A More Egalitarian Hospital Culture Is Better for Everyone

So, well managed hospitals do better than poorly managed hospitals.

I really wish nurses and doctors were a team. There's a lot that I, as a resident, can learn from the nurses. It's the rare nurse that actually tries to help you. When a nurse knows something you don't, expect it to be lorded over you. When you know something they don't, expect resistance. I've had nurses paging me in caps. Why? There are some kind, friendly nurses. Just as there are some kind, friendly doctors. I'm not sure if I'm having this experience because I'm a black resident in a white hospital.

I wish nurses were nice to me, but they bully residents. Then the residents become attendings... And don't start me on the labor and delivery nurses that make the residents cry.

I realize it's pointless to post this in the New York Times, but the "team" concept in healthcare is just a bunch of hooey to justify a single bundled payment to hospitals and cut out the doctor. The EKG anecdote is actually the perfect example. First of all, if the CEO didn't know he had bad outcomes because of poor data transmission times, he should have been canned a long time ago. (Frankly, I doubt that; it's much more likely the staff has been complaining for a while about not getting EKGs promptly and he didn't want to spend the dough to fix the problem until the study came along and provided it.) Second, who read the darn thing and instituted the appropriate therapy? The doctor, my friend. It's unlikely outcomes improved because data was transmitted faster; it's much more likely outcomes improved because the study caused people to actually focus on improving outcomes! There is no doubt that the abuse I was subjected to 25 to 30 years ago has no place in today's society, but medical care is best delivered when board certified experts steer the ship for the good of the patient, society's overall cost/benefit ratio, the institution, and the team. Think Cleveland Clinic and Mayo Clinic. Or, alternatively, maybe we could get reality TV show stars to do run things. Oh, wait...

Although your call for more equality in the sharing of responsibilities is most welcome, at the end we may lack the perseverance to drive things rationally while patients react emotionally, so that each patient benefits in real time, as opposed to the concept of quality of care by following lists (as important as they may be) of things to do...in due time. And the larger the 'elephant' (hospital) the less pliable it may become. Many of today's CEO's are not trained as physicians or nurses and that may be a liability. As you know, pioneers have tried to change things for the better, but with mixed results to change our 'culture' of entitlement (by authority). Just look at the simple task of washing our hands, cleaning the door knobs or our stethoscopes, is like pulling teeth sometimes. A good start is sharing our accomplishments by assigning each individual, however low in the totem pole, the proper role a team effort demands, a more fluid participation and contribution. It has been applied to the ICU's but not as much to a regular ward and patient's room. Patient outcome is the final arbiter, showing where we are and the distance yet to go. Assuming there is the will to excel, it will take passion to apply what's required, courage, hard work and persistence. As, no doubt, you are doing already. No easy task, especially when today's patients requiring admission may be sicker, older and with more complicated disease issues that ever before...and with less money to spare.

I get asked my opinion all the time, but nothing ever happens. I get overruled by people with far less knowledge and experience working in administration, traditionally the ones at the bottom of the totem pole. How’s that for overturning the hierarchy?

Many organizations have this particular problem...the military as well. Glad to see someone is taking charge on it, and improving job related outcomes in a way more substantial than cherry picking one stat and optimizing all functions relative to it (usually at some indirect greater cost to patient)

I served as a chaplain intern in a hospital with a good reputation for respect between the various disciplines: nurses, physical therapists, physicians, surgeons, case managers, cleaning staff, chaplains, administrators, and so forth. A chaplain is a great job in a hospital for just watching what happens. I learned, for example, that the cleaners on a unit are good people to ask “what’s up on the unit today? Who could use a visit?” This hospital happens to be highly desired by new medical school graduates in the residency match program. So, some of the “July docs” have always succeeded at everything. They arrive with a high (and mostly justified) regard for their own skills, and an imperfect understanding of teamwork. Sitting in the corner in various team meetings I had the pleasure of seeing the light dawn on a few of these folks. They learned that working together makes everybody’s life better, especially patients. The lead pathologist gave a presentation to our intern cohort. He explained that his job is a form of quality control. He said he gives the specialty care teams (cancer, heart, kidney, etc) information they can learn from. He asked us chaplain interns to keep that in mind when sitting with recently bereaved families, to know that patients, even in death, are the source of wisdom in that hospital. If I or a beloved family member ever needs a hospital, that’s one to hope for.

I thought this was a great article but there’s a key piece missing in your suggestion to change culture: the patient. I sit on a patient advisory council at my local hospital. I have for 1 year been a part of a restructuring of the maternity department and I am a local patient not working at the hospital. I am an integral part of the team and my voice is heard and valued. I go to all their meetings as part of the Redesign. The coalitions at these hospitals should include the voice of the patient as well and at least have one local patient sit on the council.

Hospitals reflect the society in which they operate, especially regarding hierarchy and leadership. In a latin country with moderate respect for rules like France, a more egalitarian functioning has lead to disorganization. This is what we have experienced in the last 50 years: nobody takes orders, meetings replace actual working time. In "anglo saxon" countries, people are more respectful of rules and there might be some place for more "egalitarism" in the organization of hospitals. What is sad is that in both systems, the patient is at the lowest point of the ladder...

It is possible for a respected surgeon at a hospital to continue to be respected and powerful to perform not so successfully and continue with his stature because nobody says anything bad about another doctor especially if he is viewed well . He can continue to do poor work for a long time because nobody is keeping score.This can happen at the best hospitals in the U.S.

I hear clinical people turning this into an argument over status and power. It is not that. What matters is the best clinical outcome to the patient that is as minimally invasive as possible - in terms of time and money spent as well as recovery of health. In our system, if the care is wasteful, hospital may get paid more, but often patients go home with prescriptions and other aftercare instructions they lack the time, money or focus to take as directed. After patients leave the hospital, generally those who provided services have no idea how well things go for their patients, unless things go so bad they are rehospitalized for the same condition. Do Americans live long and in good health? Actually life expectancy in the US has been in decline and more people are living with disabilities, chronic diseases and medical debt. For some mental health conditions, many or most people don’t get any care, given the barriers payers have created to reduce use of services to get profit. It is on thing to talk about teamwork, but the only person who is aware of how patient is doing over time is the patient. They are the general contractor of their health - teams need to organize around them, ask lots of questions and listen. Living wills are one example of patients saying what they do and don’t want, but they are not a standard of practice, but the exception. If providers want big gains in outcomes, don’t expect to get there without doing things differently.

I thought an "egalitarian hospital culture" was going to mean patients were all treated the same regardless of their ability to pay.

This can only happen if the participants are honestly open minded, admit that the current system could be improved, set realistic goals (short & long term,) and advocate for all - no one is better, just different, all have a voice. If the facility already has a history of giving lip service to trying to get various department opinions on matters and end result shows they never intended to listen, then no one will be willing to join this new effort. Example - building a new wing with sample patient rooms. Housekeeping notes difficulties with location of equipment and fall possibilities, electricians note locations of plugs out of reach in an emergency, etc., but then the architects just go ahead with their 'design.' "Never again" would any of the employees participate. Unfortunately, as more and more hospitals are being bought out by large corporations, employees are feeling more and more disenfranchised and morale is collapsing. Lack of respect is increasing for everyone including the patients, physicians complain nurses are obstructing, fear of losing a needed job silences many. As for the pre-surgery in OR check list, which our residents developed and studied, it worked great for a while, but then like many changes, staff & physicians got impatient and the list was rushed through...Without strong leadership, feedback, and continuing education, this too will fail.

I guess this is why I never did anything about my hernias! 3 other things people working in hospitals should do: listen to the patients WASH YOUR HANDS sterilize instruments These three basic things could save a lot of patients.

This was a wonderful article, but I'd add 1 thing to it: the patients' input. Some doctors, perhaps unintentionally, look upon a patient's views as, "Whom do you think you are? " I'm the one who has "owned" my body for quite some time now, and even though x-rays don't show a problem, I know when something is wrong, and I've been right every single time.

The more we corporatize medicine, the less we can expect to see the ideals of Agile implemented. Communication, teamwork, evidence based change, change based on real situations and needs. Medicine is already driven by protocol - some evidence based and some there to give the lawyers a basis for defense - and not by collaboration. We do need to see communication - not just better communication, but basic communication - between different specialists, and better communication with patients. I cannot begin to describe the goat rodeo a friend was treated to, as her cardiologist, radiologist, oncologist and surgeon took months to determine a tricky treatment. The problem was that they could not communicate or collaborate easily or on a timely basis, because her case was not standard, did not fit protocol. Even as medicine has become compartmentalized with different doctors experts in different systems, the problem of collaboration gets trickier. Who did my friend rely on to get it all coordinated - to get the answers? Her oncologist's nurse, of course.

Make health care cash only, then there will be positive change.

As a medical trainee, I broke "rules" - traditions that made little sense to me. For instance I sat down next to patients when presenting (it's intimidating as a patient having a large group of docs look down on you), led my team rounds based on patient urgency rather than location, and defended my intern when he was yelled at publicly by an attending for no clear reason. Fortunately, I was more often supported and even praised than punished. As a doc, I try to listen to the nurses, especially lower ranking nursing assistants who often spend the most time with patients.

The Doctor and the nurse are a team that work together to resolve the patients health issues...but it is the Doctor that is in charge. The doctor thas the superior education and training. the nurse is there to assist the Doctor...not to be a consultant. When I go online to research health care providers ...I do so by looking up the Doctor...his/her Educaton, Training, Awards, Years of Experience, Patient reviews, Complaints and Corrective actons. The assumptution has to be made that a good doctor will surround himself/ herself with well trained nurses. A good nurse is not a star player but a good support player that helps the medical team lead by the doctor to deliver good health care outcomes

"institutions where nurses are asked regularly for their input and chief executives hold regular meetings with clinicians to review patient results" Is this what you are advocating for? Are you kidding?!? As an MD in a system very much based on this approach, the only outcome I've noticed is more and more unecessary tests, procedures, medications PUSHED onto my patients as a result of nurse/hospital administrators who's only bottom line is to generate more revenue for their hospital. Put medicine back in the hands of the doctor. Give the doctor the TIME and space needed to provide each patient with the equal amount of TIME s/he needs to communicate their illness/needs. That is the solution to our current crisis. Not more mid-level managers further obstructing the doctor-patient relationship.

"institutions where nurses are asked regularly for their input and chief executives hold regular meetings with clinicians to review patient results" Is this what you are advocating for? Are you kidding?!? As an MD in a system very much based on this approach, the only outcome I've noticed is more and more unecessary tests, procedures, medications PUSHED onto my patients as a result of nurse/hospital administrators who's only bottom line is to generate more revenue for their hospital. Put medicine back in the hands of the doctor. Give the doctor the TIME and space needed to provide each patient with the equal amount of TIME s/he needs to communicate their illness/needs. That is the solution to our current crisis. Not more mid-level managers obstructing the doctor-patient relationship.

My husband spent 140 days over the course of a year and continues to have chronic medical issues. The poor communication and hierarchy endemic to the health system has been frustrating. My son noted that hospitals are like English country houses: each staff member has to wear a specific costume that communicates their status except the doctors who as lords of the manor wear their own clothes. And only the lords get called by their titles. Everyone else, including the patient and family, is called by their first name, just so everyone knows who is important and who is not. Nurses and patient care techs who work closely with patients are never part of doctor's consults with patients, even though they may know much more than the hospitalists who spend 5 minutes with a patient. And specialists who think only about their area. A broken system.

As others have said here, this is probably how any good organization should run. If only there were good studies to show how "Leadership Saves Lives" in our government and compared Obama to Trump.

What you describe in this article is the way any large organization should run. Unfortunately, the corporatization of Healthcare has resulted in just the opposite. Part of the problem of physician burnout is administrative bloat with too many midlevel managers all trying to justify their jobs while adding nothing of value to the care of patients. Doctors and nurses are on hospital committees to create the illusion on empowerment, but the decision making in the systems I have worked in is always top down. Physicians are seen as entities to be controlled rather than partners. Sadly, I don't see any of this changing.

Oh boy! Just what I love: More meetings! "... regular meetings that bring together hospital staff members from all levels and disciplines..." As anyone in the medical field knows, meetings are the solution to every medical problem, and the glue that holds all of those little moments between meetings together. When can I retire?

The superiority of a non-top-down, non-siloed organizational model is not unique to hospitals and has been recognized as such for quite some time in many, many fields. How to get there varies. It is interesting to see that this is one potentially successful model for doing it in hospitals.

The term “egalitarian” used in the title doesn’t convey what I see as the main point of the article. That is good communication of problems and solutions between the different staff members, patients and administrative staff. The article doesn’t call for elimination of valid distinctions between say, a physician, nurse, respiratory or physical therapist, nutritionist and lab technician. Stephen Rinsler, MD

Medical care is a team effort.

When I trained, nurses were usually specialized to specific areas of the hospital: cardiac nurses worked on the cardiac floor, oncology nurses worked on the oncology floor, etc. These nurses developed enormous clinical insight because of intense experience with their subset of patients. Nurses taught me a great deal and I felt very comfortable absorbing their knowledge into my training. It helped a lot. Nurses are not widgets they are really knowledgeable and responsible humans. The shift to making nurses working on any floor that needed a nurse, for financial staffing reasons, was a very very bad idea. I hope it has been discontinued. Working with and listening to nurses was a great part of my medical education.

And who is listening to the patient?....

This is not surprising and it's not just a culture in hospitals. What has happened is that the work force is no longer trusted to make judgement calls. Some of this has been a result of legal actions taken due to poor judgement calls - lawyers for hospitals and schools are VERY protective and don't want anyone other then the very top layers to make decisions, and only with their "okay". Much of this is justified as there is very little critical thinking taught at any level of education these days. And if it's not taught, it doesn't happen and serious consequences can happen. Call centers read a script. Doctors must order multiple tests in order to get insurance to cover something they could have diagnosed with good clinical skills. It's happened as many doctors don't have those clinical skills. It's all part of the dumbing down in this country. A fast food order taker cannot be trusted to enter the correct dollar amount for food, so a picture is put on the keypad to "idiot-proof" the process. And it just continues up the food chain from there. Until we change how we educate, we cannot safely implement very many of these highly efficient ways to do business and practice medicine.

Wow. Just wow. Speak of the elephant in the room. When this push towards 'egalitarianism' occurs in the healthcare industrial complex, it means one thing and one thing only: beat up the physicians. Tear them down. Take them off the pedestal that others imagine them to be on. Attack them till they crumble and disappear. Why?How could this be good for anyone? It's illogical, and of course destructive to us all, but it fulfills the need of some to tear down and destroy those who have achieved more than them. Those with the learning are now lorded over by those without. The latter have a hefty dose off envy and personality disorders. Combine that with power, and you have psychopathy run amok. I noticed how the author adroitly managed to avoid using the term physician, and uses the word doctor only twice, towards the end. The rest of the article is filled with euphemisms. 'Clinicians'. 'Providers'. Physician burnout is now rampant. After going through eons of training, everyone treats them like less than dirt. Disempowered and without autonomy - but they're still blamed for everything. A well run hospital would cherish its physicians and make sure they're treated well. It would cherish its nurses, and its techs, and its cleaning staff. Everyone would know their role in the team, and would support the others in their work. It's all intended to heal sick people, after all. Kumbaya.

I suspect that the size of the organization can have a huge impact on the success of this. The 300-bed community hospital where I work provided top-quality care, made money (imagine!), and - this was so important - the staff all knew each other. Whether you needed help getting an invoice paid, scheduling a patient, getting a computer fixed, selecting drugs for the formulary... there was someone you knew you could call and work it out. Then we were gobbled up by a huge academic medical center, whose quality scores and financial status were inferior to ours. Employee benefits were cut. Managers from "downtown" were sent out to run our departments. New computer systems were imposed, incompatible with legacy systems, and policies were changed so that not only did you not know who was in charge of IT any more, you were specifically forbidden to call them. It used to take 4 days to get an invoice paid - now it takes 4 months. Within 5 years, we were told to make budget cuts in the tens of millions of dollars, and 100 people were laid off a few weeks ago. Culture change, indeed. Be careful what you wish for... and why.

The benefit to patients of having many different eyes, and different kinds of eyes, on you is demonstrated in medical error rates, near hits, overall quality of healthcare. Someone once said how sad and ironic that the very scientific field of medicine does not treat the delivery of care as a science. If they did, they would flatten hierarchies, embolden nurses, aides, housekeepers, dietary assistants, EKG techs, you name it. Everyone would be empowered to heal.

The wall between doctors and nurses is an antiquated, gender driven division which does in fact detract from patient care. The solution is to create a bridge between the nursing profession and the medical profession. First, the archaic term 'nurse' needs to be changed to 'Medical Associate'. Then a pathway for this profession to become medical doctors needs to be generated. Working in the hospital should provide clinical credit towards a medical degree. This combined with required online courses would allow 'medical associates' to take the required tests to become physicians. This opportunity would put this profession in a whole new light.