Medical Safety and the Arrogance of Doctors

As American hospitals work to reduce the number of deaths from mistakes in treatment and diagnosis, hospital infections, and other banes, they run up again and again against the same obstacle to reform: the arrogance of doctors. Here is Dr. Peter Pronovost of Hopkins, an expert in hospital safety:

A few years later, when I was a physician and after I’d done an additional Ph.D. on hospital safety, I met Sorrel King, whose 18-month-old daughter, Josie, had died at Hopkins from infection and dehydration after a catheter insertion.

The mother and the nurses had recognized that the little girl was in trouble. But some of the doctors charged with her care wouldn’t listen. So you had a child die of dehydration, a third world disease, at one of the best hospitals in the world. Many people here were quite anguished about it. And the soul-searching that followed made it possible for me to do new safety research and push for changes.

Question: What exactly was wrong here?

As at many hospitals, we had dysfunctional teamwork because of an exceedingly hierarchal culture. When confrontations occurred, the problem was rarely framed in terms of what was best for the patient. It was: “I’m right. I’m more senior than you. Don’t tell me what to do.” With the thing that Josie King died from — an infection after a catheter insertion, our rates were sky high: about 11 per 1,000, which, at the time, put us in the worst 10 percent in the country.

Fortunately doctors are beginning to understand that the push for patient safety is not just about questioning their competence or undermining their authority. These problems are systemic, and no one person can insure the patient's safety by him or herself. The use of checklists for common procedures like catheter insertion can produce dramatic improvements in outcomes.

Sometimes very simple steps can have big effects:

At Hopkins, we tested the checklist idea [for catheter insertions] in the surgical intensive care unit. It helped, though you still needed to do more to lower the infection rate. You needed to make sure that supplies — disinfectant, drapery, catheters — were near and handy. We observed that these items were stored in eight different places within the hospital, and that was why, in emergencies, people often skipped steps. So we gathered all the necessary materials and placed them together on an accessible cart.

But, again, breaking down the arrogance of doctors remains key:

We said: “Doctors, we know you’re busy and sometimes forget to wash your hands. So nurses, you are to make sure the doctors do it. And if they don’t, you are empowered to stop takeoff on a procedure.” . . . in four years’ time, we’ve gotten infection rates down to almost zero in the I.C.U.