Will understanding work environment and organizational psychology help health care get better?
Our health care system is in crisis and needs significant change. So, I was excited to read Dr. Lisa Rosenbaum’s great February 2019 three part series in the New England Journal of Medicine and accompanied round table about teamwork in health care. Rosenbaum kicks off each piece with a story: how the Brigham’s and Women’s Hospital’s “shock team”, doctors of different specialties, worked seamlessly in a ‘remarkable interaction’, the failure of perfusionist to speak up during a heart transplant surgery when an error occurred and ultimately results in a preventable death of a young man, and a patient who was hospitalized 5 to 6 days longer because the different medical teams were “caught in an endless loop of passing the buck.” Each article then highlights classic research and findings by organizational psychologists and the social sciences to illustrate how we can learn and improve to make the care we provide even better for our patients and ourselves.
After reading this excellent series, I felt skepticism still existed from the peers she interviewed and possibly Rosenbaum herself. Was more evidence needed? Did doctors feel insights and observations from the social sciences and organizational psychologists in other settings didn’t apply to health care because we are different?
Yet, the status quo is not sustainable. As doctors we may have no choice to look for other ideas if change is to occur.
Divided We Fall
In “Divided We Fall”, Rosenbaum notes how the development of crew resource management (CRM) in aviation was developed to ensure individuals of a flight crew are each accountable to a shared responsibility. Individuals of a flight crew learn to “use all available resource – information, equipment, and people – to achieve safe and efficient flight operations.” CRM was created as a direct consequence of the KLM Boeing 747 crash into a Pan Am plane during a foggy day in 1977 on one of Spain’s Canary Islands. 583 people were killed. It was the largest tragedy in aviation history. It was from that disaster and others where aviation experts concluded that the vast majority of airline fatalities were “attributable to ‘human factors'”. Although it seems simple in its premise, CRM has improved flight operations and overall airline fatalities has fallen.
Cursed by Knowledge – Building a Culture of Psychological Safety
In “Cursed by Knowledge – Building a Culture of Psychological Safety”, Rosebaum’s describes the work of Professor Amy Edmondson of Harvard Business School, a teamwork expert. Over two decades ago, Edmondson observed that medical teams that made the fewest mistakes in the hospital paradoxically had also reported more errors. It wasn’t that these teams made more errors but rather they felt safe to report errors and more importantly learn from them. The psychological safety felt by those medical teams in speaking up and each of the individual’s willingness to “take interpersonal risks at work, whether to admit error, ask a question, seek help, or simply say ‘I don’t know'” is what resulted in the difference in team performance. Even Google, after studying hundreds of its teams to determine the difference in performance between average to exceptional, concluded it was the presence or absence of psychological safety and not how smart individual team members were, degree of extroversion, or experience of team members that mattered.
Rosenbaum also speaks to Professor Chip Heath of Stanford Business School about the “curse of knowledge”: the more we know the more we assume others know. In a 1990 study carried out by Stanford graduate student Elizabeth Newton, participants were asked to either tap out the rhythm of a well-known song like Happy Birthday (“tappers”) or to guess the song (“listeners”). Tappers were asked to predict what percent of listeners would guess the correct song. They thought 50% of the time. In reality, it was 2.5% of the time or 20-fold less than expected. What appears obvious to you isn’t obvious to someone else.
Heath notes that as medicine becomes more complicated, understandably each specialty develops its own language and that the problem of communications among doctors and patients and the “dismissive treatment” of doctors to other doctors is “‘endemic’ to specialized environments. ‘The curse of knowledge makes you think others aren’t pulling their weight. It’s hard to image not knowing what you know.'”
The Not-My-Problem Problem
In “The Not-My-Problem Problem”, Rosenbaum provides the classic phenomenon known as the bystander effect. The bystander effect is the observation that individuals are less likely to step in and help if others appear available. As a result, a “diffusion of responsibility” occurs and nothing happens. The “bystander effect” was first proposed by psychologists Darley and Latané in explaining why no one came to help 28-year-old Kitty Genovese, who screamed for help for 30 minutes as she was being stabbed outside her Queens apartment building in 1964.
Will we act?
When Rosenbaum wonders if acting on these insights will make the delivery of health care better, she runs into the usual explanations of why the health care system is dysfunctional and not getting better.
It’s lack of resources. A colleague felt that “the ideal system would require twice as many people, which would cost you twice as much… No one’s going to pay that kind of money, which is why we never really progressed.”
Health care is too complex. It’s amazing we are able to provide the level of care we do at all.
We need evidence before we try new approaches or ideas.
This last belief was expressed by Rosenbaum. It wasn’t clear she believed it or was merely playing a devil’s advocate. Note how Rosenbaum’s reflection on CRM mirrors that of many in medicine when it comes to new approaches to work, “we still have much to learn about how CRM may be best deployed in medicine”.
It was in 2000, that the Institute of Medicine recommended CRM-based training to cut down on medical errors. Now nearly two decades later, we are still wondering the best way to deploy CRM in medicine. When the aviation industry had the Canary Islands disaster, it didn’t wait for evidence. It studied the problem and then implemented change.
Optimism for change
Yet, despite my concerns and those highlighted by Rosenbaum, perhaps she shares my optimism that change can will occur. It’s possible we can work together better as doctors if we simply look to others and build off their expertise. There is plenty of evidence in other fields and organizations on the consequences for miscommunications, failure to provide psychological safety, and diffusion of responsibility and accountability. What is common in all of these examples, is that people are the ones providing the service whether doing surgery or flying planes. Knowing this, health care should move more quickly. Rosenbaum concluded her three part series in the following way.
“Medicine gives lip service to culture, but we’ve never prioritized applying the methods of social sciences toward the achievement of the culture values to which we’ve laid claim. Though historically the imperative to develop a more traditional clinical science justified this neglect, maximizing the benefits of all we’ve learned will require a new kind of knowledge, one derived from the expertise of those who study who we interact with the world around us. In the highly demanding environments of modern medicine, it often feels like the only way to survive is to put your head down and keep going. To avoid becoming bystanders to our own culture’s unraveling, we must learn to shape our social environments as much as they have shaped us.”
The real questions are: Will we? How quickly?