Speaking Up to Hierarchies

Getting decisions made with enough sources of data is important for all of us. I have just come across another example within the medical field, where the impact of this is perhaps more accute since it can end up being a life-or-death issue, or at least a quality of life issue for many people.

While many of us think of doctors as highly intelligent and highly trained -- which they are, we usually then assume that they will be in positions to generate incredible leverage in decisions on patient care -- which they do. However, in important clinical settings there are groups of doctors involved in decisions about care; in these situations it turns out that issues of status and hierarchy play out as they do in many organizational contexts. Questioning the "assumed standard" of a brilliant researcher or a senior surgeon becomes very difficult, according to two recent posts, here and here.

image: Dartmouth Medicine, 2004

Here is an exerpt from the first post, by Dr. Pauline Chen in a NY Times medical blog:

Even as some clinicians attempt to compensate by organizing multidisciplinary meetings, inviting doctors from all specialties to discuss a patient’s therapeutic options, “there will inevitably be a hierarchy at those meetings of who is speaking,” Dr. Srivastava noted. “And it won’t always be the ones who know the most about the patient who will be taking the lead.”

It is the potentially disastrous repercussions for patients that make this overly developed awareness of rank and boundaries a critical issue in medicine. Recent efforts to raise safety standards and improve patient care have shown that teams are a critical ingredient for success. But simply organizing multidisciplinary lineups of clinicians isn’t enough. What is required are teams that recognize the importance of all voices and encourage active and open debate. (my emphasis)

Since their patient’s death, Dr. Srivastava and the surgeon have worked together to discuss patient cases, articulate questions and describe their own uncertainties to each other and in patients’ notes. “We have tried to remain cognizant of the fact that we are susceptible to thinking about hierarchy,” Dr. Srivastava said. “We have tried to remember that sometimes, despite our best intentions, we do not speak up for our patients because we are fearful of the consequences.”

As Dr. Chen notes, there is the need to build in ways that medical teams encourage active input of all points of view in spite of fear of the consequences to rank and status. Sound familiar?

Here are some methods to encourage this:

• setting team agreements on debate, multiple POVs
• modeling by senior staff
• active after-action review of gathering/listening for points of view and the effects on care
• checklists for potential contraindicators.

What does your organization do to make sure questions are considered before critical decisions?