How Hospitals Benefit From Being Nice: A Guest Post

Julie Salamon has been guest posting here on the themes covered in her new book, Hospital. This is her last post.

Rudeness isn’t new to the medical profession. In the original charter of the American Medical Association, approved more than 150 years ago, physicians were warned to “avoid all contumelious and sarcastic remarks.”

But now the medical community acknowledges that bad behavior isn’t just about manners. It can harm patients and result in serious financial consequences for hospitals through loss of efficiency and decreased productivity.

Last week the Joint Commission on Accreditation of Hospitals issued a “sentinel event alert,” which warned that “rude language and hostile behavior among health care professionals goes beyond being unpleasant and poses a serious threat to patient safety and the overall quality of care.” By January 1, 2009, the 15,000 hospitals, nursing homes, and other health agencies monitored by the Joint Commission will be required “to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior.”

This week the American Hospital Association’s Hospital and Health Networks published an article on the subject under this headline: “The right culture can result in the right outcomes and help avoid costly litigation.”

The New York Times recently reported that doctors are being advised to apologize to patients as a way to fend off malpractice suits.

Momentum has been building. Three years ago a publication from the National Institutes of Health reported, “Dysfunctional nurse-physician communication has been linked to medication errors, patient injuries, and patient deaths.”

About that time, Maimonides Medical Center in Brooklyn began a program to encourage employees to follow the hospital’s Code of Mutual Respect, whose provisions include this one: “The Medical Staff agrees to refrain from any behavior that is deemed to be intimidating, including but not limited to using foul language or shouting, physical throwing of objects …”

The program coincided with the year I spent immersed at the hospital to write a book. During that time, a senior nurse explained,

Think about it. You can’t do surgery without your instruments. Our instrument techs make thirty thousand dollars a year, and we expect them to be these highly skilled, ambitious people who are going to make sure the tray is going to be built exactly the way the surgeon wants it. But they don’t have the same drive the surgeon has. It’s not the same drive even a nurse may have.

How do you motivate someone who makes twelve dollars an hour? By saying, “Your next raise you’re getting another twelve cents?” I think what beats them down is the hierarchy — the respect they’re given or not given. Everyone beats down on the one below.

Here is the hospital’s “respect survey” and how people have responded over the past three years:

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The Joint Commission might urge medical people to follow the advice of Maimonides, the 12th century philosopher and physician who wrote: “The perfect man needs to inspect his moral habits continually, weigh his actions, and reflect upon the state of his soul every single day.”

Will more self-scrutiny help avoid litigation and improve patient care?


andy

I can't believe you are promoting Immortal Technique!! I love you all! Immortal Technique has the sickest rhymes of any emcee alive today. It's true that his lyrics are extremely political, but if you can get past that (or even enjoy it) then you will find a very talented lyricist.

Go Tech! Go Freakonomics!

M Todd

When I was in college I worked for a studio on the weekends shooting weddings. The owner stressed one thing, be super nice to the bride and her family. The reason was two fold, one it was their special day so add to the joy and two in the event of a screw up with the equipment or processing they will be more forgiving in the event their wedding pictures are screwed up.

In the medical profession as in all professions accidents happen and mistakes are made. If the family remembers a doctor who cares and is nice and respectful, they will extend a certain amount of grace to the doctor and be less apt to sue. If the doctor is an arrogant prick and makes a mistake they will have no problem suing them.

It is a simple human principle, if we like someone we give them a pass. If we don't like them we want justice and blood. A good example is our current president. The same people who wanted Clinton's head on a stake for purgery dealing with his sexual harassment suit are more than willing to give Bush a pass for a war that has cost countless lives and billions of dollars.

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frankenduf

I completely agree that kindness wards off litigation- even if the staff screws up, the family will be less likely to sue- in the end, it's caring which bonds patient and practitioner.

ps- contumelious??- this must somehow show that doctors back then were much more literate than now

Dennis

Yesterday at a local pharmacy (Florida) a pharm technologist informed me of an unpleasant incident with a physician. It appears that this physician became upset when she didn't recognize him; "Don't you know who I am?" The double irony is that she was new to the job (six weeks) and the doctor is new to the area (one year.)

As physicians we're taught to keep our mouths closed in the unfortunate case of a medical error, as this admission of guilt can lead to an adverse result in case of a lawsuit. However, we are human and subject to errors, and when committed, many of us feel badly (and embarrassed) and would like to apologize, not necessarily to try to avoid litigation, but because it is the right thing to do.

Health care has revolved around physicians since time immemorial, and they (we) have grown accustomed to being in the drivers seat for the most part. With this comes power and, as we all know, power inevitably corrupts. With this power sometimes comes a perceived "exemption" from normative behavior including treating fellow human beings with respect.

Regarding the example of the salary issue mentioned above the difference is that the employed person's salary is set by the hospital, basically by supply and demand. As a parallel example, due to the nursing shortages nursing salaries have significantly increased. Also, at least in Florida, as of 2006, some 30% of hospitals were losing money and similar data may be present in NY. http://www.fha.org/facts.html

There is downward pressure on non-scarce employees.

On the other hand a self-employed physician's salary is less dependent upon market forces (though it should be in part) and more dependent on issues of self-sufficiency and initiative.

Malpractice is a tough nut. There are probably 10 times as many incident of malpractice, both minor and major, than lead to a lawsuit. When you have so many different players in the mix such as physicians, nurses, pharmacists, lab techs, orderlies and so many different systems in place something is bound to occur. Our system basically sucks because the attorney's cut of the deal is usually 51% of the settlement (Florida) counting fees, expenses etc. A better system would be a 3-member panel of unbiased experts that any patient could bring a complaint to to seek redress for injuries. More people would seek help and they would get more of the money than the attorneys.

Regarding saying "I don't know" it is difficult for most physicians to say, and is probably hard for everyone to admit ignorance. What I say when I'm faced with a difficult clinical issue, and don't know the answer or the diagnosis, I routinely tell the patient "I don't know but I will find out or send you to someone who will be able to help you."

This communicates to the patient that you will do your best for them and also act as their advocate even when your roll in his/her care will be limited.

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jz-md

to Scott:

You may have preferred: "I do not know the cause of the TIA at this time, but I am looking for a carotid or aortic atheroembolism, a clot from the heart, or a

in-situ thrombus." The physician was fishing,.....appropriately so.

However, many patients/families can not deal with ambiguities or uncertainties. They want concrete statements only. They freak-out to hear, "I don't know." You were scared and likely may have been upset with anything the physician would have said. It is rare to work with a family that stays calm and patient in that setting.

Mark

I have heard so many many people complain that doctors don't tell them when they don't know something.

The question I ask everyone who whinges to me about this is "How many times did you admit you didn't know something today? Or apologise because you screwed up?"

In almost EVERY case, the answer is "I didn't"

Give Medico's a break - Which would you prefer:

1) A doctor focusing on that he didn't hurt your feelings

or

2) One who is focused, to the exclusion of ANYTHING else, on making you better and NOT screwing up.

Also - I have a close circle of friends who are mainly nurses - how do they describe their job? "Doc's make your body better, we make you feel like we care. Don't bother the doc's with emotions, that's our job"

patrick daly

As a surgeon, I do not condone intimidating behavior directed at staff, nor do I criticize staff in a personal manner. I am however, very critical of myself and how I conduct an operation because that is how I was trained to behave-as a perfectionist who will only accept a perfect outcome. This leads to high stress levels-does it get any more stressful than the obligation to do your best to repair a person who has placed the ultimate trust in you? We are do our best everyday, and yes mistakes occur, some of which are preventable. The raging doctor either does not exist anymore or is on his or her deathbed, the one who throws instruments (assault), propostions nurses (harrassment-by the way, its a two way street), or curses out staff (suspensions occur including loss of priviliges). When doctors are rude, why not try to find out why? Maybe a drug seeker whined and threatened a lawsuit, maybe a patient pathology came back with incurable cancer, maybe the doctor was called all night long for 3 nights and did not sleep. These are not excuses, they are reality and the general public has no clue and does not want a clue, they want Dempsey and Clooney telling them everything is ok. That is not medicine, it is fiction. We try our best but even the best have bad days, everyone does.

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Scott

What would potentially lessen malpractice litigation is for doctors to speak in a kind and direct manner and to admit when they do not know what is going on.And to do so not as they are rushing out of the room. My wife was in for a TIA recently and they ordered every test under the sun...with very little communication from the doctor other than "well, we are going to do this test next". It became clear they were fishing. Admitting it would be nice. A TIA is more complex than setting a broken arm. Some honesty would have been appreciated.

We did get the honesty we needed, but it was from the nurses. Seems a little backwards.

Jen

My Dad is dentist. Many years ago my parents went through an ugly divorce. During that time my

Dad lost a malpractice suit. He told me that usually, when dealing with unreasonable patients who blamed him for things he had no control over, he would apologize and offer freebies if necessary to calm them down. But during the divorce my normally mild-mannered Dad was angry and kind of crazy. When dealing with this patient who was upset he was dismissive and rude. This resulted in a malpractice lawsuit that my Dad lost in arbitration. The amount of money involved was small but it affected his insurance rates for years.

Gregor

What tosh. Doctors need to act MORE like real people, not less. The stress and inumerable auxiliary problems restrictions on how doctors can behave as human beings should not be underestimated. If you want them to be good people, you should have started on them while they were in kindergarten.

jz-md

As typical, JCAH ( a for profit entity that derives revenue from charging it's hospital subscribers) is decades late with this. Twenty years ago, this would have had a real impact.

The culture has already changed via work-place and sexual harassment law.

scott

to jz-md: you are correct. But I think that the physician has the responsibility to try and ascertain his/her audience and respond appropriately, not just lump all patients together. As a customer, I deserve individual treatment.

to pup-md: yes, you are correct as well. Doing this will take more time.

Pup, MD

At the hospital, I hear people try to say that doing your job with compassion doesn't take any longer than doing it without. Unfortunately, that's about the dumbest thing I've ever heard. But I'm glad when those are the people I'm taking care of patients with (because apparently we're going to be at the hospital later than everybody else!).

The only incentive doctors have to treat others with respect is the maintenance of their own self-respect. And most docs over about 50 lost their self-respect a long time ago. Us younger folk have been promised that our salaries are only going to plummet over the course of our careers, so our self-respect is all we're going to have left.

Anne

It is not just in the medical profession. It ranges everywhere from medical to law to business all the way down to food making industry. As a teenager making nine dollars per hour at a deli, I have to say that I've encountered more rude people than I have when I was interning at a hospital. It really just gets down to how people are deep down inside. I believe we are all sometimes selfish and rude creatures, especially on a bad day.

Al Marsh

I don't know about the US, but I'm in the UK and I see nurses smiling, being polite etc as WAY down on the list of priorities. The British politics blog Nought Point Zero touches upon these points in this post: http://noughtpointzero.blogspot.com/2008/07/our-brief-nhs-experience.html

To summarise: it's quality and efficiency that matters most and politeness is about 50th on the list of priorities, in my view.