By Bruce Ramshaw, MD
‘Vulnerability is not weakness. Vulnerability is the most accurate measure of courage. Vulnerability is the birthplace of innovation, creativity and change.’
—Brene Brown, PhD, LMSW, The Gifts of Imperfection
Mrs. George (not her real name) was not unlike many patients we see for complex abdominal wall problems. Several years earlier, she had an open abdominal vascular procedure and developed an enlarging incisional hernia. She recounts that when she complained to her primary care physician and her surgeon, she was told she was getting fat and there was nothing wrong with her abdominal wall. Eventually, she became angry because her physicians simply were not listening to her. After a while, she sought a second opinion, and that surgeon told her she had an incisional hernia. Due to its size, she was referred to our hernia program.
I first met her in the office. She was with her sister, who had recently received a lung transplant. They both had been smokers, and Mrs. George’s lungs were compromised. After our team explained the options and risks, she decided to have an abdominal wall reconstruction. Although the procedure went well, she began to develop pulmonary complications on the third postoperative day and required intubation. That was not unexpected. What was unexpected was a computed tomography (CT) scan a few days later that showed liters of fluid over her liver; she had a common bile duct obstruction and her gallbladder had perforated. We placed drains to evacuate the bile from her abdominal cavity, and she was able to be extubated soon after that. A few days later, she had a distal esophageal obstruction and required an esophagogastroduodenoscopy and dilation. The CT also revealed a left ureteral obstruction that caused pain but eventually resolved.
Through all of these complications, I got to know Mrs. George and her family. Her husband was a quiet, kind and gentle man, and her daughter was a tough and passionate woman (much like her mom). They and the sister I had met at the office were present and were supportive throughout. When patients have complications like this, surgeons sometimes try to avoid seeing the patient and especially the family, not only because of the time it takes but also because of the discomfort involved in seeing your patient suffer from multiple complications. I have done that, I am ashamed to say, many times in my career.
In this case, our patient care manager and I did try to spend extra time with Mrs. George and her family because of the suffering that she was enduring. After almost a month, Mrs. George’s anger at her primary care physician and her surgeon for not diagnosing her hernia was transitioning into an increased effort to heal and go home. In the process, we were developing a loving relationship with each other. One day, while she was up in the chair, with three drainage tubes coming out of her right upper quadrant, she said to me, “Come here, I want a hug,” and as I hugged her, she said, “I love you.” Without thinking about a response, I said, “I love you, too.” This was one of the most important moments in my maturing as a surgeon and as a person.
Love and Leadership
Many in our profession would try to convince us that we should keep a healthy emotional distance between ourselves and our patients—that it may be dangerous to care too much, and we should especially not get too close, or God forbid, love our patients. But is keeping a healthy emotional distance really the right thing to do? “Healthy distance” may actually be a facade that keeps us from being authentic and fully human to the benefit of our patients and even for ourselves.
Brene Brown, a self-described “researcher-storyteller,” is a research professor of social work at the University of Houston. After eight years of research on the topic, she characterizes being an authentic human being as having “wholeheartedness.” She defined the characteristics that produced a wholehearted human being as things such as trust, faith, hope, joy, belonging, gratitude and creativity. Sadly, characteristics that prevent wholeheartedness are more telling, and representative of our profession: perfection, certainty, self-sufficiency, fitting-in and judgment; they look like the goals of our surgical training. What do patients consistently ask for from a physician? They ask for authenticity, empathy and ultimately love, so that they feel cared for. This is especially important when unexpected complications occur.
There is a growing realization that organizational leadership in the 21st century is rapidly changing. The command and control leadership of hierarchical organizations made up of increasingly fragmented department silos is giving way to the leader as a facilitator of small teams. Other industries are realizing that the leader most likely to ensure long-term success is one who embodies the wholehearted human being described by Brene Brown. When will the health care profession realize this? In our industry, that is designed specifically to care for other human beings, why do we find a lack of love in our organizations?
As physicians, we have been inundated with “evidence-based medicine” and “quality measures,” but what is really needed in health care is evidence-based management. Creating an environment that facilitates love and empathy should be a primary focus. More than a dozen studies demonstrate that the moment when medical students begin to lose their ability to be empathic is when they step into the clinical environment. Instead of recognizing that the clinical care environment is the problem, medical school leaders have suggested identifying applicants with higher empathy for medical school admission. Evidence-based management would allow for organizational change that would foster love and empathy in the clinical care environment, instead of suppress it.
Love Does Not Exist in a Hierarchy
In the 1960s, Stanley Milgram ran a series of experiments to see if the horror of the Holocaust in Nazi Germany could be repeated in the United States. He demonstrated, based on various conditions, that up to 90% of normal adults would deliver a potentially fatal electric shock to another person while participating in an experiment to help improve learning. In his book, Obedience to Authority, about this series of experiments, Milgram describes the conditions necessary to achieve this disturbing result:
“To create this evil, a hierarchy is necessary. Authority systems must be based on people arranged in a hierarchy. Thus, the critical question in determining control is: Who is over whom? How much over is far less important than the visible presence of a ranked ordering.”
The fragmentation of responsibility allows a person to relinquish accountability to someone higher up the chain of command. For years, we have seen this erosion in the nursing profession: Nurses have given up their responsibility to the authority above them—the doctor. In fact, a variation of the Milgram study was conducted in health care: In a study in the Midwest, more than 90% of nurses in the study were going to give a fatal dose of a drug that was not on formulary (it was an experimental drug in the hospital only on a clinical trial) based on a phone order by a “doctor,” who was actually the experimenter using a name that was not a physician on the hospital staff. This is unlikely to happen today (nurses have mandates and guidelines that prevent such phone orders), but there are new authority figures that perpetrate similar harm: the electronic medical record, and more and more, hospital policy and government mandates. How many of us just give up resisting mandates and policies that make no sense when we want to avoid the hassle of dealing with some authority figure, who will label us as disruptive or a nuisance?
Developing Care Communities (Teams) With Patients
If conditions of fragmentation and hierarchy can create environments that lead to a lack of responsibility and facilitate the potential for harm, can different conditions create environments that lead to accountability and that foster love and empathy? The Robbers Cave experiment, conducted over a three-week period in summer 1954, can help us understand the potential.
A group of camp counselors (actually, the experimenters), randomly divided 22 boys, aged 11 and 12 years, into two groups. Each group was given a name and the two groups were initially isolated from one another. During this period, the counselors allowed for group bonding while each group had no knowledge that the other group existed. Then, they brought the two groups together for a variety of competitive activities. What a mess! There was screaming and yelling of derogatory comments and many fights broke out. Clearly, it was not difficult to fragment a group of boys and create perceived hatred for each other.
Then the real experiment began. The counselors created a series of obstacles and challenges that required the two groups to work together to achieve common goals, such as fixing the broken-down bus so they could go to town to watch a movie. As the groups worked together, the hatred and fear melted away, replaced by new connections and friendships. By the end of the experiment, the two groups had become one, unified by the achievement of solving problems together. This “realistic conflict theory” has been demonstrated over and over again, and the solution of having small teams work collaboratively with a common goal should have no better application than in health care.
If we can create conditions and environments that lead to bad behaviors, we can also create conditions and environments that foster love, empathy and engagement, a passion for what we are privileged to do: care for another person. These conditions, based on numerous studies, include the creation of small teams given the resources, authority and responsibility to provide care for a defined group of patients throughout their entire cycle of care. A team is not the several thousand employees who happen to be employees of a hospital or an academic medical center, a few people who come together on a certain day in the operating room, or even a departmental silo, but a small group composed of the diverse skills the patient needs; in health care, each team should include the patient and the patient’s family.
Challenges Can Bring Teams Together
In sports, teams compete against each other. In health care, our teams are designed around a group of people suffering from a health problem, and with these patients, our teams can be driven to define, measure and improve the value of care. The spirit is cooperation, not competition. To do this, we must be vulnerable, transparent, empathic and loving; we must be wholehearted persons. As physicians, we will need to be leaders on these teams, facilitating an environment that will allow us to trust and love others on our team, especially including the patient and family members for whom we provide care. Visionary leaders who will create such a unifying atmosphere are desperately needed in health care.
About 24 hours after Mrs. George was discharged, her family brought her back to the emergency room with frequent vomiting and dehydration. The next day, she developed lesions on her left buttock, groin and perineum that became one of the worst cases of shingles I have ever seen. Each day, her husband helped the nurses with the various care tasks and tried to comfort his wife. Each day, our team saw her and heard about the intense suffering she experienced: regular dry heaves every few minutes, rarely with anything to vomit, excruciating pain in the area of the shingles lesions, severe depression and a desire to be medicated to blunt this suffering. At one point, she stopped breathing and a code was called. She was given Narcan and sent to the medical ICU. She continued to have problems. Fluid built up in her lungs, and after several pleuricenteses, a chest tube was placed. Her husband and sister continued to love her and try to encourage her; our hernia team, the patient care manager and I continued to love her and her family and tried to support them in any way we could. We were a team trying to facilitate Mrs. George’s healing.
We asked for help from many other medical and surgical consultants. We even considered sedating her and putting her on a ventilator just to relieve her suffering. Over the next month, Mrs. George appeared to be giving up; the suffering had become too great. I can’t remember in my career having watched someone suffer in the hospital so much and not be intubated and sedated in the ICU.
It was at this point that another one of Mrs. George’s care team acted. Her daughter, who lives in another state, came back to the hospital when she heard her mom was giving up. I don’t think anyone else could have done what Mrs. George’s daughter did. Out of the love and special relationship they had, her daughter would not allow her mom to give up. As I write this, I am tearing up because of the power of authentic love for another human being that I witnessed. Over the next several days, Mrs. George became stronger. She requested less pain medication and participated in more physical therapy. She had hope and an understanding that the love of her daughter and the rest of us on her care team would not give up. About three months after her initial operation, she was discharged home. But soon after that, she needed a laparoscopic cholecystectomy, resulting in an additional week in the hospital. She finally is now home and recovering well.
In children’s hospitals and in hospice care, we often see authentic love. Why should we not show the same loving care for every person who is suffering a health problem? Peter Pronovost, MD, who is the head of the Armstrong Institute for Patient Safety at Johns Hopkins, is also one of the pioneers of clinical quality improvement applied to patient care. In his keynote talk at the Planetree Conference a few years ago, he told the audience what the key to patient safety and quality is. It is not a technology, like a radiofrequency identification sponge system in the operating room, and it is not a strong group of managers implementing mandates and checklists. He said the key is found in loving our patients. I would only add that in order to do that, we need to design the system conditions that will allow our care teams to be in loving environments, facilitated by visionary leaders.
This is the last article in a series I have written about complexity science applied to health care [October, November and December 2013; March and April 2014]. You might notice that complexity science is not mentioned anywhere in this article. You might think this last article is a bait and switch, just to get this touchy-feely subject published. If you think that, you are wrong. At the core of complexity science is the principle that all outputs of a complex system come from simple rules. As human beings, we have the option to make choices based on two basic rules: Shall we act out of fear and defensiveness or out of love? These two basic responses actually come from different parts of our brain: fear from the amygdala of our lower brain, and love from our higher cognitive structures. When we react out of habit and defensiveness in response to stimuli (read: “existing structure”), we behave in the way that Brene Brown found prevents us from living a wholehearted life. When we act motivated by authentic love, our actions can create different exciting life-giving, long-term results. Imagine if we had the conditions in health care to regularly act out of authentic love.
Dr. Ramshaw is chairman and chief medical officer at Transformative Care Institute (nonprofit) and Surgical Momentum LLC (for profit), and co-director of Advanced Hernia Solutions, Daytona Beach, Fla.