Getting Our Egos Out of the Hierarchy!

[BethBoynton]

Recently on FB there was a lively discussion about this sign that was posted in a waiting room somewhere, it read, "Don't confuse your google search with my medical degree". Some found it funny, some thought it was informational, and I thought it had an obnoxious tone! I googled the message and found all sorts of shirts and coffee mugs proclaiming the same message.

There seems to be something more going on in this proclamation than simply a statement intended to inform or honor one's education. There's an underlying theme of superiority and inferiority going on here and I don't think it has anything to do with education at all! The language is polarizing and flies in the face of respectful communication and collaboration that are so necessary for safe, compassionate care and patient empowerment. I'm not against the hierarchy, but I am against power dynamics that feed our egos.

Discussions about the hierarchy in healthcare can quickly turn into a power struggle. Physicians who have long been at the top of all decision-making are reluctant to share power, nurses face increased accountability in taking more power on, and patients present along the entire spectrum from wanting to be in charge to totally dependent.

Although the old hierarchy makes sense sometimes, (such as during a cardiac arrest with the physician yelling out orders to the team) it has also contributed to ineffective communication and teamwork, poor conduct, and unsafe care. When the hierarchy is toxic these dangerous behaviors are all too common:

Nurses who are afraid to speak up or challenge authority

Physician's who don't know how or when to listen to others' expertise

Patients who withhold information or concerns because they are totally dependent on medical providers.

If we are going to have safe care, healthy workplaces and rewarding careers we need to ask ourselves and each other; What makes the hierarchy healthy? In my opinion we need the hierarchy for clinical decision-making and related use of expertise, but not for egos-driven goals involving power and status.

I'm referring to superiority and inferiority complexes that plague doctors and nurses respectively. Those with more power in the hierarchy falsely believe that they know more about what others need and want and listening is therefore unnecessary. Those on the other end have little faith in the value of their own ideas or observations and hesitate or worse don't speak up.

For the hierarchy to be healthy we need to balance it with collaborative leadership and followership. In such a system, the hierarchy is the structure and the collaboration is the process. The former requires knowledge and skills where the latter requires respectful communication and emotional intelligence. Healthcare professionals must be adept at both. Yes, physicians may lead more often than not and yes the nurses's assistant will follow more often than not, and nurses will be leading and following almost all the time, but we must all be able to do both! And with respect and grace.

Collaborative leaders at all levels are confident and emotionally mature. They use their expertise and authority for optimal clinical outcomes. They are not rattled when challenged by team members and are able to consider new input. If they input shifts care decisions they are grateful and if not they explain their reasoning, making it a teachable moment.

Collaborative leaders understand this dance of being in charge while listening and following as necessary and supporting others so they are able to bring their best to the table. Their egos are in tact and they are using the hierarchy with great wisdom. All the while making healthcare safer.

[Anonymous865]

Medical professionals are missing the fact that the rise of the "google MD" is a symptom.

It is a symptom that patients do not feel they are getting the amount or quality of information they want from their physician or nurse. How many of you think you spend enough time on patient education?

It is a symptom that people no longer trust "authorities." Do you trust politicians to tell you the truth? How much do people trust the news media to provide unbiased reporting. How much do people trust police? How often do you read about judges who are impaired or incompetent?

The medical community is partially to blame for this loss of trust.

For years hospitals just allowed an impaired or dangerous medical professional to resign. They even provided a good or at worst a neutral reference. The dangerous professional just moved to another hospital and continued to practice. Physicians cover for each other.

In the past a patient chose their Dr. They went to the same physician for years. Their Dr spent time with them buidling a trusting relationship. Their PCP cared for them in the hospital. Now the patient gets at most 15 minutes with their PCP. Most of that time is spent collecting data for meaningful use and putting it in the computer. No time is spent building a relationship with the patient. When the patient is admitted to the hospital, they get assigned a provider. No one cares if the patient likes or trusts the provider. Every few days the patient gets a new provider. The patient doesn't know from one day to the next who is going to show up and announce that they are the provider. The providers don't have time or don't think they should have to answer the patient's questions.

The relationship between the nurse and the patient is no better. They get a different nurse every shift. They have less face time with the nurse than with the physician. The nurse may be doing a fantastic job reviewing the patient's labs and communicating with the physician, but you cannot build a trusting relationship with a patient unless you can spend time actually talking with the patient.

Yes. There are many reasons that medical professionals are spending less time building relationships with patients. Some of it is because of money and some of it is because of specialization. Whatever the cause the result is less communication and less trust.

Patients are justified in feeling they have to do their own research, because physicans are not always honest with their patients. I do not know a single ob/gyn who will tell the patient that uterine fibroids are a benign condition and that watchful waiting is one option. I know many women whose ob/gyn discovered uterine fibroids during their routine check up. The fibroids were asymptomatic, yet every single physician told their patient that they had to have a hysterectomy because they had fibroids. I do not know one single ob/gyn who will tell patients that uterine artery embolization is a treatment option for fibroids. Patients are justifiably suspicious that ob/gyns are recommending hysterectomies, because it is a money-maker for the physician. They are probably right, since the NIH estimates that up to 2/3s of hysterectomies are unnecessary.

One physician recommended that my good friend's 95 yo father have a TAVR. He quoted the success rate of the TAVR. The success rate he quoted them was for 60 and 70 yo patients not 90+ yo patients.

Providers don't tell patients about treatment options unless the provider offers those treatment options. It is often up to the patient to discover that a newer, better treament option is available at "Big Name Medical Center."

Putting up a sign like this in the waiting room is not going to treat the problem. It is just going to exacerbate the problem. It is going to shutdown communcation.

Fix the problem by teaching the patient about reputable sources of information, by encouraging the patient to ask questions, and by building trust with the patient.

[BethBoynton]

Great points! You speak eloquently to the importance and erosion of provider and patient relationships. Hard to measure and essential for best outcomes. They also help us to find meaning in our work. Thank you for your insights.

[twozer0, NP]

Medical professionals are missing the fact that the rise of the "google MD" is a symptom.........

I'm quoting the whole thing here just shortened it for easier reading.

The reason you people heading to the internet for information is because we now live in a very "I NEED IT NOW" society. Think about how things functioned before the internet or before cell phones. This type of behavior did not exist because it was not made available. I think its natural for people to feel curious about symptoms that they might have and want to learn more about them but I also think the ball is our of their court when it comes to understanding how the body works and how to fix it. The web is full of terrible information, from less than credible sources (I'm looking at you wikipedia!) and can put ideas in peoples heads that need not be there. The last thing you need is a patient freaking out because their leg is numb and the google search is saying arterial occulsion but in reality is meralgia paresthetica...

I do agree that the patient/provider relationship is lacking, I'll blame this on the healthcare shift from patient centered to profit centered. You're no longer a patient, you're a client (a $$ sign). Providers have less and less time to spend with patients and explain everything, which is unfortunate. We'll have to wait and see what the future of healthcare holds but I don't feel that we'll be seeing what we had in the past regarding time and patient involvement (maybe more efficient?).

[MamaRN92]

Madame-the meme is funny to those of us who are dealing not with well informed "determined" patients. It's the Diabetics that come to the ER in DKA and a Pepsi in their hand and argue with their plan of care or well meaning family members who think webMD or a Google search trumps their provider's knowledge. If you feel someone is inappropriate state your case. But it's a fine line between advocating and arguing.