“Honk if you love Jesus!”
Just this evening, I informed a nurse that we would be delaying a case for 45 minutes due to a patient’s recent ingestion of liquids. Nil per os or “NPO” guidelines are logically and somewhat evidence based, and quite traditional in surgery. The allotted time made us consistent with the recommendations, but the nurse’s immediate response was rude and cantankerous because in her view of things it went against her expectations. She started a scene in front of several other staff, used provocative phrases like “you people,” and confrontational judgments like “ridiculous.” Ultimately, my attending made the decision, so all of her commentary did nothing more than insult me and create a negative scenario in front of others. She has yet to apologize.
I recently had a co-resident go downstairs to check on a patient scheduled to eventually go up to surgery. Upon seeing an anesthesia person, the attending surgeon immediately started gathering his things to go to the surgery. She informed him that she was not there to pick up the patient, but to prepare them, and suddenly found herself in the middle of what can only be described as a “hissy fit” or “temper tantrum” to anyone who witnessed it. In an inappropriate tone of voice, he began criticizing her, the anesthesia staff, the hospital, his breakfast, and anything else he could think of that could be included in his lambasting reverie.
How did the message relayed to the nurse create such negative energy? What did it accomplish, especially if wasn’t even in the patient’s best interest? Why did this bit of information, relayed to a surgical attending—a head surgeon and leader—create such havoc? What’s more, how did it further the patient’s needs?
Medicine boils down to empathy toward a suffering human that creates a blind sense of self-righteousness in the empathizer and gives them a sarcastic and critical tone towards the rest of humanity.
A nurse attempted to burden me with her indignation because of her perception that she was the only advocate for this patient. On the floor, my fellow resident went from a functioning cog in the machine to a frustrated, unfocused, and emotionally hurt unit for the same reason. What makes this issue become a real problem is the after-effect. Our frustration at being attacked spread to everyone we told. It made us less effective and distracted. It made us shorter with others. Thus, each interaction afterward created more insult, negative feelings, and slower action.
Stressed out and anxious to accomplish their goal for the patient, the nurse and attending physician took out their frustration without thinking. Both reacted immediately, and directed their disagreement at whomever they saw before them. Then, as the thinking began to expand beyond the current circumstances, they started to incorporate all the other groups (“you people,” “the hospital”) that might be involved in creating a situation outside of his and her expectations.
Had their thinking been broad in the first place, they would have seen that we are all advocating for the current patient, as well as the others we must take care of. Then their expanded thoughts produce camaraderie, not criticism.
This phenomenon of verbally massacaring the “offending” messenger occurs constantly in the medical profession. I believe that it occurs as a result of the human stress or fight/flight response. In a life-threatening situation, our danger alarms are triggered. We immediately trigger defenses and strategies to repel the threat. We hone in on the present conflict with all of our senses. Our body and mind tenses and prepares for a battle!
These things are vital in a life-threatening situation, but certainly not in a hospital setting! Focusing on one situation creates danger for the patient, and the other patients who are neglected. It ignores information, a doctor’s most valuable asset. It predisposes us to repel help, other ideas. It sets us up for conflict, eliminating teamwork. All of these issues are terrible risks!
One might think that nothing threatens medical professionals, in other words nothing triggers the fight/flight response. But our mind’s other pathways—those that process anger, bad news, frustration—overlap with the stress response. Moreover, our tired and over-worked baseline pre-disposes us to feeling easily threatened. Medical education and the medical/legal institution teaches through pressure, criticism, and judgment. The stress response becomes increasingly sensitive under these circumstances.
When someone honks at us at an intersection, if we’re honest with ourselves, our first reaction usually involves berating the individual honking at us. Usually, we have a few fleeting thoughts of that person’s car having a piano fall on it, our some other horrible-yet-deserved tragedy. Only after a moment do the other factors working their way into our head to help us “see the light.” Not just the one that has been green for 10 seconds but we missed because we’ve been texting. Instead, it’s the light shed on us and the situation: the horn isn’t necessarily a threat! Maybe our behavior caused the problem (it did in this case–text later!), perhaps that person has a pressing place to be (like the hospital?) or is simply being polite to let us know. Maybe they want us to realize we are discourteously wasting others time and providing a hazard on the road. Maybe we have a bumper sticker that says, “Honk if you love Cheez-its!”
No one honks at a PJ
The messenger behind us was right to honk, we conclude, but only after we overcome our stress response—and hopefully before we lashed out!
So why do medical professionals seem to have such a poor ability to overcome that stress response? I suspect it has to do with the nature of medicine I noted above, and perhaps some ego sprinkled in. The risks of treating other humans, the pace, the workload, the poor personal health habits, the legal and economic pressure, and everything else involved in creating the frenetic pace and the lifestyle of working in medicine all contribute. That horn’s message grates on our psyche way more when we’re leaving a long day at the office than when we just got out of a massage after a restful weekend. Under constant, intense pressure our behavior becomes reactive and instinctual. We lose our ability to contextualize our circumstances and lose perspective.
What would happen if the stress level diminished and medical pros could react effectively? With perspective, the nurse who inquired about my patient realizes that I am acting in the patient’s best interest and becomes a part of the team. If she feels a disagreement, she knows that my attending is the one in charge and discusses the issue with her. The surgeon realizes that my fellow resident is there to prepare the patient for surgery. He reminds himself that we are all dedicated to a patient’s well being, but that includes all the patients in the hospital, some of whom unfortunately have more pressing needs. He reflects upon his experience with emergencies of his own and his knowledge of the limited manpower available after peak operating room hours. He considers the hierarchy of the hospital before deciding where his concerns will be most usefully voiced. In all, he appreciates the process, finds something else to do while he waits, and later contacts the appropriate channels to see what can be done to improve the system. My fellow resident continues functioning effectively.
Where does ego come in to play? Many people in the medical profession thrive off the concept that their work validates their existence. Other work takes on a less relevant feel. Others over commit to this one thing—perhaps because they must to keep up intellectually, or because they choose to for its reward in gratitude and stature, or because that’s their personality—and so their value becomes related to their position. Sadly, bad news really does become a threat to them on a certain level.
The pugilistic verbal confrontations that occur with information exchange call to mind “anger management” issues. I’m mad my case isn’t going right now, and I’m too stressed to realize it’s the nature of the situation, so I’ll take it out on whoever is around. This is immature, does nothing to alleviate the problem, and in the end usually creates a few—and the patient and other patients all lose. Instead of driving forward with the green light and committing ourselves to pay better attention, it’s like we get out of the car and start a fight about getting honked at. There is no justification.
Not everyone will agree with this perspective.
Some people make a living off of the system’s brokenness. Others use the system and ignore the broken parts. The latter have convinced themselves that some people don’t act appropriately, or are lazy or less motivated. But they are working hard toward their personal goal, wrapped in the sheep’s skin of patient care. In fact, they might not see everyone else working hard, and in the right direction. One truly seeking to make medicine work—and therefore last—needs to focus on the really obvious broken parts. The fundamentals of why medicine feels wrong right now.
And in general, next time we hear bad news or out hackles get raised by someone clueing us in to something we weren’t expecting, we should take a minute to consider things a bit further. First, to whom will voicing our concerns be most effectively done? Second, what about the situation might we be missing? Third, what issues in our lives might be limiting our ability to step back and see the forest instead of just this single tree? And finally, what good will it do to massacre the messenger?
