Lucian Leape, MD
There are not many people who could address a gathering of medical professionals associated with one of the most highly regarded academic health systems in the country and talk to them about their part in a pervasive “culture of disrespect.” Talk to them, that is, and not be hissed off the stage. But
Lucian L. Leape, MD, is someone who can.
As Lee Fleisher, MD, chair of the Department of Anesthesiology and Critical Care, noted, Leape’s career falls neatly into two parts. A graduate of Harvard Medical School, Leape trained and practiced in general, thoracic, and pediatric surgery, and ultimately became head of pediatric surgery at Tufts University Medical Center. In 1986, however, he changed directions, becoming more involved in health policy and became, Fleisher said, “one of the instrumental people” who began to throw a light on some of the darker aspects of health care. He became a prolific chronicler of patient safety issues. Writing in JAMA in 1994, for instance, he noted that, “180,000 people die each year partly as a result of iatrogenic injury, the equivalent of three jumbo-jet crashes every 2 days.”
Understanding Why Errors Occur
In that same early article, Leape cited many reasons for the errors that harmed patients, and at Penn Medicine this month he recapitulated them. The most important reason that physicians and nurses “have not developed more effective methods of error prevention,” he wrote, “is that they have a great deal of difficulty in dealing with human error when it does occur.” But, he clarified, “It’s not because of bad people – it’s because of a bad system.” Part of the disrespect he identified in his presentation shows in the lack of action taken to reduce medical errors. There are proven ways to reduce the likelihood that they will happen – demonstrated conclusively in industry, for example – but until recent years, health professionals have been very slow to follow suit.
As Leape noted, it is not easy to change systems. Where systems have been changed, the results are impressive. Leape cited an effort at Johns Hopkins Hospital, led by Peter J. Pronovost, MD, an anesthesiologist and critical care physician, to eliminate central line infections through a team approach, preventing an estimated 1,500 deaths a year. The University of Michigan was able to duplicate those results. Here at the University of Pennsylvania Health System, the overarching Blueprint for Quality and Safety included an initiative to reduce hospital-acquired infections. Under the leadership of P. J. Brennan, MD, chief medical officer and senior vice president of UPHS, the rate of infections associated with central lines fell at the Hospital of the University of Pennsylvania by more than 90 percent in three years.
The Importance of Teamwork
And despite the increasing call toward interprofessional collaborations, Leape feels that part of the problem in health care is that “we don’t really work together well.” He elaborated: “We really have a culture in medicine . . . of disrespect,” at all levels. Leape cited several recent surveys: 95 percent of nurses said they had witnessed or received abuse, primarily from doctors. (The percentage of abusive doctors, he added, is 5.7 percent – “a small number making it bad for so many.”) Pharmacists reported condescending doctors hanging up on them. In a 2010 survey, 53 percent of medical students reported some signs of burnout; 14.3 percent experienced moderate depression; 15.2 percent considered dropping out. Part of the reason, Leape implied, was how they are treated.
As Leape suggested, the forms of disrespect in health care vary, such as passive-aggressive behavior, as shown by “autonomy nuts.” They, he said, don’t value the opinions or expertise of others. “They are not interested in being team players,” Leape explained. “It really undermines everything we’re trying to do with quality improvement.” In a 2012 Academic Medicine article, Leape drove that connection home: “Disrespect is a threat to patient safety because it inhibits collegiality and co-operation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices.”
Categories of Disrespect
Leape described a recent class of 60 that he taught, which included doctors. For the first paper he assigned, those in the class asked patients what is was like to live with severe health problems; for the second paper, they asked about the patients’ experiences in the health care system. For many of those enrolled in the class, Leape recounted, “it was a transforming experience.” Out of 41 interviews, 30 patients reported what Leape characterized as serious problems with the system, mostly because of the physicians who had cared for them. Many doctors, they told the interviewers, were rude, demeaning, and disrespectful.
In introducing Leape, Fleisher pointed out that he came to Penn Medicine both “to teach us and to learn from us.” At this point in his presentation, Leape started to ask survey-style questions of those in the audience. For example, he asked how many had witnessed demeaning and humiliating treatment. About 20-25 percent of those in the room raised their hands. Another: “is it safe to talk about your mistakes?” The overall data show that less than 50 percent of those surveyed feel it is safe, that there is still a punitive environment. With the Penn audience, Leape estimated about 60 percent raised their hands. “You’ve clearly made some progress!”
What might have been more of a surprise to those in the audience was Leape’s discussion of “institutional disrespect” as demonstrated in the treatment of both health care workers and patients. The disrespect, he said, “is baked into our daily work.” For example, Leape stated that health care workers are 30 times more likely to have an injury on the job than those who work at Alcoa – where they might be dealing with molten metal! Nursing aides and orderlies suffer injuries at four times the national average, and nurses frequently must risk unprotected contact with blood-borne pathogens.
How Would You Want To Be Treated?
On the matter of how health care professionals treat patients, Leape noted that the patient is not always brought into the decision-making. “Let me make this very simple,” he said. “All we’re talking about is treating people as you’d want to be treated.” Instead, patients often are not informed about their care. In addition, patients are often kept waiting at their appointments. Leape quoted his own cardiologist, who does his best to be on time: “Everybody’s time is important.” Keeping appointments can be done, Leape insisted. “There’s a science behind this,” informed by principles of management and efficiency. Keeping patients waiting, sometimes for long periods: “It’s totally unnecessary – and it’s disrespectful.”
As he concluded his remarks, Leape mentioned the “privilege” he had of meeting Paul O’Neill, the former U.S. Secretary of the Treasury who had been CEO of Alcoa for 12 years. How did O’Neill make Alcoa “the safest company in the world”? By treating every worker with dignity, providing support, and offering appreciation. That, said Leape, is the challenge.