A Lot More About
The White Wall of Silence
People have faith in their own objectivity and assessments. But when creating opinions that effect the lives of others, there should be some recognition of the weaknesses, biases and subjectivity of all human beings. Healthcare workers have a fanatical faith in the objectivity and goodness of their colleagues and themselves. One of the reasons they have it is that they keep overhearing each other confirm it (ever hear how dismissive they are of everyone else's perspective?). They don't hear evidence to the contrary. They don't recognize or believe evidence that would engender a more realistic humility.
Human minds filter and refine information until it meets expectations. It is possible that one of the reasons that health care professionals do not believe patients who complain about iatrogenic injuries is that caregivers do not expect health care workers to be guilty, especially when the claim is against themselves. However, they do expect patients to lie. One intern wrote about learning that the first rule of medicine is "Patients always lie."
As a rule doctors do not recognize injured patients as victims who need help after negligence, or even malfeasance, on the part of other doctors, but rather assume that the patients must be lying hypochondriacs or lunatics or wealth-seekers looking to cash in on law suits that will ruin the lives of innocent friends and colleagues.
Physicians are hardly exempt from the need to create satisfying cause-and-effect story lines. Habitual ways of thinking direct the mind to fall back on old explanatory devices. Patients who have become victims are branded and believed to be crazy or paranoid. When that label is applied to patients by members of the medical community, it is accepted at face value by the rest of the community. The reporting in these instances is based on biases, not on discovery and evaluation. When the frontline workers in medicine fail to record the data when they witness the original injury and fail to record accounts of it that are offered to them by injured patients, frequently they are interpreting the evidence of their senses to conform to what they believe. Instead of what an independent third party would see, they see what their group believes - which includes the need to defend other healthcare professionals. Even when they do see the problem and overtly create a record that hides it, they do not see that as creating a wall of silence. We have been unable to find anyone in medicine who will entertain the idea that such a thing might exist.
They believe in protecting each other. They believe what each other say. They do not believe patients. Patients who are the victims of intentional injury cannot get their information inserted in the record. Often they cannot even get diagnosis and treatment. Mandatory reporting laws and incentives are inadequate to the task of motivating the people on the front-line to report even crimes against patients even when they witness them firsthand (for instance, see Majors).
But the bigger problem is the extent to which the perceptions of people in medicine are not objective and not lucid. The biggest problem might be the extent to which their interpretation of truth is subjective and self-serving.
The code is ubiquitous - The silence is total
Owen Findson, a journalist for the Cincinnati Enquirer, was interviewing me about something else when he asked what I was doing now. In telling him about the work I was doing on patient safety, I happened to tell him the above scenario and he said, "You know, two and a half years ago my wife had a minor procedure to remove a bump on her arm. She has been in chronic pain ever since. She has been going from doctor to doctor, but no one will examine her." That is the wall. That is the code. That is the silence.
If colleagues were not more important to doctors than the well-being of patients, that patient would have been examined. But you can bet none of those doctors regard their actions as creating a wall of silence. Without acknowledging what they are doing, even to themselves, they always will protect themselves and each other even at the expense of patients. Even when the patient is another doctor.
They may not know they are doing it
Those who share a paradigm understand each other. They agree on similar information. Information beyond their paradigm is eliminated. It is rare to find a doctor who admits to the existence of a wall of silence, although it is discussed by medical researchers and written about (see Michael Swango). Doctors, in maintaining that wall, go as far as to blacklist patients (see blacklisting patients) and deny there is any wall of silence, or any such thing as blacklisting, while doing it. They don't just deny it to others. They are in denial themselves.
While remaining in collective denial about it they steadfastly maintain the wall. From what I gathered from a doctor who actively was doing it, he thinks he merely was protecting innocent healthcare workers from negative information. Some of that information was the injuries themselves that he was telephoning colleagues telling them not to diagnose. Diagnosis of the injuries was evidence that no one in healthcare wanted to gather. So they didn't. Which means they didn't diagnose injuries that needed treatment, which caused the injuries to become worse. In that particular case, the knowledge and experience of front-line workers, that was not recorded at the scene when the injuries were intentionally inflicted, was evidence of a crime. Their careers depend on not indicting anyone else in medicine. They are, in fact, a group of people dedicated to protecting each other, which would be why medicine has been called the profession that supports crime.
But in medicine they deny the evidence of their senses when it does not satisfy their perceptions of themselves. As Lucian Leape said when talking about mere errors, "Although error rates are substantial, serious injuries due to errors ... are perceived as isolated and unusual events—outliers." [Error in medicine. JAMA 1994;272:1851–7.] Negative information often is viewed as something that would be misunderstood by others and therefore in need of correction. I also have heard the reporting of such referred to as being negative. The pressure, even in this, was to look on the bright side, one of the cultural habits making ignorance a goal when a specific ignorance benefits the group (see agnotology).
In the same way, they view crime in medicine as too unusual to do anything about and rarely report it. As part of her explanation of why she had not reported the nurse who was serially murdering patients, a nurse on the scene of the Majors case wrote to me that millions of people each year are perfectly happy with their health care. We hear that a lot when asking about problems in medicine, like when we bring up the unacceptably high rate of preventable deaths.
There are less extreme forms of it, but blacklisting can be as blatant as communicating to other healthcare professionals to watch out for a certain patient to prevent that patient from obtaining evidence that could reflect negatively on the care of another caregiver. When a doctor blacklists a patient, the doctor doesn't think he/she is creating a wall, only protecting colleagues. When a patient arrives asking for treatment, it is routine for the doctor to ask how the patient got injured. When the patient says that another doctor did it, and the doctors to which that is told do not write down the answer, they do not think they are creating a wall. When doctors examine the patient in ways that will not locate the injuries, they do not think they are creating a wall. When doctors do everything but create an accurate record of the injuries, they do not think they are creating a wall. But to the patient desperately seeking help, treatment and justice, it is wall.
Us versus Them
It would be a rare species of animal that did not divide the world into friends and foes. Even tadpoles preferentially associate with other tadpoles according to how closely related they are, according to biologist Jay Phelan of UCLA, co-author of the book Mean Genes. It is time for the world to realize that doctors and nurses are no different and have strong biases that shape their perception of medicine.
Driving in a fog is dangerous
If a journalist wants to learn something about healthcare, he/she asks three doctors and accepts the paradigm they pronounce. There is little or no appreciation for the collective agenda and lack of objectivity in medicine. Leonard Downie, Executive Editor of the Washington Post, says that accountability reporting is one of the most important functions of the media in a democracy - bringing to the attention of the citizens information about the people who have power over them. Where in journalism is that done for patients? That rarely happens when medicine is the subject.
Healthcare practitioners are revered the way priests used to be. We believe they know what's true and have our best interests at heart. This may be due in part to their believing that about themselves. That the phrase "white wall of silence" is not in common parlance is an indication of the extent of our faith in them and their faith in themselves. The injured patients running into the wall do not have the vocabulary to understand, describe or adequately respond to their dilemma. A journalist trying to make sense of the experience of such patients will accept the characterization of them given by the healthcare community and assume they must be paranoid cranks. And the silence continues.
In hospitals they cut you open and reach inside you. There is no greater way in which you could put your well-being in someone else’s hands. There is no other place on earth where it is more necessary to have someone looking out for you. When the people cutting you open turn out to be drunk, or angry, or lustful, or jealous, or just plain human in other ways, you need an ally. In operating rooms, as is true elsewhere in medicine, patients don't have one. The nurses won't speak up (see loyalty and survey). The anesthesiologists won't speak up. Other doctors are disinclined, to say the least, even to diagnose, let alone report, the injuries afterwards.
It is part of physician training to create records that protect themselves and other physicians (see defensive documentation). It also is a matter of written public policy. It also is a matter of loyalty. It also is a matter of career preservation. It also is a matter of an antipathy for the experience of patients. It also is a matter of self-deception. All of that can be referred to as an "inability of the system and its managers to solicit and integrate the knowledge and experience of front-line workers," and perhaps must be referred to that way in order to keep the healthcare community from shutting down the discussion. But characterizing it in that way only makes the discussion sound as though we just need to encourage those front-line workers to get them to report. We might as well discuss how to encourage clouds not to cast shadows.
The "encourage" discussion has been had. There are people trying to teach them ethics and people trying to inspire more compassion in them. At times it has risen to the level of being a demand. Ggovernments have passed mandatory reporting laws to that end. I have argued against such laws saying that they only end the discussion, as though the problem had been solved, at least until such time as it becomes evident that those laws have no effect and healthcare workers still do not report. Which appears to be where we are now, once again wondering about how systems and managers can "elicit" information. It is a cycle that will never improve as long as we continue to maintain this inaccurate notion of what the problem is.
The gap between truth and belief is deadly.
Speak to patients who have been injured in healthcare. Ask what they told their doctors. Get their medical records (patients can get them for you) and look at what those doctors wrote down. They did not write down what the patients told them. If you look long enough, you will find worse. Physicians and others not only will not record the truth. They record things that are not true.
Whether it is the history of a patient or a nation, humans share basic needs that often are not met by accurate recollection. During World War II when the Soviet Army marched into Europe, it began a legendary, drunken rampage. Looting and rape occurred on a scale that shocked the rest of the European countries. Yet when historians went to the Russian veterans to collect their stories, no one talked about atrocities. Veterans want to be appreciated and respected. No matter how much interviewers pushed, they did not get information about the bad things. Why do we think people in medicine are different? Why do we imagine they are going to admit, or even believe, in their own problems and abuses? Why do we think the police almost never can find witnesses in medicine? Why do we think victims almost never can get witnesses to testify in court?
It is time for a realistic understanding of the humans who populate the medical professions and for the creation of systems that understand that some people are evil and some people are incompetent and some people have appetites that ruin the lives of patients on purpose. Systems that do not address those problems cannot address smaller problems. That which enables, protects and covers up the big problems does the same more easily for the small ones.
Their belief in their own goodness is so resolute
that they cannot accept information to the contrary
Doctors will not record the complaints of patients about other healthcare professionals. Pleading patients cannot get the origins of iatrogenic injuries put into their charts. This is more than a matter of perspective and the extent of its destructive impact is unappreciated. The front-line workers will never collect this information. We must create a different source for gathering the information.
We could start by eliciting information from patients, perhaps by giving them a place to report that is not run by people who harbor the subjective, self-interested delusions of those working in healthcare. People in healthcare who read this will cry foul, somehow dismissing the fact they don't even report crimes against patients. That is the problem. That is all one needs to know to understand it, but such facts are dismissed and ignored by people working in healthcare. That shows interests and goals superseding the safety of patients. They don't even protect patients from crimes. They don't even believe in the crimes when patients complain about them. We will never be able to get them to. They see themselves as humble, concerned, attentive and honest when they don't even believe or report crimes.
They are incapable of recognizing when they are covering up crimes, so steadfastly do they believe in the goodness of their group. We must stop having discussions about how to encourage them to report or how to require them to report. We must recognize it as a condition we cannot change and instead move on to finding another source for the information. They will maintain the wall of silence forever. We must find a way around it.
People have a natural inclination to believe and protect members of their group (see culture of safety). People in healthcare feel an immense loyalty to each other. Even when they don’t, they know they need to be able to work with each other. Turning in a colleague can damage a career (see loyalty). The inclination to derail lawsuits and prevent blame from being assigned is huge. They would want their colleagues to do the same for them. The result is a wall or code of silence, unacknowledged but routine denials of care, and a fog enshrouding healthcare that prevents anyone, inside or out, from seeing the landscape.
The problem with investigating this wall of silence is that it is a wall of silence. It is one built of well accepted, and well rationalized routines.
When medical experts testify for patients, too often there is a closing of the ranks around those experts ostracizing them from the community. They sometimes are ostracized by or suspended from their professional organizations for having testified. Medical experts who testify for patients have been sued for defamation by the doctors they testified against. Doctors have countersued injured patients to force a withdrawal of complaints. Patients routinely are warned about defamation suits that can bankrupt them just for complaining. Little attention is paid to how medicine defeats its victims and protects itself by keeping problems quiet. There is almost no recognition of how wide and deep it is. There is almost no recognition of how medicine protects serial offenders and incompetence at the expense of patients. There is almost no willingness to incorporate the above issues into patient safety discussions.
The will and the way
The information needed to make patients safe competes with the medical community's need to keep its secrets. They do not want patients to be safe as much as they want themselves to be safe. Their reputations, their careers, and their egos are more important to them than the well-being of patients. It is a conflict of interest that will make medicine unnecessarily dangerous for patients until it is recognized that is the fundamental problem and the discussion becomes about what to do in response to that. Saying, "We don't believe anyone goes to work to do a bad job" stifles progress. Whatever their original intentions might have been for entering medicine, once they have to pay their student loans and their receptionists and their insurance, the incentive to find out if they are doing a bad job competes with their own survival. So they don't find out. They believe in unfounded, self-serving delusions while the information needed to make patients safe is not recorded or reported or even believed in by them.
The wall of silence will not be overcome by pretending that it is merely a matter of motivating them or requiring them to report and record. Discussions about requiring or eliciting the reporting of information from them only delay the day when we will talk about the real world. They never will be reliable reporters of the most important patient safety information. They never will produce the solutions that make the most patients safe.
Some other source other than front-line workers will have to be developed for gathering information because the people on the front-line never will relinquish the power and the protection inherent in the secrecy. As long that information is not gathered, patients cannot be kept safe even from exploitation and abuse let alone error. If patient safety needs to be discussed in terms that assume that healthcare workers are innocent, perhaps we at least would be allowed to say that healthcare workers are only human. It is natural for humans to protect themselves, for instance through self-deception and denial. Currently patient safety discussions require the participants to assume that healthcare workers are free of self-deception and are selfless, objective, well-intentioned and as honest as saints. They are not.
In court under oath they distort information and mislead
juries to protect each other. As the judge wrote when overturning the verdict in Sheridan vs. Jambura in 1999, "The syntactical contortions which
counsel and the witnesses wound through to deliver these opinions were wondrous
to observe. . . I have great difficulty when the expert appears to be straining
an opinion to meet the requirement of advocacy. Unfortunately in my experience,
this latter spectre occurs far too frequently in medical malpractice cases,
where it appears to me that medical witnesses are willing to bend their
testimony…" The judge’s order setting aside the jury verdict was appealed,
ultimately to the Idaho Supreme Court, which affirmed his decision and ordered a
Sheridan vs. Jambura et al, Memorandum Decision, District Court of the Fourth Judicial District of the State of Idaho, in and for the County of ADA, Case No. CV-PI 97-00266-D, July 19, 1999.
We know of more than one case where healthcare professionals lied under oath to protect each other. If they do that under oath in court, is it reasonable for patient safety initiatives to assume that healthcare workers are honest and blameless and put the safety of patients before all other concerns? In their daily practice they do the same thing that they do in court and believe they are doing the right thing when they do it. When they lie, cover up, distort the truth, destroy and falsify documents, refuse to report negative information, and in general do anything necessary to protect themselves and their colleagues, the fact that they believe they are doing the right thing when they do that might be the fundamental problem with patient safety - their subjectivity, their self-delusion, and their fundamental dishonesty hiding behind the belief that they, alone among people, are above all of that.
Patient safety requires sunshine, truth and accountability. Provider safety requires the opposite. But no one in patient safety is allowed to discuss that. To suggest that healthcare professionals are not innocent is treated as blasphemy. To suggest that the well being of patients might not be their highest goal gets one eliminated from the discussion.
The patient safety movement works with false assumptions. It discusses a paradigm that is not grounded in reality. Meanwhile, hanging out there unappreciated, is the fact that the least likely person to report a crime committed against a patient is anyone working in healthcare. That statistic, by itself, is a wall of silence around the worst thing people in healthcare do. Their response to the worst thing is to make the wall higher and thicker.
See also the page Wall of Silence on this site that covers Janice M. Scully, MD's unsuccessful attempt to get her adverse event into the record rather than hidden behind the wall of silence.
Arendt writes that some kinds of power depend on isolating the world of power from the regular world. That's what a wall of silence does.
Patient Safety and a White Wall of Silence are mutually exclusive.
Constantly patients are told to be active participants in their healthcare while being denied the information necessary to do that. The information necessary to make informed choices is hidden behind a white wall of silence.