The Silence in which Providers Swim
A survey of 1,600 physicians by Columbia University’s Institute on “Medicine as a Profession” revealed that 46 percent of the doctors in the survey had witnessed “serious” medical errors by their colleagues without reporting them. This was true even though 93 percent said they realized they should turn in such doctors. But that’s just what they are willing to recognize as a reportable problem and admit on a survey. Other studies show that in fact only 2% of adverse events are reported (see Medical Reporting).
Medicine is united and successful in silencing and defeating victims of error and abuse. Without hearing from them the community of patients is prevented from developing the vocabulary necessary to manage its healthcare. People do not think in statistics and studies. They think in stories, but the patients with the most important stories are not permitted to tell them. When I talk to victims of iatrogenic injuries, they are afraid to tell me what happened to them. They have been warned that they can be sued or retaliated against if they do. Others who already have been sued have signed settlement agreements containing gag orders or non-disclosure clauses. Whether they sued or were sued, whether they won or lost, they were forced to sign gag orders.
In healthcare the production and circulation of information is controlled to make profit and prevent democracy.
People have a right to complain to an authority without getting sued, but there is no appropriate authority to which an injured patient can complain. The police do not keep track of these things. Medical boards do not have the perspective of patients at heart. There is no one who will tell patients how difficult it will be to get iatrogenic injuries treated and what to do about that. Healthcare has systems set up to protect providers (risk management departments, state medical boards and boards of registration), but nothing to advocate for patients when things go wrong. There isn’t anyone to guide injured patients in how to survive in the post-injury world, let alone collect their stories in order to understand the problems.
People in medicine do not see this as a problem. And they are in charge of patient safety.
Sources of Silence
Humans live in packs, groups, tribes and families. From time immemorial it has been natural and normal for us to watch each other’s backs. Attack Pearl Harbor and people in Maine enlist. Bonds are defined in a wide range of ways. Aim at a police officer and all other police officers aim at you. Being members of the same profession can be as strong a bond as being members of the same family or religion or nation.
Throw into the mix the tenacious psychological tendency of people in a group to believe that their colleagues are as honest, skillful and well-meaning as they themselves are, and the unity of the group further coalesces. All an outsider has to do is speak ill of a member of someone’s group and it is received as an attack on themselves. Like aiming at a cop.
Who do you tell?
Whatever squabbles, jealousies or differences might exist among themselves, tell a doctor that another doctor raped you and whatever concern he might have for your wellbeing is at odds with the attack you are making on a member of his group. This is natural. This is normal. This is part of what it is to be human. People trust members of their group more than people who are not.
The need to trust is at the core of our beings. In medicine they are a team depending on each other. They are loyal not only because of how betrayal can end a career, and not only because of the reprisals that betrayal engenders, but also because of the need to function as a unit of mutually supporting members and the friendship, trust and bonding inherent in that. It is the definition of harmony: concord between different parts to achieve dependable unity. Relationships like these can give meaning not only to work but to life.
The problem is that patients are outside of this group. So who is going to be loyal to them?
It is part of a sustaining environment
And yet one patient safety group writes that “Establishing a culture of safety where people are able to report both adverse events and close calls without fear of punishment is the key to creating patient safety.” Others state it this way: “an environment fostering a rich reporting culture must be created.”
For someone in medicine to report someone else in medicine is a betrayal of the highest magnitude. You would have to re-code their DNA to change that. The betrayer loses the trust of everyone in the system. It is not possible to work without that trust. No policy enacted from above can preserve or recreate trust destroyed by betrayal. The betrayer’s career is over (see loyalty). To suggest changing their culture to one that is “without fear of punishment” and/or that is “a rich reporting culture” is to bring to the subject such a shallow understanding of human bonds as to be talking about a fairy tale.
Without fear of reprisal?
The white wall of silence is not going to be undone by mandatory reporting laws or any of the initiatives of well-meaning people imagining that culture and people are as malleable as snowballs. Improvement in safety will come from recognizing what we cannot change and working with it, not from imagining that we can make a fairy tale happen on earth. The white wall of silence, like other walls of silence in other professions (the blue wall among police for instance), always will exist. We must recognize that and work on how to survive in spite of it.
Kristina A. Fox was burned internally by a device in a hospital. An article written about it in 2006 stated that hospitals are under no obligation to look for evidence of such burns or report the details of such cases. A predictable number of times per year patients will be injured by this device in this way, but mandatory reporting laws do not require them to collect data that could help them learn how to protect future patients, or that would enable current patients to understand the problems they suffer as a result. Hospitals are against collecting such data. That would create liabilities. Another example of the fact that the overriding interest of healthcare is not the safety of patients. If it were, reporting such life-saving information would be more important to them than the potential monetary liabilities.
Not to disparage the good work being done but…
Another part of the current trend in the quest for patient safety is the assumption that medicine is the one place on earth where all the personnel are good and well meaning.
A patent safety group writes “We don’t believe people come to work to do a bad job. . . ” as though in medicine there were no mean or jealous or lustful people whose motivations are unfriendly. As though there were no addicts or pederasts. As though there were no people who have been promoted beyond their level of competence and no people whose fathers have hospital wings named after them and so they are able keep their positions in spite of the damage they are known to be doing (see Dr. Hodad, a page on this site). As though in medicine there were no people who care about keeping their careers more than they do about the fact that they are doing a bad job.
Wherever there are people, there are people who are bad, in both senses of that word. Medicine is not immune. And yet the people leading the patient safety discussion don’t believe that people go to work to do a bad job. If they are unmoved by the statistics on the amount of crime committed in medicine, perhaps they should to speak to a few of the victims.
Walls of silence are normal
For instance, the police have a blue one
Another patient safety organization writes, “When an error contributed to the injury, the patient and the family or representative should receive a truthful and compassionate explanation about the error and the remedies available to the patient.”
When a patient gets raped by a healthcare provider, is the rapist going to tell the victim the remedies available? Does an alcoholic or a sex abuser give a truthful and compassionate explanation about the “error” and the remedies available? Does the perpetrator note his or her own excesses and exploitations in the record?
A culture of collusion and cover up
Medical personnel will never report the worst abuses. Patients will have to become part of the information collection system if negative information is to be collected. Currently no one listens to patients wanting to have negative experiences recorded and tabulated. And when those patients speak publicly, they are silenced with lawsuits. Otherwise more information would be available to help the patient community survive the perils of medicine.
I am grateful for anyone doing anything in an attempt to increase the safety of patients. I don’t want to discourage anyone from working on anything having to do with patient safety, but so much of it is the equivalent of saying that the best way to cross the ocean is to freeze it.
Not to discourage anyone from working on the problems, but suggesting “eliminating fear of reprisal” is like suggesting freezing the ocean. It also is ignoring the warm and productive fruits of the trusts and bonds that result in silence. They need that and patients need for them to have that. What is missing is a way to protect patients when the loyalty of caregivers to each other protects incompetence, indifference, error, and abuse as it currently does.
Crime and Silence in Medicine
Currently silence masks the problem. Silence is one of the fundamental problem for patient safety. Almost no one in medicine will turn in a colleague (while blissfully and self righteously believing that they would) while the victims themselves cannot get the police or state medical boards to do what the public views as their jobs (see elsewhere on this site). If the victims speak, they get sued into silence. If healthcare workers speak, they can lose their jobs. Meanwhile patient safety initiatives dream about creating a culture in which criminals turn themselves in.
Until we are working to address crimes committed by healthcare professionals against patients, we are not working on the problems that are fundamental to all patient safety issues. Instead we are patching cracks in the veneer to hide the termites and rot in the wood beneath. The systems that arrest rot and termites are what will prevent the veneer from cracking. The systems that work on crime will work on error too. The systems that do not address crime in medicine cannot address the widespread, fundamental problems of patient safety.
But there is silence about the fundamental problems. Suggesting that the problems are worse than well-meaning errors gets you ostracized from the discussion. So the discussion isn’t about the fundamental problems. Healthcare providers swim silently as they drown patients who have become problems for them. If that statement seems harsh, you don’t know anything about what the healthcare industry does to patients who are injured in healthcare. So far I’ve never met a caregiver who does.
What does that say about their ability to do anything about patient safety?