On June 23, 2015 the Washington Post ran a story titled Anesthesiologist trashes sedated patient — and it ends up costing her. While preparing for a colonoscopy, a patient hit "record" on his smartphone to make sure he heard the instructions his doctor would give him after the procedure.
When he played back the recording he was shocked to find that while he lay unconscious, the surgical team had mocked him, told an assistant to lie to him, and then put a false diagnosis on his chart. The patient sued the doctors and their practices for defamation and medical malpractice, and a jury ordered them to pay him half a million dollars.
This story is horrifying. One might even call it a patient's "worst nightmare." To treat a patient in such a manner while they are sedated and vulnerable is both callous and unprofessional. For the staff at the Arnold P. Gold Foundation Research Institute, this incident raises several questions:
1. Does authenticity matter?
Do clinicians have to truly care about their patients? Or do they just need to act as if they care -whether a patient is present/conscious or not? We would argue that both are necessary. The Arnold P. Gold Foundation seeks to ensure that compassion, respect and empathy are at the core of all healthcare interactions. The Chairman of our board, Dr. Jordan J. Cohen, calls humanism 'the passion that animates authentic professionalism'. We believe that clinicians must strive to truly care about their patients in order to serve their best interests. While it may not be possible to muster 100% empathy for all patients every single day, no healthcare provider should ever ridicule and demean their patients.
Michael Kahn suggests that our minimum standard should be "Etiquette-Based Medicine." In his words, "a doctor who has trouble feeling compassion for or even recognizing a patient's suffering should nevertheless behave in certain specified ways that will result in the patient's feeling well treated." Such etiquette-based behavior should extend to communications when the patient is out of earshot as well. There is evidence from neuropsychology that behaving kindly and respectfully actually helps you feel that way.
2. Beyond the impact on individual patients, how does unprofessional behavior affect the culture of healthcare?
The old adage "If a tree falls in a forest and no one is around to hear it, does it make a sound?" may be relevant here. If this patient had not recorded the conversation, he would not have been aware of the disparaging comments, but those comments still 'make a sound' in the clinical environment around him. There are serious ramifications on the culture of medicine, on teamwork, on trainees, and even on the safety of the patient.
Increasingly, medical educators are pointing to role modeling as a significant factor in professional identity development. When students' role models are cynical and derogatory, as was the case in this recent incident, these unprofessional social norms are passed down intergenerationally and perpetuate a culture of healthcare that harms patients and siphons meaning and joy from the work of being a healthcare professional.
We must advocate for safe spaces in which healthcare trainees and professionals can talk openly about challenges in clinical care; they must be provided with opportunities to openly share their own (sometimes negative or frustrating) experiences with patients, and develop strategies to cope and communicate constructively. They must have avenues to share stories from 'the trenches' and to role-play potential responses to unprofessional colleagues and supervisors. In addition to opportunities for reflection and renewal, safe reporting opportunities must also be made available. We do draw hope from the work of Thomas Inui and colleagues who have successfully changed the culture of an entire medical school. Their aim is to liberate "individuals and groups from automatically reproducing existing patterns and gives them the ability to explore and change." In the end, those of us in healthcare need to insist upon deliberate change in the culture of medicine to become more humanistic; our patients' lives depend on it.
3. How can we ensure that the professionalism of healthcare employees remains intact?
Though we hope that students and health care providers do learn to speak up in the moments when they witness unprofessional behavior, we also acknowledge that it is not easy to do so. We need policy and legal recognition that professionalism in healthcare is a factor that affects a patient's experience of care, patient's health outcomes, patient safety, and provider burnout. Fortunately, some prominent organizations are bringing the importance of professionalism in education and practice front and center:
--The ACGME Clinical Learning Environment Review (CLER) mandate addresses professionalism issues in the environments in which residents work and learn
--The LCME states that "A medical education program must ensure that its learning environment promotes the development of explicit and appropriate professional attributes in its medical students."
--The Joint Commission has a zero tolerance policy for disruptive physicians.
The Digital Age brings with it the ability to easily record interactions. While this particular recording was accidental, other patients may secretly record their physicians. This both stems from, and contributes to, a culture of mistrust between practitioners and patients. Healthcare professionals should not practice in fear that they might be secretly recorded, but with the intention to express the highest standards of compassion and professionalism, regardless of who is listening.
The Arnold P. Gold Foundation Research Institute