June 18, 2018
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Getting radical in patient care safety — Part 2

Erik Steele
By Dr. Erik Steele

I used to think I was Dr. Wizard Oz — all knowing, and all powerful. Twenty-five years in practice have hauled back the green curtain from my illusion and exposed this truth: my patients are better off if I share the power in patient care with patients, nurses and other members of the patient care team.

So is the patient. In fact, there is growing evidence that when everyone else in the patient care system always defers to the doc, care may be less safe than if others feel empowered to challenge physician authority at critical times and on critical issues. The best health care organizations are now teaching patients and patient care staff to question — and even challenge — physicians when those nonphysicians think the physician is making an error in the patient’s care, and teaching physicians to welcome those challenges. The result can be a substantial reduction in medical errors, safer patients, more satisfied health care staff and better physicians.

It seems paradoxical that patient safety could be improved by taking authority and power away from that member of a patient care team with the greatest knowledge about patient care — the physician. That’s like improving airline safety by taking authority away from the captain — the most senior member of the crew — and giving some to the less experienced people in the cockpit. Exactly, and that is just what airlines have done. The result of this change in cockpit culture has been a dramatic improvement in airline safety. This and other airline safety initiatives have taught safety experts everywhere that complex systems such as health care are less error prone when one person does not have so much authority and power that everyone else is afraid to challenge the mighty Dr. Oz.

The history of airliner crashes is replete with disasters in which the crew knew that the captain was making risky decisions but said nothing, or failed to say something repeatedly and emphatically, because they were afraid to challenge the king of the cockpit. So is the history of medical errors. In fact, about 40 percent of the time investigations of medical errors find that someone involved in the patient’s care was worried an error might be made but failed to intervene, often because they were afraid to effectively challenge the physician or some other more senior member of the care team.

One of the main reasons people are reluctant to speak up when they know something is going wrong is what psychologists call the Power Distance Index (PDI, power distance, or power ratio), meaning the perceived difference in the power held by each of two people in a relationship. The greater the difference, the more reluctant those with less perceived power are to challenge those with more. That’s especially true if those with more perceived power are seen as likely to be unwelcoming or dismissive of anything that seems like a challenge, or to retaliate against those they see as challenging their authority.

The need to tackle power differentials goes beyond patient safety. Patients empowered with more knowledge about their options for treatment of a given health problem often choose less aggressive interventions than those recommended by their physician, and may be more likely to forgo futile end-of-life care. Less of a power distance between patient and physician can therefore mean more shared decision-making in patient care.

Tackling the power distance in health care in order to improve patient safety and decision-making is difficult work. It requires tackling long-standing cultural norms, investing money and other precious resources in the training of physicians and other health care professionals. It requires tackling not just physician behavior, but how senior nurses relate to junior nurses, and how junior nurses relate to housekeepers, etc. It requires patients to stop saying, “Whatever you say — you’re the doctor.”

Radical improvements in patient safety can only happen if many health care traditions — such as high power distances — are killed off. Patients, nurses, physicians and others in health care must work in a new partnership that embraces these changes in their roles. Patients have the most to lose if we fail to do that, and should be not only embracing these changes, but demanding them.

Erik Steele is the former chief medical officer of Eastern Maine Healthcare Systems. He recently accepted a new job at Summa Health System in Akron, Ohio.


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