Mean spirited insults close off the necessary wisdom, communication, and relationships so necessary in complex healthcare
The recent trending Twitter hashtag, #DoctorsAreDickheads, started after Stevie Boebi posted a YouTube video describing the time it had taken to reach a diagnosis of her medical condition. The resultant social media response became, as it so often does, an unruly dogpile. In this case, it was the medical profession squashed at the bottom. Next time it could be any convenient target group: nurses, teachers, policemen, lollipop ladies. In this particular iteration, what followed were hundreds of stories describing wrongful diagnoses, erroneous treatments, missed opportunities, and especially how the white coat brigade were individually and irrevocably to blame.
We do not for one moment question the sincerity of Ms Boebi’s frustration, or that many others have suffered from medicine’s imperfections. What we take umbrage with is the overly convenient cause and effect. It is rarely an individual doctor’s inadequacies that cause such problems: it takes a village, after all.
Moreover, has any situation ever improved by calling someone a dickhead? Instead, this sort of language leads to an arms race of finger pointing, excessive shouting, and inadequate listening. Dismissing somebody as a “dickhead” is also virtually tailor made to encourage backlash. Some doctors took the bait and argued back, pointing out that some patients fail to give a clear history or understand the diagnosis even when it is fully and compassionately explained, or even fill their prescription. This blame game should not be tolerated from either side of the erstwhile healthcare partnership. This is why we would all be rightly appalled if there was, for example, an equivalent hashtag about patients.
“My doctor is a dickhead” represents the perfect get out of jail card for the 21st century. Welcome to the age of “it’s not my fault, it’s yours,” “I’m great but you suck,” and “if I don’t understand then you didn’t explain.” Welcome to a world where insulting somebody has morphed into empowerment. These two authors are not only tired of this, we are also scared by how easily patients and providers inexorably drift apart.
Specious accusations are all too easily heaped on anyone in authority or with a tough job to do. It is just that the result of medical mistakes is that much more critical than in many other professions, and being sick is that much more rotten to begin with. Medical errors—or what can be better understood as human errors in a medical environment—can be truly awful and sometimes lethal. To wrongly attribute the root cause to a fallible individual, however, is to squander the opportunity to meaningfully improve. Although we get the human need for blame, more important is what is the collective plan going forward? This should start by accepting how complicated healthcare can be. Next let’s encourage behaviour that builds rather than tramples.
We have previously discussed how, even deep within the whizz bang world of intensive care medicine, arriving at the correct diagnosis is difficult and imperfect work. Even where no expense is spared, no test is skipped, and no consult foregone, we do not always pinpoint a treatable condition. Humans and their myriad of presentations are eye wateringly complex. This is why up to half of our medical diagnoses may be ultimately wrong or incomplete. Moreover, more testing can make it more wrong as well as more right. After all, those tests are as imperfect as humans; false positives and false negatives abound. Medicine is as much a philosophy for dealing with uncertainty and managing probabilities as it is anything else. It is not, however, an exact science.
Regardless, to get closer to the correct answer, all of us should recognise and overcome ingrained cognitive biases, and we will name (and shame) only the top two. There is the anchoring bias (i.e. the patient with “sepsis” who actually has acute gallstone pancreatitis) and the confirmation bias (“ah yes, it does look like pneumonia on the chest x-ray” in the patient, for example, with systemic lupus erythematosus related diffuse alveolar haemorrhage). These biases are why the good doctor does not rest on their assumptions, their laurels, or their backside. Instead, we must challenge (and rechallenge and rechallenge) ourselves and our co-workers to search for alternatives. We must be similarly energised when it comes time to treat. We must attack and soothe on all fronts: therapeutically, psychologically, and compassionately.
Clearly this is hard. Just as clearly, it doesn’t get any easier if our patients really do think we are “dickheads.” Moreover, overtaxed and under-resourced systems encourage error. Similarly, human brains look for comfortable and familiar patterns whether they be patient or practitioner. All of this means that what we needed is not the soothing comfort that comes from individual blame, but rather the hard graft that comes with accepting collective responsibility. Our systems need checkpoints, fail safes, and predictability, but above we all need to commit to making things better not worse. In an effort to remove emotions from medicine, we could all—doctor, nurse, patient, caregiver—learn a thing or two by following Dr Atul Gawande, and joining his “Checklist Manifesto.” Good checklists can free our attention from the mundane and make sure that important steps are never missed. Unfortunately, bad checklists can make us unthinking and automatic.
There is an assumption that doctors should just tolerate these insults, but what is less well understood is the profound and harmful nature of rudeness. Mean spirited insults close off the necessary wisdom, communication, and relationships so necessary in complex healthcare. We should all get more comfortable with life’s hardest sentence: “I don’t know.” Nobody gains by leveling harsh accusations at fallible humans, regardless of their proximity or salary. Doctors are not dickheads, we are just heads, and, like our patients, these heads are connected to hearts.
Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine and head of research and development at University Hospital of Wales, and an editor of BMJ OnExamination. He is on Twitter: @Matrix_Mania
Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb
Competing interests: None declared.