When the Jewish Healthcare Foundation commissioned this project with Creative Nonfiction, we had something specific in mind. We wanted to build on a study by the American Association of Critical Care Nurses, also called Silence Kills, that highlights how health care professionals avoid conversations crucial to good patient care. Over 50 percent of the 1,700 nurses, doctors, and administrators surveyed have witnessed serious mistakes, broken rules, and incompetence, but only 10 percent ever speak up. Another 25 percent said they’d prefer to leave their jobs or even their professions to avoid confrontations about injurious conditions.
We wanted to use real-life stories to break the code of silence among clinicians about the medical errors and system malfunctions that plague health care. Built into the culture and governance of health care organizations, and exacerbated by overeager and ever-ready malpractice attorneys, is a harmful reticence to disclose, acknowledge, or discuss error. What results is a dangerous, if often inadvertent, collective complicity in harm. If errors aren’t disclosed, they can’t be fixed. Like Sisyphus pushing his rock uphill, only to have it tumble down again, clinicians are consigned to endless repetition of the same mistakes.
Why? Many fear retaliation for candor and nonconformity. But the results of ignoring serious care problems can be lethal for patients. Hiding behind myriad excuses—It’s not my fault; This situation is beyond my control; Bad things happen; I’ll lose my job and the trust of my peers—even health care workers with good intentions can be party to behaviors that range from insensitivity to negligence, from unintentional assault to manslaughter.
The Jewish Healthcare Foundation’s program-operating arms, the Pittsburgh Regional Health Initiative and Health Careers Futures, teach a quality-improvement method we call Perfecting Patient Care; its first principle is to treat mistakes and glitches as opportunities for learning, not blame. But, time and again, new trainees face demoralizing resistance from their colleagues. We had hoped to receive essays that would highlight the consequences of this professional “conspiracy,” the silent avoidance of problem solving for error reduction.
The essays submitted, however, took us into new waters. We received a host of submissions—not just from health care professionals ruing their silence on medical errors and its aftermath, but from passionate victims (patients and families) of indifferent, careless, and discourteous providers. Certainly, the power of these real tales derives from the underlying emotions—anger, regret, shame, pain—resulting from unsatisfactory care. Beyond the “sin” of silence, healers in these stories reveal a broader host of missteps: disrespect and indifference, incompetence and haste, arrogance, uncertainty, and avoidance. Sometimes what inhibited successful treatment was simply failing to listen, sidestepping complex problems that resist simple solutions, or being overwhelmed by a horror of the real diagnosis. It often turned out to be the patients’ or their families’ penchant for candid discussions that saved lives and brought healing.
Heroic as many of the patients and their families were in these accounts, they should not have had to resort to extremes to be cared for appropriately, with dignity and respect. It is fashionable, and I would personally prefer, to blame “system” and “organizational” failures and “cultures” for the misadventures in patient care portrayed here and every day in real life. But organizations are collections of individuals, each with their own will and responsibility to protect the people they serve. We need caregivers who confront error and bad judgment, who embrace candor and honesty, the foundations of a new culture of problem solving, risk avoidance, courtesy, and patient centeredness.
There are ways organizations can remove the sense of betrayal among patients, families, and workers. They can adopt a culture of transparency. Dr. Lucian Leape from Harvard Medical School often cites a recent study of several thousand doctors that showed less than half would inform a patient about a serious error and even fewer would provide information to prevent future errors of the same kind. Instead, Dr. Leape recommends an alternative culture of full disclosure in which health professionals would immediately take responsibility for an error or omission, apologize, and explain what will be done to prevent a recurrence. Evidence suggests patients, families and co-workers respond well to open acknowledgment, sincere apology, and immediate, remedial problem solving. We hope the power of these stories will inspire health care professionals to break rank and cross the barrier of silence.