Indoctrination

There was a recent article in the NYT about mortality and morbidity (M&M) conferences.  The gist of the article was this:

•  Hospitals hold M&M conferences which are closed to non-physicians during which they discuss medical errors
• These used to be conducted as screaming sessions during which an error would be identified and presented, and the person who committed it would be publicly berated by more senior physicians (and I'm guessing mistreated for quite a while after, because, well, that's just what happens).
• The idea was that if you made the person "remember" their mistakes by publicly humiliating them, then they (and others who saw it) would be less likely to commit similar mistakes in the future.
• However, at some point, someone actually studied the effects of these ritual humiliations, and found (surprise!) that people tended to try cover up their mistakes in order to avoid being singled out and publicly humiliated.  A culture of secrecy developed.  It didn't result in fewer medical errors, and in fact probably prevented the identification of systemic problems that caused errors.
• Now most M&Ms are not conducted like this.  

This rings true to me.  Think about how you would feel if someone did this to you.  Perhaps you would be less likely to commit that particular error again.  But would you be less likely to commit other errors?  Would you become obsessed with perfection and become less efficient, potentially harming other patients that way?  Would you become very anxious and isolated, and make other mistakes as a result of that?  If you did make a mistake, would you ever ask for help in trying to fix it, even if you needed it?

However, according to the people who commented on this article, any person who might have any of those responses, "needs to grow a pair," "needs to be less focused on themselves," "needs to understand that it's for the good of the patient that this public humiliation must occur," "needs to be less selfish."

They just wreaked of indoctrination.  It's like they're so far in it that they can't see with any objectivity the real repercussions of how they're acting.  You know, like the witch burners at the Salem Witch Trials (it turns out this phenomenon is pretty well studied). 

(I've seen this happen to some of my friends who are now residents, and I'm sure it will happen to me too, at least temporarily, when I do residency.)

ANYWAY.

This same person also did a study to try to figure out why residents chronically violated duty hours.  Apparently, there were senior physicians who argued that it was because these residents were slow, incompetent, and lazy.  And who wanted to fire them.  Oh!  Senior physicians also complained that other residents displayed a shift work mentality, and that other residents were lying about their hours. Yay!  Isn't it great to know that as a resident, you just can't win?

So, the results were:

The respondents did not exhibit a "shift work" mentality in relation to their work. We found that residents: (1) occasionally stay in the hospital in order to complete patient care tasks even when, according to the clock, they are required to leave, because the organizational culture stresses performing work thoroughly, (2) do not blindly embrace noncompliance with DHR but are thoughtful about the tradeoffs inherent in the regulations, and (3) express nuanced and complex reasons for erroneously reporting duty hours, suggesting that reporting hours worked is not a simple issue of lying or truth telling.

One of my least favorite parts of medicine is the tendency to ascribe negative motivations to, well, EVERYONE.  This runs the gamut from those manipulative drug seeking patients, to those horrible parents with the abnormal social history, to those lazy lying residents who don't work as hard as I did when I was a resident.  And while it's true that some people do fit those descriptions, those descriptions get cast around A LOT more often than patients -- and residents -- really deserve. 

It's really a shame this happens.  While it can't be good for residents, I can also say with certainty that it is bad for patients too.