The Psychology of Care Giving
Does anyone tell them that they will believe
that their self-interest is virtuous no matter what the cost to patients?
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 not
another bird. They cannot learn to recognize 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. Other times it is a
hindrance. Apparently for all the creatures on earth except four, it is a
hindrance. And even for those four sometimes it is.
The same can be true about awareness of others.
"If we had a keen vision and feeling of all ordinary human
life . . . we should die of that roar. . . "
- George Eliot in "Middlemarch"
People in college who major in acting often are required to increase
their self-awareness by taking a course in the
psychology of acting. In it they learn how their profession can distort their
perspective. For instance, when they are being paid to perform a role, when that role ends
it is common for actors to believe that their careers are over
and they never will work again. They feel this way because their personal
experience supports this belief. Speaking with other actors also can support
this belief. Careers do end that way. It is understandable that they would worry
about it, but it is a subjective viewpoint. It is common,
but it is subjective and inaccurate. So
in college they are taught to understand that they will think these things and why, that their view is subjective,
that their feelings of despair during these periods are normal but not based on
an objective assessment of the facts and
what to do about that.
Things that once were obvious go off screen.
Does anyone teach students studying medicine how their
professions will warp their perceptions? Does anyone even teach them that it
will, that their profession's view of the world is subjective? Does anyone teach
them about how delusions are reinforced? Does anyone tell them that the
experience of being part of a group of people who have the same interests and
fears commonly results in shared delusions being reinforced through repetition
and agreement. Does anyone tell them what that has to do with healthcare? That
health care is just such a group?
Psychology courses for performers sometimes teach about the part
of ourselves that, beginning in childhood, learns what behavior is
rewarded and what is punished. That is a powerful influence on a person's
thinking. Being personally rewarded is one of the primary sources of insensitivity
about the costs of one's reward to others and a primary source of the rationalizations that mask
or dismiss the moral problems and legal problems with the source of the rewards.
What behaviors were rewarded for the tobacco company
executives to give them a perspective that enabled them to swear under
oath that they did not believe that smoking was addictive or bad for people?
What shared worldview and quips and jokes and agreements were repeated that
united them in their beliefs? More than a hundred years earlier Mark Twain had made jokes
dismissing the addictive
nature of tobacco and audiences laughed. Scientific studies and surgeon
generals' warnings aside, for at least a century the general public had known that it was addictive and
unhealthy. Yet somehow tobacco executives with MBAs and decades of management
experience believed in what they were doing. It has long been
known that one of the best ways to get someone to believe in a thing is to get
them to participate in it. Frequently, belief results from action even when the
belief is not supported by reason, knowledge, experience or argument.
"Lack of sensitivity is perhaps basically an unawareness of
ourselves."
- Eric Hoffer
What behaviors in medicine are rewarded in ways that give healthcare
professionals self-serving delusions like the ones held by tobacco executives?
Does anyone tell medical students what those delusions will be? Does anyone make
them conscious of the powerful need caregivers have to believe in themselves as
healers, and how that alone will cause them to filter information to support
their beliefs, and even manipulate what information get through to them and what
information is available to others?
The gap between truth and belief eventually is fatal
Does anyone tell them that it is normal for
healthcare professionals not only to be unaware of evidence that contradicts
their worldview, but even to find ways to dismiss or deny that which they can't
avoid discovering? Does anyone suggest to them what all this has to do with
the couple of hundred thousand patients who die unnecessarily each year in
medicine?
Like imagining that what is good for physicians is
good for patients,
like liability limitations.
Disorientation
Does anyone explain to them that once they have prescribed a certain treatment for a patient, they will have
a strong need to believe that they have done the right thing and to disbelieve
it when they cause damage? Does
anyone explain to them why they too will believe that the lawsuits and complaints
of patients are
frivolous in spite of all the evidence to the contrary? Does anyone show them court cases in which healthcare professionals
distorted medical facts and/or lied under oath, and why they too can
find themselves similar sins and/or crimes while believing it is the right
thing to do, and what that says about integrity in medicine
at every level? Does anyone show them examples of charts doctors have created of patients
that entirely distort the patient's medical condition and the information the
patient has reported and why they themselves, if in similar circumstances, will do the same thing someday? Does anyone tell
them how the fear of litigation or losing licenses hinders honest reporting?
Does anyone explain to them how likely it is that at some point in their careers
they will hide information and possibly even falsify documents, and how, while
doing that, they will believe themselves that they are doing good?
Does anyone tell them that they, like all people, will trust
members of their own group more than people outside their group, and how that
makes healthcare professionals distrust honest patients while trusting healthcare workers
whose self-interest alone should have raised questions to reveal lies and cover-ups in which the medical community willingly
participates without question? Does anyone explain to them the mental contortions that they will
go through in order to maintain belief in
themselves and protect their careers and protect their reputations and protect
their colleagues, and how that will cause them to be in denial about problems
that they, and their profession as a whole, cause for patients on a routine basis?
Like the all the unnecessary deaths each year taken in stride
with no one thinking the problem is with them or anyone they know.
Does anyone explain to them why they never will be able to
see medicine through the eyes of patients and so never will see the perspective
that could be regarded as the most important one? Does anyone even suggest to them that the
perspective of patients might be the most important one? Where else in our consumer
economy is it the perspective of the provider believed to be the most important
one?
Does anyone tell them that when you are in the middle of
something it is hard to see it? Since what we continually hear from healthcare
professionals is that no one outside of it could understand it, it doesn't
appear so.
Parallel Worlds
Does anyone show them examples from other professions to give
them some perspective? Examples in which people wanting to build a dam or
skyscraper hired geologists for whom the profit motive was strong enough for
them to find
a rationale for erasing a fault line. Soil engineers managed to find
bedrock for foundations where no one ever had before and never would again. 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). Or politicians who made promises about plans to reduce
environmental impact that may have been heartfelt at the time but that
were forgotten as soon as
the building permits were obtained. Does anyone explain the parallels between
that and what healthcare professionals do everyday?
Or, on a smaller scale, does anyone show them examples of
simple things like perc tests. Perc (for percolation)
tests measure the ability of a soil to absorb liquid. If it absorbs liquid too
slowly, it is not suitable for septic tanks and cannot be a good building site
for homes in the absence of city sewers. In many counties, property
owners and builders are allowed to conduct their own perc tests and report the
results to the people who issue the permits. All one does is dig a small hole,
pour water in it, let it drain, then refill it and record how long it takes to
drain again. The people who will get paid more for a passing the test tend to find
results that will, people who want to sell or build on a piece of property.
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 in the house, but who left them crippled, taking a loss economically,
unable to flush toilets, hauling laundry to a Laundromat, and spending money they
don't have to get another professional to drain the septic tank weekly, and
another professional to add additional length on to the septic field (which makes it so that it needs to be drained every two weeks instead of every week)
and to become experts on soil percolation, anaerobic decomposition, building
codes and such in an attempt to solve problems that were not caught by any of
the professionals who actually installed the septic in poor soil, all of whom trusted each other, and each of whom believed
this wasn't their responsibility. None of their lives were effected by the
results of their collective work. So none of them honed the perceptions and
habits necessary to notice whether their collective effort was going
to produce a good result. They each did their own jobs correctly according to
standard practices.
The end buyer in this day and age might create a web
site to help future victims of the same circumstance to benefit from what he/she
has learned. Things learned are things like the fact that the person who installed the septic tank
could have noticed that the soil was of a type unlikely to result in a healthy septic tank, but that installer's benefit is not served by awareness of that.
That installer could lose jobs for pointing out that problem. So installers
do not pay attention to that. They are not expected to and they are better off
if they don't. So they don't.
The backhoe operator
hired by the installer does this work often enough to become sensitive to soil
types too. But that operator's interests are not tied to the end result so it
simply is not something about which that operator is concerned. There is no
personal reason for that backhoe operator to become 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 paying attention only to doing that which
he/she was hired to do. Plumbers, realtors and others involved in delivering a
finished house to an end client each could have been sensitive to such problems
and protected the end client, but it is not in their interest.
Systems or Operators
For all the arguments about how this is a systems problem,
the origin of this problem was a selfish human who felt safe from liability. The
problem was allowed to endure by all the other people in the chain in a system
that shielded the operator and rewarded selfish behavior. Honest people whose
highest goal really was the well being of the end client would behave
differently. But people behave according to personal rewards and punishments over and above
altruism. People being paid to do a job who believe they are immune to
repercussions for how they do that job are dangerous.
Harming someone was not the goal of the person doing the perc
test. And it wasn't the goal of all the people who were insensitive to the
problem along the way. But whether or not the ultimate result of their
collective effort was harmful did not need to be on their radar. The long-term
well being of the end client was not on the chart.
In systems like that people go to work believing they are doing a good job
even when in the end, collectively, they are not doing a good job. 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
done. More accountability could have fixed that. Having a stake in the ultimate outcome
could have helped too - making it so that how things turn out for the end client matters to each person in the chain.
The nurse or anesthesiologist who watches operations
everyday, but says nothing and reports nothing and personally is better of for
remembering nothing about unusual or bad events in the operating room is just a
backhoe operator who doesn't give a damn about the kind of soil he/she is digging
and the end result for someone else. Having no stake in the outcome discourages
honing the skills and perceptions that produce good results. It is why so many
patients die unnecessarily each year. This is a world that puts their own well-being at odds with the well-being of patients
to the extent that they don't even report the problems that are killing patients. It is in their own
interest not to report. Does anyone even tell medical students that
only 1.5% of adverse events get
reported?
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 policies resulting must behave as though 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, a system of people prepared to proceed with their
work and earn their livings in routine ways is rocked by reporting. People
figure out who caused the rocking and rock them back. 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 not touching the biggest problems. We already have mandatory
reporting laws. When they were passed there was no increase in reporting.
Shouldn't someone explain to medical students that they won't report either and
why?
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 the most important thing to them is the welfare of their
patients, but they are humans. For humans self delusion is normal. Since it is
delusion, they will not recognize it. And they will not recognize 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 healthcare
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 is true often only is self-interest in a cocoon of
unrecognized rationalizations.
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 be easily 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.
And members of the 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 a group, 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 when they complain. 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?
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 survival. 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
Conflict of Interest |