Pigheadedness and Medical Errors

Megan McArdle, after reading an article in The New York Times, wonders if “disruptive doctors actually account for a notable percentage of medical errors.”

This New York Times article suggests that doctor arrogance is a significant cause of medical error.  I certainly wouldn’t be shocked if this were true.  Still, given the thinness of the data, I have to wonder:

“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.

There are lots of arrogant doctors out there, but I’m not sure how often this translates into medical errors. The doctors I know who are the biggest jerks aren’t necessarily any worse at practicing medicine than other doctors. Of course I tend to send my referrals to others for obvious reasons.

Whether this results in more errors is a different matter. If a doctor is so arrogant that they won’t follow protocols to ensure that the correct body part is labeled for a surgery, then it certainly is plausible that this could lead to errors. Going by anecdotal evidence can also magnify the problem. A nurse witnessing surgery being performed on the wrong body part by an arrogant doctor is certainly going to remember this episode, and might unintentionally over-estimate the frequency of such episodes compared to other medical errors.

Megan wonders about “nurse pigheadednesss.” To some degree this is a problem. I have had cases where nurses failed to give blood pressure pills or insulin because the blood pressure or sugar was normal. Of course they were normal because they were on these medications, and failure to give the ordered medications resulted in loss of control. Realistically this type of situation does not generally cause serious long term harm (but could cause me to complain in a manner which the nurses causing the problem might see as arrogant). I also fear that doctors who are jerks contribute to some problems with nurses. Nurses who are reluctant to call me in the middle of the night with a change in a patient are probably reluctant because of being yelled at by the handful of doctors foolish enough to do this. It is far better to take a call at 3:00 a.m. when a patient is just starting to deteriorate than to be surprised when doing rounds the next day.

The real pigheadedness which perpetuates many hospital problems is “administrator pigheadedness.” That’s the belief by many hospital administrators that their hospital is run perfectly and that anyone who complains must be an arrogant physician or troublemaker. Some medical errors are caused by isolated mistakes by the people involved. Far too many medical errors are caused by systems errors. The climate for fixing such errors is better now than it was ten to twenty years ago, but I still see too many errors persisting due to “administrator pigheadedness” and the failure to respond adequately to complaints.

Update: Kevin B. O’Reilly responded to Megan’s post with a link to an excellent article he wrote for American Medical News. His article reports:

In July, the commission issued a sentinel event alert on disruptive behavior that said “intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. … Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions.”

The commission’s alert cited research showing such behavior impedes communication among the health care team and can harm patients. A spokesman said the commission was contacted by the AMA and is reviewing the Association’s requests.

In principle it makes sense to attempt to reduce disruptive behavior, but definitions including “condescending language or voice intonation” are overly vague and risks taking this too far. The article presents some valid objections raised at an AMA meeting:

“The definition is very important,” said Stephen L. Schwartz, MD, a delegate for the Pennsylvania Medical Society. “Intimidating colleagues is wrong; everyone would agree with that. But let me point out that intimidation is in the eye of the beholder. If I ask someone a question and they feel intimidated, did I intimidate them?”

Arthur E. Palamara, MD, a delegate for the Florida Medical Assn., agreed. “We need some absolute standard of what constitutes disruptive behavior.”

He and other delegates expressed concern that some health care organizations are using disruptive behavior policies to retaliate against physicians who are outspoken about quality of care. When “we say something about it, we are now titled disruptive physicians,” Dr. Palamara said.

Jay A. Gregory, MD, a general surgeon and chair of the AMA Organized Medical Staff Section Governing Council, said the commission’s definition is workable. But the new standard allows health care entities too much latitude with their own definitions. It is imperative, he added, that medical staffs exert control over any complaints against physicians.

Other delegates also said the rule can be used against physicians who have competing economic interests.

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2 Comments

  1. 1
    Jerry says:

    To quote Ron:

    “In principle it makes sense to attempt to reduce disruptive behavior, but definitions including “condescending language or voice intonation” are overly vague and risks taking this too far.”

    I agree with the first half and have a question concerning the second half: taking what too far? Are we talking about a blame-game? If so, then yeah; already too far. 
    But if (as I hope) we’re talking about improving a bad situation by asking everyone to improve themselves, and possibly by stressing non-violent personal communication skills in medical, nursing, and business schools, then we haven’t taken it far enough. Indeed, it would be hard to over-do.
    And how do we get our schools to stress these vital skills? By complaining about our current lack of them? Yes; energetically but without blame – state the facts, our own experiences, and suggest a solution. Get hold of anyone and everyone who is in a position to do something about the training our doctors, nurses, and business people (and others) receive; let them know that they can improve their training in this way.
    Changing a heartless society isn’t easy, but people genuinly do care, so it’s not impossible. Unfortunately, we all glorify what I call the NY syndrome. To quote a popular character on a popular sit-com:
    “We’re New Yorkers! We don’t push our feelings down; we shove ’em into somebody else’s face!”
    That popular sit-come went on to present this moral (paraphrasing again):
    “Kids, you don’t have to choose between keeping your emotions bottled up or shoving them in somebody else’s face; you can simply acknowledge them, then let them go.”
    It’s a lesson we “kids” need to learn. We all can, but we have a duty to help our next generation be better than we are. This is one sure way to accomplish that.

  2. 2
    Ron Chusid says:

    Jerry,

    I’m speaking in terms of hospitals taking action to deny hospital privileges. In that case complaints of condescending language or voice intonation is overly vague, easily allowing abuse.

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