Qualy #125 - Hierarchies in healthcare, physician burnout, and a broken system
Episode Stats
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Summary
In this bonus episode, Dr. Peter Atiyah talks about the importance of respect for authority figures in medicine, and why it's important to have a good relationship with them. Dr. Atiyah is a cardiologist at the Veterans Administration Medical Center at the University of California, San Francisco. He's also a professor of internal medicine at the Johns Hopkins University School of Medicine.
Transcript
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Welcome to a special bonus episode of the Peter Atiyah Qualies, a member exclusive podcast.
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The Qualies is just a shorthand slang for qualification round, which is something you
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do prior to the race, just much quicker. The Qualies highlight the best of the questions,
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topics, and tactics that are discussed in previous episodes of The Drive.
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So if you enjoy the Qualies, you can access dozens more of them through our membership
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program. Without further delay, I hope you enjoy today's Qualies.
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I had a similar experience at UCSF when I did a graduation speech that actually launched
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my whole career as ZDoggMD because I later put it on YouTube. It's in my 1999 UCSF graduation
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speech. It's there. It's all captioned and everything. And I just went through it as I saw it, and it
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was all just like, this is bullshit, this is bullshit, this is bullshit, this is why, this
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is bullshit. It's about actually connecting with our patients, isn't it?
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And the majority of the faculty behind me were just like stone-faced for 90% of it, and then
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finally start to crack. And you see Michael Bishop, who's like a Nobel Prize winner, finally
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he's like... And afterwards they were like, that was very well done. But there was one
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guy who was like, that kid shouldn't be allowed to graduate, and actually was lobbying to have
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my graduation revoked for giving that speech. I mean, so this is the thing. It's a hierarchy.
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And I can tell you don't like hierarchies so much.
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I probably have more respect for it than you, actually.
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Yeah, I don't... I don't know. I feel like I'm not as... I don't bristle as much at it
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as probably some people. I mean, I would say for a surgical resident, I respected it much
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less than the other residents, and I definitely got into trouble on a few occasions as a result
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Yeah, I've met people who completely have absolutely disregard for any hierarchy, and
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many of them go on to just do the most amazing things. So I always felt like I wish I had
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Well, you know, it's a complex thing because I think certain personality types don't like
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to be in the middle or bottom of hierarchies. They either want to be on the top or they want
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to be off the hierarchy. It's hard for them to feel like other people are controlling
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them or they're beholden to others in the higher hierarchy. And they either have a tendency
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to dominate those underneath or to treat them as equals inappropriately, in which case the
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lower down in the hierarchy don't have the competence. And what they need is actually
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to be trained and lifted and supported. And instead, it's like, why aren't you at the
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level that I'm asking you to be? And so it's interesting. It becomes tough in the higher
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I think the problem I had in residency was I really loved hierarchy when I could respect
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the person I was reporting to. So, you know, luckily I did my residency at a hospital
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where most of the residents were just exceptional. So it, for the most part, was really easy to
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respect the hierarchy. But the problem was when I encountered somebody and I didn't think
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that they were good enough or smart enough or knew enough, I wouldn't hesitate to just
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steamroll them. And that gets you into a lot of trouble.
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I saw that in you when you were a medical student. I remember it. It was one of your
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characteristics that I actually respected a lot. Because again, like you said, and you kind
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of described our team pretty well. And the person at the top was fairly narcissistic.
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The one in the middle was kind of a non-entity. Then there was me, who was the class clown.
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And then there was you. And it speaks to our medical training in general that it really
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is about kissing the ring of the authority figure. So one day you will be the ring that's
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kissed. That's the majority of our training. The first two years, we're fed a bunch of information,
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50% of which is wrong, but they don't tell us which 50%.
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And then the 50% of the residual will be outdated by the time you finish.
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Exactly. So it's 100% bullshit. And yet we're expected to kind of suck it all in and regurgitate
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it with respect for this hierarchy. And we don't ask questions. We don't step out of that. And
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you're right. You have to respect your authority figures, which is important when you trust and
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respect them. But when you're questioning things like, why are we doing this? Why are we giving
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Lasix to this person? Or what's going on with this renal failure? Actually, what about the root cause of
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that? You start asking this question. No, no, no, no, no. That's when I was told, hey, you speak,
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then think you should reverse that. They don't want to hear that from a medical student. And
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we had the short white coats and everything. You guys had the long white coats. It wasn't as
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It was very unusual. Yeah. I didn't realize how, quote unquote, special that was until I saw that
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there were many programs where even the interns were still in short white coats. And I didn't
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realize what a big deal that was, how much obsessing went into the white coat thing. I feel like an idiot
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even just voicing this right now, because I've never thought about this for like 20 years.
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But what a big deal that white coat is. And I feel bad. Maybe I should be more respectful of the
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white coat. You know, when I came from UCSF, nobody wore a long white coat except for fellows and
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attendings. So even the residents wore short white coats. I think Hopkins was that way. They're just
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starting to change it. When I came to Stanford, I saw you wearing a long white coat. And my conditioned
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unconscious wanted to smack you. Like how- I haven't earned it. You haven't earned it. I haven't earned
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the long white coat I'm wearing as a R1 as an intern. It's such an interesting process. It's almost
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militaristic. It's a very military hierarchy. And the question is, is that good? Do we need that? I
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think some degree of organization hierarchy is important when people's lives are on the line. Same
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within the military, right? Yeah. You're friends with Jocko Willink and these guys. I mean, what would
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he say about this? I don't know. I'd hate to speak for anybody, especially Jocko. But the challenge
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comes when you have to make a decision that is probably not the best decision for the patient,
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but it's the one that's coming down from the person just above you. And I always found the
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stickiest situations were, and I had an example and I want to be very careful. I don't reveal too much
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because this was such a vivid example in my residency. But there was a time in my residency when
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I was an intern and it was a small surgical service. So it was me and a chief resident only.
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So you didn't have all like the 17 layers. So it was, you know, you basically had attending fellow
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chief resident intern. So there was only like four people in the chain of command.
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And there was a situation that was in my mind, clearly a case of someone that needed to go to
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the operating room. I don't think you even needed to be a physician to know that this person needed
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to go to the operating room. I think if you walked into McDonald's and just polled a hundred people
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there, 97 would say, yep, that's a surgical case.
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Yeah. And the third would be like, I want extra.
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Right. The other three, they might miss some finer detail. So I called the chief resident and this was
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a weekend that I was on call. And I said to him, hey, I got this case and you know, blah, blah, blah,
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blah, blah. It needs to go to the OR. And he was like, just deal with it yourself. And I said,
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look, I know you're upset at me. I've already called you twice today. This was 8 PM. And I had
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already called him twice on the Sunday and he had had to come in both times because of the injuries
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were so severe that I was calling him about that they had to be taken to the OR. So he'd already
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been to the OR twice that day. It's a Sunday. He's pissed. It's his day off. So now I'm calling
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him at 8 AM or 8 PM to say, this is a surgical case. He's saying you fix it yourself. I'm saying,
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look, I technically could address this in the ER, but that's not the best thing to do.
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And he was like, stop being such a fucking pussy.
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So again, I don't want to get into the details of it because it could kind of give away the
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identity of any of the people involved. In the end, I did deal with it in the ER. And I dealt with
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it the best I could, admitted the patient. The next day, everyone's rounding and they see the
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patient and they're like, God damn, how did this not go to the OR? So what I realized in that moment,
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and I was very early in my internship, I mean days into my internship actually, what I realized was
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the mistake I made was I didn't call the attending directly.
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Yeah. Again, it was so obvious that this chief resident was wrong. It's so obvious he was being
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a lazy sack of shit. So I should have just called the attending. Now, at the time, that wouldn't
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even occur to me. I mean, that's like, you can't break the chain of command. But I look back at that
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and I view that as probably, certainly one of probably my five biggest failures in residency
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was the weakness, the inability to break that chain of command and deal with the consequences of
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it. Because there would have been consequences of that. Even though it was the right thing to do,
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and even though that patient would have gotten much better care, I would have paid an enormous
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price for that through the duration of my residency, at least in that era. And I don't know, I feel like
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in some ways I was just a coward, you know, or deer in headlights. I just didn't know what to do.
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You know what? I want to dig into that because this story is at the center of what we're now calling
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burnout. And I don't think it's burnout. I think it's moral injury. And Talbot and Dean and others
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have written about this in STAT and other places. You were in a position where all the system was
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arrayed to make it very difficult for you to do the right thing for the patient. You knew it was
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the right thing. You knew the patient needed to have this done. And you knew that it would cause
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serious consequences to you to have it done. And you erred on the side of, okay, well, maybe the
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system is this way for a reason and it'll be okay in the morning and it may not have been.
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And then you had to live with the shame and the guilt of not having done something that was
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self-destructive, that was not in your best interest to help this other person. And to this
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day, I can tell sitting across the table from you that this bothers you deeply. You're saying it's
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one of the five things- This bothered me so much that for at least 12, 15 years after, I would
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contemplate asking one of my friends who was still at Hopkins. You know, by this point now,
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a few of my friends who had finished were still attendings at Hopkins. I had contemplated asking
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them to dig through the medical records to find out what happened to that patient because I couldn't
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remember the patient's name, but I remembered the date. So I was going to say, hey, go back to this
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date and look at everyone that came in the ER on that day. And I will be able to figure out which
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this person is. I want to know what this person is doing today. And I kid you not, this is actually a
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really funny story. I mean, funny in this one twist. I know you're a huge fan of Dr. Oz, right?
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Right. So I was on that show and a little embarrassed, truthfully, because I felt silly
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and I didn't think it made sense for me to be on, but nevertheless, I was on. And I didn't know
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when it actually aired, but when it aired, I heard from the patient's mother who was also there.
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And to make a very long story short, it reconnected me with the patient who was doing
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exceptionally well. And it was, you know, in a way, maybe it's wrong that I could alleviate some
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of the guilt by knowing that the patient turned out okay. But it was unbelievable because even this
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patient said they'd never watched this show before, this Dr. Oz show. They just happened to be in the
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waiting room, I don't know, getting their car fixed or something. And they saw it on TV and they're
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That patient recognized you across the years on TV.
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Yeah. This would have been 15 year Delta. And then connected with me through my blog or
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Really, we have to let that sink in. That at the heart of all of this, and you're, you know,
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listen, you're an amazing scientist. Your podcast is unbelievable. Like I listened to it,
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I'm enthralled by it because I'm also a huge nerd. But the fact is that was a human connection
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that you made that also was a victim of a system that was so broken that it caused you moral distress
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that lasted for years and was only partially ameliorated by reconnecting with that human at
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the center of that. Now, let's take that, that you suffered, and scale it by a thousand times every
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single day when we have to take care of patients. We know full well what needs to be done. We know where
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the fuck-ups are and where things have gone wrong and where our system has failed, and we have
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powerless, not only powerless, if we do the right thing, we will lose money, we will lose time with
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our family, we'll be charting all night, and it still may not work for the patient.
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