On tribal hierarchy
On day one of the “Academy of Emerging Leaders in Patient Safety” conference, we started by watching a video featuring a patient’s mother who brought up the tribes of healthcare (doctor tribe, nursing tribe, etc) and the role that the element of hierarchy played in her son’s unfortunate outcome. In healthcare, we often witness two of mankind’s most primitive motivators – the desire to care for others and the drive to survive. The “doctor tribe” is predominated by competitive, type A, detail-oriented individuals, and deference to the hierarchy is one of our tribe’s oldest traditions. In the patient safety community, the need to address this specific tribal tradition is frequently discussed. Knowing that old habits die-hard brings up a number of questions: Is hierarchy still alive and well? How can it be addressed? How receptive will the tribe be to solutions proposed by external parties?
Take a moment to reflect on your first day being a contributing member of the doctor tribe. The first of July is always filled with bussing new faces with bright eyes and bushy tails. Interns everywhere can be found lying in wait for pretty much any opportunity to learn. From my first day, I vividly recall one of my first lessons learned from residency. After divulging info on bedside rounds that altered the patient’s plan of care, my attending applauded my attention to detail, which moved my chief resident to create a pseudo “lunch and learn.” Over a lukewarm cafeteria luncheon, my chief educated me about the inner workings of hierarchy in the doctor tribe. Interns field nurse calls, consults, and patient concerns which they report to mid-level residents who report to chief residents who report to attending. In lieu of advising open, multidirectional communication amongst all members of the team, my chief encouraged a step-wise approach to conveying information and performing duties. While well meaning and true to our traditional tribal culture, this interaction, which reinforced our hierarchal norms, highlights one of the greatest barriers to truly developing a culture of patient safety. Quality improvement and culture change requires openness and buy-in from the various tribes of healthcare. Finding a way to normalize the changes required to prioritize patient safety as well as to integrate the value of quality improvement into our tribal culture is imperative. As the rising generation of healthcare providers, we have a unique opportunity to effectuate culture change while leading the generations to follow.
In reflecting on the topic of tribal hierarchy, I was reminded of the following relevant reads:
In Tribe: On Homecoming and Belonging, Sebastian Junger discusses the human propensity for ancient tribal behaviors like loyalty, inter-reliance, and cooperation. He uses the returning veteran community to outline how the absence of/ pursuit of connectedness impacts individuals. For the “doctor tribe,” we must consider how elements of loyalty and commitment to the team must be accounted for in creating a safe space and process for event reporting and process improvement. Quality improvement efforts cannot take place without accounting for their impact on and incorporation into tribal culture.
In Outliers by Malcolm Gladwell, he reviews Hofstede’s “Power Distance Index (PDI),” which considers the extent to which less powerful members of organizations/institutions (like hospitals or amongst the doctor tribe) accept and, perhaps more importantly, expect unequal distribution of power. This differential plays a notable role in healthcare due to the presence of healthcare providers and patients of varying cultural backgrounds (Power Distance Index by Country). Individuals with lower PDIs are relatively less concerned with status, and subsequently less influenced by hierarchy, as well as more open to sharing the decision-making responsibility. The converse is true of individuals with higher PDIs who may be impacted by hierarchy to a greater extent. From the perspective of the healthcare team, patient safety requires open and honest communication amongst team members, yet an individual with a higher PDI would be more reluctant to challenge or give suggestions to their superiors. Examples of countries with low PDI include the US, the UK, the Netherlands, and Germany, whereas high PDI countries include Mexico, China, Philippines, Panama, Guatemala, and most of the Arab world. Today, we learned that 40% of patient/families in one prominent healthcare system were aware of breakdowns in care and uncomfortable bringing them up. Difference in PDI plays an equally significant role from the patient perspective.
In Quiet: The Power of Introverts in a World that Can’t Stop Talking, Susan Cain points out the extent to which our culture undervalues introverts by focusing on what is loss in disregarding their viewpoint. While composed of many personality types, the “doctor tribe” is one of many dominated by the extrovert perspective. This book highlights the need for us to acknowledge the differences amongst individuals within the medical community, and to potentiate the strengths and minimize the weaknesses that lie within them.
The “how-to” guide to optimizing patient safety certainly remains a work in progress, but one thing that is definitely reassuring is the continued commitment of individuals like #AELPS18’s participants and coordinators to seeing this mission through to completion.