White Wall of Silence
Denial isn't always conscious
As early as the 1950's, the psychologist Solomon Asch did a series of laboratory experiments that showed that three out of four people will give an incorrect answer to a simple question after overhearing others give that incorrect answer. These were questions that children could answer correctly if left alone to come up with their answers. But intelligent adults overhearing other adults give wrong answers, also gave wrong answers. Recent research (lead by Dr. Gregory Berns, a psychiatrist and neuroscientist at Emory University in Atlanta) using MRI's shows that they are not lying. They actually see solid, physical things differently based on what others have said about them. They do not believe their own eyes as much as they believe in the group's thoughts about what they see.
Seeing is believing what the group believes
These
studies were done with groups of strangers with little in common. Imagine how much more influence the false answers would have had if uttered by members of the same profession - for instance if all the subjects had been police officers. Imagine how much more influential it could have been if all the subjects were not just members of the same profession, but
knew each other and worked with each other everyday, like members of a surgical team. Could there be a less sinister explanation for how James Burt was protected by all other healthcare workers, by the hospital, and even by the state medical board?
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 one's own weaknesses and biases. Healthcare workers have a fanatical faith in their own and their colleagues objectivity and goodness. But one of the reasons they have it is that they keep overhearing each other confirm that they have it (ever hear how dismissive they are of everyone else's perspective?). They don't hear evidence to the contrary.
Perspective
Human minds filter and refine information until it meets expectations. It is possible that since doctors do not expect colleagues to behave badly, they do not believe it when patients complain about it. It is possible that they 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 these patients must be hypochondriacs or lunatics or wealth-seekers looking to cash in on law suits that will ruin the lives of their 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. Since 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. The frontline workers in medicine refuse to gather the data being offered to them by patients, the only people who will testify to it, and instead report something that defends other healthcare professionals. And they do not see that as creating a wall of silence.
Silence is the opposite of safety
When they do not believe what the patient says, they do not waste time making a record of it. They don't write down what doesn't make sense to them. If the patient says he/she was injured on an operating table, the doctor is not likely to believe it. No record is likely to be made of the claim (perhaps especially if the doctor believes it - see loyalty). If they feel the need to note something about why the patient was there, they may ask a series of questions, or perhaps the same question in a series of different ways, until an answer is given that they are comfortable writing down.
"When did you first notice the symptom?"
"How long after the operation was it before you thought you noticed this?"
"Was there ever a time prior to this when you had a similar symptom?"
"Have you ever had an accident or sports injury or illness that produced a
similar symptom?"
It is a cross examination fishing for any piece of information that can be used to reject the patient's claim.
Living in a fictitious world built on a denial of facts.
If they never get an answer they like, they still aren't likely to record any of the ones that they don't like. The patient probably will be asked if he/she has been back to see the surgeon (or whoever injured the patient). If not, that is the course of action that will be recommended and the appointment effectively will be over. Any real attempt to examine the patient will be unlikely in part because no one in medicine wants to verify injuries that could be used to indict someone else in medicine, and no one in medicine wants to get dragged into court to testify. If the patient has been back to the surgeon already, the doctor usually will ask what the surgeon said, and it almost doesn’t matter what the patient says. The doctor will agree, often by saying something like "Well, that surgeon has a very fine reputation and I’m confident that he/she knows what he/she is talking about." But no real exam, and no record of the patient’s claim.
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 the information they have to report 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.
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. They always will protect themselves and each other even at the expense of patients.
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 while doing it.
If they really do not believe in it, while remaining in collective denial about it they steadfastly maintain it. It is likely that they do not consider blacklisting to be maintaining a wall, or even to be blacklisting. From what I gathered from a doctor who has done that, he thinks he merely was protecting innocent healthcare workers from negative information. Some of that information was the injuries. Diagnosis of them was evidence that no one in healthcare wanted to gather. So they didn't. Which means they didn't diagnose injuries that needed treatment. In that case, the "knowledge and experience of front-line workers" that was not gathered was evidence of a crime. Their careers depend on not indicting each other. A group of people dedicated to protecting each other . . . well, isn't that why medicine has been called the profession that supports crime?
But in medicine they believe in a paradigm that denies the facts that are right in front of them. 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.] In the same way, they view crime in medicine as too unusual to bother doing anything about and rarely report it.
Black Listing
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 be used to sue or indict some healthcare professional. 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 current doctor does not write down the answer, they do not think they are creating a wall. When the current doctor examines the patient in a way that will not locate the injuries, that doctor does not think it is creating a wall. When current 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.
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 agenda and lack of objectivity of healthcare professionals. 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. 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.
Delusion kills.
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. It rose to the level of being a demand. The federal government passed mandatory reporting laws to that end. I argued against those laws saying that they only would end the discussion, at least until such time as it became evident that those laws had no effect and healthcare workers still were not reporting. 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 description 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.
Rewriting History
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 won'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.
Loyalty
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 it secret. 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 delays the day when we will begin talking 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.
Secrecy
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.
Even honest?
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
new trial.
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 is works from 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, 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.
"Real power begins where secrecy begins."
-- Hannah Arendt in The Origins of Totalitarianism
She 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 most important information necessary to do that - the information necessary to chose who is going to deliver that healthcare.
Note:
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.
Book:
Wall of Silence, The Untold Story of the Medical Mistakes that Are Killing
Millions of Americans
by Rosemary Gibson and Janardan P. Singh
Lifeline Press ; ISBM: 0-89526-112-X
Newspaper article:
http://www.thestar.com/printArticle/193080
If that link becomes dead, an excerpt from the article is here:
silence excerpt