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Psychology of Care Giving

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Awareness of others.

Mirrors sometimes are put in bird cages to give birds someone to play with. Birds never become aware that the image in the mirror is themselves. They do not have that capacity for self-awareness. Only four animals do: elephants, dolphins, apes, and humans. Sometimes self-awareness is important for survival, but apparently most of the time it is a hindrance. Otherwise, wouldn't more than four creatures on earth have it? Even for the four that do, sometimes it is such a hindrance that ways to avoid it are found.

Parallel Worlds

Do health care professionals ever look at examples from other professions, parallel worlds, in order to better see themselves? Like examples in which people wanting to build a dam or skyscraper hired geologists for whom the profit motive was Seeing their own interests as yoursstrong enough to find a rationale for erasing a fault line. Soil engineers have found bedrock for foundations where no one ever before had and no one ever would again. It wasn't there. Or like economists who made projections that agreed with no one - other than other people being paid to work on the same project - but that were not criticized by the rest of the profession (like the average retroactive medical study done by a physician). Does anyone explain the parallels between that and what healthcare professionals do everyday?

Why is not more done to put Health Care Professionals in touch with it, especially when they are students? Does anyone show med students analogues of simple things -like "perc" tests. Perc (for percolation) tests measure the ability of a soil to absorb liquid. To get a building permit on some pieces of property it must pass the test. The people hired by builders to conduct those tests are more likely to get hired to do those tests again if their tests find what the builders want them to find. It is in the interest of the testers to conduct tests in ways that pass.

That bias can produce results that are good only for the providers. The person who suffers is the end client, the young couple with three kids who trusted the realtor and all the other licensed professionals who put them into a house that will be plagued with unaffordable expenses because of a biased perc test. The people who were supposed to protect them will say it’s “buyer beware” (like patient advocates do in hospitals when things go wrong).

With the perc test the well-being of the professionals was not affected when their collective work produced poor results. They did not need to hone the perceptions and habits necessary to be sensitive to whether not just their individual efforts, but also their collective efforts were producing harm. They each did their own jobs according to standard practices and produced a bad result. That is what is in their interest.

There is no personal reason for the backhoe operator on that job to be sensitive to the connection between the soil being dug and the result that will be experienced by the person who has to live with it. That operator will have a more successful career for doing only what he/she was hired to do – dig the hole without making waves even when it is obvious that the perc test never should have passed this soil for the installation of a septic tank. In fact, the operator is unlikely to become sensitive to whether the soil could pass the test. It is not in his/her interest to become sensitive to that. It is in his/her interest only to focus on his/her process without worrying about the ultimate outcome.

Plumbers, realtors and others involved in delivering a finished house to an end client each could have developed the sensitivities necessary to understand the problems that would beset the end user, but it is not in their interest. So they don’t. They follow their equivalent of best practices and don't go looking for problems.

Systems or Operators

For all the arguments about how this could be viewed as a systems problem, the origin of this problem was selfish humans feeling safe from repercussions while following standard practices. The problem was allowed to endure by all of the other people in a system that shielded the operators from the outcomes for the end customer. An honest person whose goal really was the well-being of the end client would have behaved differently within that system. But people behave according to personal rewards and punishments over and above altruism. People paid to do a job in a system that protects them from being effected by the ultimate outcome of their collective work are dangerous.

Harming someone was not the goal of the person doing the perc test. But in systems like that people go to work believing they are doing a good job even when in the end, collectively, they are not. Obeying regulations, traditions, protocols, and standards and having a good reputation and an unbroken chain of satisfactorily fulfilled contracts does not mean that the good that should have been done has been. More accountability could have fixed that. Having a stake in the ultimate outcome could have helped. Making it so that how things turn out for the end client matters to each person in the chain is good for the end client. That can be accomplished by arranging for end-clients to have access to enough information about outcomes for the community to be able to see where good outcomes are most likely, expecially if the data traces the problems all the way back to the person who conducted the original perc test.

The nurse or anesthesiologist in an operating room who watches medical procedures everyday, but says nothing and reports nothing and personally is better off for being unable to understand when what is being done is going to produce a bad outcome. If they do notice, they are better off for not remembering it.

Such caregivers are just backhoe operators who don't give a damn about the kind of soil being dug. Having no stake in the outcome discourages honing the skills and perceptions that produce good results. It is the reason for the demise of many of the patients who die unnecessarily each year. Can that really be called "errors" or "systems problems" as though some tweaking of the system will solve it?

Medcine is a world that puts the well-being of caregivers at odds with the well-being of patients to the extent that they don't even report the problems that are killing patients. Their own interests are violated by reporting. (Does anyone even tell medical students that only 2% of patient harm problems get reported accurately?)

All of which could change if the patient community had objective information about outcomes.

Caregivers have managed to conclude that patients are better off when caregivers are less accountable

One of the mantras of medicine is that everyone in medicine means well. In patient safety discussions it is forbidden to mention examples of when they did not. All discussions must assume that everyone in medicine blameless. The thinking is that this will encourage the reporting that is requisite for making medicine safe for patients.

No matter what laws or regulations are passed to hold blameless those who report, systems are rocked by such reporting. A colleague reporting you has betrayed you. That is not tolerated. People usually manage to figure out who betrayed them. Then things change for the worse for the person who reports no matter what the system does to enforce "blameless" reporting. Reporting is a breach of loyalty that is not easily forgiven.

Any proposals for improving patient safety by requiring objective reporting are out of touch. There already are mandatory reporting requirements. AMA guidelines require it and in some places caregivers are required to abide by AMA guidelines. Shouldn't someone explain to medical students that they won't report, even when it is required, and why?

Denial

People at the top of the profession in medicine state that no one in medicine would fail to report a problem. Yet every study done on it finds that the majority of problems are not reported, but that is dismissed by healthcare professionals. Shouldn't medical students at least understand why they will deny the studies and statistics and form beliefs based that they will believe are founded on personal experience when it really only is self-interest? Like the tobacco executives.

We didn't even mention the seductive nature of caregiving.

Would it do any good to tell them?

Does anyone tell people in medicine that they may believe in their hearts that their goal is the welfare of their patients, but that they are humans. And that for humans self delusion is normal. And that it is normal not to recognize one's own delusions.

Does anyone tell med students that they will not recognize it when trusted colleagues and subordinates and superiors manage things in self-interested ways?

If some patient tries to get to the bottom of a problem, the health care professionals may find themselves "failing" to report information that the community of patients needs to have, and yet believe that what they are doing is for good of the community of patients. Conflicts of interest create such delusions. Healthcare professionals are only humans. For a grand illustration of this, just witness what the AMA did believing that it was in the interests of patients.

Does anyone tell future healthcare professionals that someday if a patient says that his/her injuries were inflicted intentionally by someone working in healthcare, the future healthcare professionals are likely to go as far as to telephone other healthcare providers to warn them not to discover those injuries lest those diagnoses be used to indict a colleague. Yet when asked if there is such a thing as blacklisting, in their hearts they will believe it when they say, "No." Wouldn't it help if, as they were doing that, there was an echo in their minds of the words of some college professor telling them that they would do this, and that when they did they would believe in what they were doing? Shouldn't there be an echo in their minds of a warning about how they will rationalize distorting and lying, and how what they will believe to be true often only is self-interest in a cocoon of unrecognized rationalizations.

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Does anyone explain to them that an inability to imagine any viewpoint other than their own is normal in medicine and reinforced by the culture in medicine? Does anyone explain cocooning to them - the inclination to find sources of information that reinforce self-serving views, and how that insulates them from learning the truths that would save the lives of patients when those truths might not easily be accepted by people whose pride or income might be impinged?

John Stuart Mill defined intelligence as sufficient detachment from one's own case to consider it as one of many.

Does anyone explain to them that once they are healthcare professionals they never will be able to see the world of medicine from the viewpoint of patients, in part because the world of medicine takes care of its own differently than it takes care of patients. Negligence, exploitation and abuse are not likely to be visited on members of their own team, for one thing. Members of their team know who to talk to when things are not right. And when they talk people will listen to them. That is the opposite of what patients experience.

How many light bulbs does it take to change a culture?

Social animals, from hyenas to humans, keep track of large social networks, form long-term alliances with each other and compete with rivals. This is natural for them and for us. Does anyone explain to healthcare professionals how their being in the group called "healthcare professionals" unites them against other groups, like patients, when patients become problems, as from adverse events, especially when those events are the fault of the healthcare professionals?

Did you ever hear entertainers complain that their audience was stupid? Healthcare professionals make similar statements about patients all the time. For instance, medical professionals talking about cases like Catherine Wood and Gwen Graham have been heard by this author to say that the problem is that the patients didn't complain. There is no appreciation for the extent to which medicine is an imposing and overbearing industry that crushes patients for complaining. Does anyone explain to future healthcare professionals why they will never see themselves as crushing, blacklisting, and denying care to victims, but instead will see themselves only as protecting themselves and their colleagues from suits and complaints that they will imagine to be frivolous?

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Currently what we hear from people in medicine is protestations that they, and only they, are objective about the world of medicine. There is no apparent awareness of their own subjectivity and their own conflicts of interest. That is a major failure of awareness. But such awareness perhaps is not important, or even beneficial, to their well-being. It is a matter of life and death only to patients.

What medicine benefits from not understanding about itself kills patients.

". . . the quickest of us walk about well wadded with stupidity."
- George Eliot in
Middlemarch

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Shouldn't someone tell med students about the note below that I don't know where to put yet:

Correspondence Bias
or
Fundamental Attribution Error 

If a caregiver sees a patient trip in the hallway, he/she might consider the patient to be inattentive, a possible sign of dementia. If the caregiver him or herself is the one who trips, he/she might be more likely to blame the institution for the condition of the hallway and get angry if anyone disagreed with his/her objective assessments.

When do caregivers see themselves as inattentive or possibly deteriorating into dementia? Caregivers never are the problem, right? The problem is the system, which might need some tweaking, right? Everyone in medicine must be held blameless, mustn't they? Because no one goes to work to do a bad job, do they? Because there is no self-deception or sociopathology in medicine, is there?

Will we never eradicate such biases, and the similar problems that make medicine so unsafe and inefficient. We keep focusing on, even micromanaging, the people and practices inside medicine in order to fix them. We've tried that for 160 years. That's long enough. It's time to face the fact that that is never going to work. Instead, we must change the world around medicine so that it adjusts on its own in order to ensure its own survival. We can do that. We just need to get honest, unbiased information so that the patient community can learn the who, what and where of safety and effecifacy and go there, rather than blindly going wheverever and paying whatever it happens to serve the interests of medicine to command them to.

That kind of information never will come from caregivers. It must be culled from patients. Surveys cannot do that. Aggregating charts cannot do it sufficiently because the charts are created by biased people with a conflict of interest. It must be culled by knowledgeable people doing the detective work necessary to gather all the information they can, getting second opions about outcomes from caregivers whose full-time jobs are to advocate for patients in settings where that is all that happens, and digging to cull from patients information about their experiences that the patients didn't even know was worth mentioning.

This has been done with success. Doing it more can start with one group of patients in one community. It probably even can be done profitably so that rather than having to build a massive infrastructure and roll it out for the entire nation one day, instead it can sprout here and there, like restaurant franchises, until they are nearly everywhere.

Everyone doesn't have to be part of one in order for everyone to benefit. When the market driven by them becomes safer, more effective and less expensive, everyone will benefit.

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