Upend the Hospital Hierarchy

In less than a week, I've read two newspaper stories that told tales of doctors behaving badly. The first, from Kaiser Health News, recouned how a surgeon accidentally broke a surgery tech's finger because she was so angry the tech had given her an incorrectly loaded device to use.

In another, a nurse wrote a blog post for The New York Times about an incident in which a doctor, known for his bad temper, yelled the word "Why?" in her face when she questioned his judgment about a patient.

"This was intimidation, plain and simple," the author, Theresa Brown, wrote. "But it was also an example of a doctor's abusing the legal, established hierarchy between doctors and nurses."

The fact that doctors sometimes don't take nurses seriously, and that doctors sometimes rebuke nurses for questioning their judgment, isn't news. Both of these stories are among the many that describe doctors yelling at nurses who second-guess them, doctors berating nurses for paging them in the middle of the night, and doctors causing (or nearly causing) patient harm or even death because they didn't bother listening to their nurse colleagues.

In reading the post, titled "Healing the Hospital Hierarchy," I found myself thinking, not only about the terrible position these nurses find themselves in when physicians refuse to listen, but also about the word "hierarchy" itself. Is a hierarchal mentality among physicians and nurses really the best way to care for patients?

Brown writes:

Most people in health care understand and accept the need for clinical hierarchies. The problem is that we aren't usually prepared for them; nor are we given protocols for resolving the inevitable tensions that arise over appropriate care… Nurses cannot give orders, but they are considered the "final check" on all care decisions that doctors make, and we catch mistakes all the time…if the physician won't [recognize the mistake and correct it], the nurse's only fail-safe option is to refuse to perform the order.

Let's think outside the hospital for a minute. The three branches of U.S. government aim to provide each other with checks and balances, ensuring that one branch of government doesn't chug forward alone, reckless and unchallenged.

Although our government doesn't always function perfectly, we live in a democracy, not a dictatorship. There's no lone person pulling the strings, calling every shot. There's no one single-handedly declaring war or making it illegal to wear yellow on Tuesdays. The U.S. president may be the commander-in-chief, but he doesn't govern in a vacuum or operate alone.

In my middle school social studies class, the three branches of government were illustrated with a circular graph showing arrows pointing in a loop, not with arrows pointing down a chain of command.

This structure suggests that each of the branches is equal and illustrates the checks and balances they provide. Their functions are different. How they operate is different. But they are equally necessary to the functioning of the whole government.

In light of that, the current top-down structure of patient care—where power starts with physicians and flows down to nurses—is flawed.

Wouldn't it be nice if hospitals could rethink hierarchies, instead of simply "healing" them? Wouldn't it be nice if hospitals used a circular graph to illustrate the roles of physicians and nurses, showing that both groups are equally responsible and accountable for patient care?

Wouldn't such a change in mentality help squash the notion that nurses can't challenge physicians and instead remind them they can and should challenge them when needed? And wouldn't it remind physicians that nurses aren't being "insubordinate" by doing so?

Adopting such a structure would require a huge shift in mentality; but it wouldn't change physicians' and nurses' roles and responsibilities. It would simply re-affirm the need for checks and balances, and challenge physicians to operate as part of a democracy, not a dictatorship.