What would you do? Imagine you are a well-trained nurse. You care about your patients and are especially concerned about a terminally ill patient who is scheduled for surgery. You know that the surgery will have consequences affecting the patient’s quality of life. In your opinion, the surgery is likely to increase the patient’s suffering. You also know the patient has neither been informed that the surgery is optional nor that there are alternatives to surgery such as hospice care.
Amanda Trujillo is a nurse who was fired by Banner Health Del E. Webb Medical Center in Arizona “for requesting multi-disciplinary hospice care case management consult for a pre-transplant patient with end-stage liver disease.”
For the Arizona Board of Nursing, Trujillo’s dismissal wasn’t enough. In a move that could result in the loss of her nursing license, the board ordered Trujillo to undergo a psychiatric evaluation. For the crime of helping a patient explore alternatives, Trujillo faces the loss of her career.
We all know what Trujillo’s real crimes are: (1) Challenging a doctor who thinks his decision making autonomy is more important than a patient’s right to own his or her body, and (2) Challenging a doctor who thinks that all important knowledge resides in him and that the knowledge of other individuals is not worthy of consideration.
There are signs of changing norms in the medical profession. In his book Why We Make Mistakes, Joseph Hallinan observes that over the past two decades, patient deaths due to anesthesia “have declined more than forty-fold.” Anesthesiologists, he explains, have taken steps to flattened the “authority gradient” and “encouraged nurses and others to speak up when they see someone—especially the anesthesiologist—do something wrong.”
Of course, we all know compassionate, dedicated physicians who respect their staff and value their input. Dr. Peter Pronovost, a professor at John Hopkins School of Medicine, has worked tirelessly to improve patient safety by changing the culture at Johns Hopkins Hospital. The chain of command has been flattened, and anyone on the staff can intervene on behalf of the patient’s well-being without fear of retribution. At Johns Hopkins, nurses such as Trujillo who circumvents the hierarchy will not find themselves publicly reprimanded and humiliated.
I highly recommend Dr. Pronovost’s book Safe Patients, Smart Hospitals. Pronovost, an anesthesiologist himself, tells the story of his confrontation with a surgeon in an operating room. The patient was having what Pronovost believed was a potentially fatal allergic reaction to the surgeon’s latex gloves. The surgeon repeatedly refused to change his gloves until Pronovost instructed a nurse to page the hospital’s president.
Why would a surgeon put his patient at risk? Pronovost writes candidly that we doctors are “trained to believe that we don’t have to follow the rules or ask for anyone’s help. We are the smartest people in the room and can figure out any problem on our own.”
It is not just doctors who are to blame, cautions Pronovost. Poor communication and lousy teamwork are problems at every level of healthcare, from administrative assistants to top executives.
Pronovost’s diagnose is that a “toxic culture … is at the core of most hospital errors.” The false belief behind this culture—that doctors should not be questioned—discourages doctors from either questioning themselves or seeking advice from others.
Sadly, as the Trujillo case indicates, despite the work of Pronovost and others, many hospitals are still stuck in the dark ages: The comfort of the stereotypical arrogant doctor comes before patient safety.
Human arrogance is not limited to doctors. Arrogance can be found in any occupation and in all positions of leadership. It compromises our health, it compromises the health of our organizations, and it compromises the economic health of our nation.
