-ups do not heed the warnings of so-called “whistle-blowers” who bring attention to critical problems within an institution. Authors Aled Jones and Daniel Kelly argue that when it comes to preventing harm, the focus is generally on why people don’t speak up or blow the whistle on harmful practices. The prevailing notion is that people are too often silent and so our energy must be spent on getting them to raise their voices to protect patients from harm.
Looking at several recent scandals in the National Health Service in Great Britain – problems at the Mid Staffordshire National Health Service for example – the authors report that the conventional wisdom was that people did not speak up to prevent harm. In fact, numerous reports document that the contrary was the case: many people tried to bring attention to poor quality and practice but that no one listened. A nurse tried to raise her concerns. Rather than be supported by her nursing colleagues, she was told to “watch her back.” A junior doctor raised concerns to management and a post-graduate Dean and no one took action. “Inquiry counsel Tom Baker described the repeated raising and subsequent disregard of concerns in Mid Staffordshire as ‘a cry from staff who appear to be being ignored’.
The authors go on to consider the notion of “organisational silence ” or “cultures of silence.” They argue that a more accurate definition of what goes on in many healthcare institutions that ignore employees or staff attempts to raise critical concerns is not silence but rather organizational deafness or what they call “the deaf effect.” As they put it, “The term ‘Deaf Effect’ has its roots in management and information studies literature, being defined as occurring ‘When a decision maker doesn’t hear, ignores or overrules a report of bad news to continue a failing course of action’ When organizational deafness is the prevailing mode of response to concerns, then the authors go on to argue, silence does become the dominant mode of response because voice is viewed as futile and silence viewed as the only option. Deafness leads to silence and silence becomes, as they put it, contagious. “If employees are ignored when one concern is raised, this can lead to silence about a range of other concerns.”
The question thus becomes how does one fight deafness and the deaf effect and encourage voice. In order to do this, organizations must encourage voice and thank people, reward people, and encourage people who deliver not only good news but bad. In the UK, the government is beginning to do this by recognizing whistleblowers on the Prime Minister’s New Year’s Honours List. In the US, managers need to do the same. I would suggest getting rid of any and all signs in managers office alerting staff that this is a “whining free zone.” I would also hand out cards like this one that I made up (I stole the idea from a natural food store in Portland, Oregon.) It’s the Don’t Shoot the Messenger Card.
In another post, I will consider the issue of organizational silence because I think it is one that must also be considered. But for now, everyone in the patient safety movement should be reading this new article and putting into practice what we should all be preaching.
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. Read more >>
On Monday, my husband and I flew back to San Francisco from Boston after a two week visit. As we were sitting in the airport waiting for our 4:13PM flight with United Airlines, we were told that the flight was delayed two hours. The reason? Unspecified “maintenance.” Needless to say, we weren’t ecstatic about the delay. As an anxious traveler, I also worried about which particular maintenance issue had caused the tardy departure. Was it a serious engine problem? If so, would whatever repair was performed actually maintain us in the air for six hours at 36,000 feet? I know I have written about the wonders of the airline safety model, but I’m only human and worry is something at which I excel. Read more >>