The Psychology of Healthcare
Does anyone tell them that they will find ways to believe
that their self-interest is virtuous?
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 for 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
perspectives. 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. It is common for professional performers to feel
despair during these periods because of their subjective view of the world. So
they are taught to understand that they will think these things and why, that their view is subjective 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?
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 to others and a primary source of the rationalizations that mask
or dismiss the moral and legal problems with our actions.
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 behaviors in medicine are rewarded in ways that give healthcare
professionals similar self-serving delusions? Does anyone tell medical students
what those delusions will be? 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?
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 or lied under oath about simple medical facts, and why they too can
find themselves doing the same, and what that says about integrity in medicine
at every level, even in the charts they create of patients? Does anyone tell
them how the fear that healthcare providers have of things like litigation and
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
persuade themselves that they are doing the right thing? Does anyone tell them that they,
like all people, trust members of their own group more than people
outside their group, and how that makes healthcare professionals distrust
patients who honestly report problems and at the same time trust healthcare workers whose
self-interest should have raised questions about the lies and cover-ups they
resort to in order to protect themselves? 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
they and their profession as a whole causes 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 is the most important one? Does anyone even suggest to them that the
perspective of patients is the most important one? Where else in our consumer
economy is it the reverse?
Does anyone tell them that when you are in the middle of
something it is hard to see it?
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. And soil engineers who managed to find
bedrock for foundations where no one else ever had been found 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. Politicians who made promises about plans to reduce
environmental impact that were heartfelt at the time but forgotten as soon as
the building permits were obtained. Does anyone explain how people in healthcare
do the same?
Or, on a smaller scale, 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. People who want to sell or build on a piece of property find ways
to pass the test.
The person who pays 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, all of whom trusted each other, and each of whom believed
this wasn't their responsibility. None of their lives were touched by the
results of their collective work. So none of them honed the perceptions and
habits necessary to ensure a good result.
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 a type unlikely to work for a septic tank, but that installer's benefit is not served by awareness of that.
That installer would lose jobs now and then from paying attention to that. So installers
do not pay attention to that.
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. It
does not effect that operator.
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 operators liability 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 who believe they don't 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. People go to work believing they are doing a good job
even when 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 was
done. More accountability could have fixed that - having a stake in the outcome
would have helped. Making it so that how things turn out for the end client matters
personally 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 dam 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 the selfishness and the conflict of
interest 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. It is in their own
interest not even to report.
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 a routine way is rocked by reporting. The people
in it figure out who rocks it and rock them back. Things are not be the same for the person who reports
no matter how hard the system tried to enforce "blameless" reporting. It is a
breach of loyalty, one not easily forgiven. Any proposals for improving patient
safety that require objective reporting are not going to touch the biggest
problems.
Would it do any good to tell medical students that they will
dismiss this information out of hand believing that no one in medicine would fail
to report a problem? Every study done finds that the majority of problems are
not reported, but that is dismissed by healthcare professionals. When the
students become healthcare professionals they will do the same.
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. Because conflicts of interest create
delusions. And healthcare professionals, as humans, are not immune. 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 when they diagnose that patient 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 and why? 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 isn't?
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 cacooning 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?
Does anyone explain to them that now that 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? Does
anyone tell them how that distorts their view of the world and that they are not
objective?
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 about problems in
healthcare. 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 be sure are 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 self-interests. It is a matter of life
and death only to patients.
". . . the quickest of us walk about well wadded with
stupidity."
- George Eliot in Middlemarch
Conflict of Interest |