Qualy #125 - Hierarchies in healthcare, physician burnout, and a broken system
Episode Stats
Words per minute
207.8733
Harmful content
Hate speech
3
sentences flagged
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
00:00:00.000
Welcome to a special bonus episode of the Peter Atiyah Qualies, a member exclusive podcast.
00:00:16.100
The Qualies is just a shorthand slang for qualification round, which is something you
00:00:20.120
do prior to the race, just much quicker. The Qualies highlight the best of the questions,
00:00:25.320
topics, and tactics that are discussed in previous episodes of The Drive.
00:00:30.000
So if you enjoy the Qualies, you can access dozens more of them through our membership
00:00:33.520
program. Without further delay, I hope you enjoy today's Qualies.
00:00:40.440
I had a similar experience at UCSF when I did a graduation speech that actually launched
00:00:44.200
my whole career as ZDoggMD because I later put it on YouTube. It's in my 1999 UCSF graduation
00:00:49.400
speech. It's there. It's all captioned and everything. And I just went through it as I saw it, and it
00:00:53.460
was all just like, this is bullshit, this is bullshit, this is bullshit, this is why, this
0.86
00:00:56.640
is bullshit. It's about actually connecting with our patients, isn't it?
00:00:59.180
And the majority of the faculty behind me were just like stone-faced for 90% of it, and then
00:01:04.120
finally start to crack. And you see Michael Bishop, who's like a Nobel Prize winner, finally
00:01:07.260
he's like... And afterwards they were like, that was very well done. But there was one
00:01:12.260
guy who was like, that kid shouldn't be allowed to graduate, and actually was lobbying to have
00:01:17.140
my graduation revoked for giving that speech. I mean, so this is the thing. It's a hierarchy.
00:01:22.740
And I can tell you don't like hierarchies so much.
00:01:25.920
I probably have more respect for it than you, actually.
00:01:29.780
Yeah, I don't... I don't know. I feel like I'm not as... I don't bristle as much at it
00:01:35.540
as probably some people. I mean, I would say for a surgical resident, I respected it much
00:01:40.040
less than the other residents, and I definitely got into trouble on a few occasions as a result
00:01:46.300
Yeah, I've met people who completely have absolutely disregard for any hierarchy, and
00:01:50.500
many of them go on to just do the most amazing things. So I always felt like I wish I had
00:01:55.660
Well, you know, it's a complex thing because I think certain personality types don't like
00:01:59.120
to be in the middle or bottom of hierarchies. They either want to be on the top or they want
00:02:02.960
to be off the hierarchy. It's hard for them to feel like other people are controlling
00:02:07.340
them or they're beholden to others in the higher hierarchy. And they either have a tendency
00:02:11.960
to dominate those underneath or to treat them as equals inappropriately, in which case the
00:02:16.800
lower down in the hierarchy don't have the competence. And what they need is actually
00:02:20.460
to be trained and lifted and supported. And instead, it's like, why aren't you at the
00:02:25.200
level that I'm asking you to be? And so it's interesting. It becomes tough in the higher
00:02:30.320
I think the problem I had in residency was I really loved hierarchy when I could respect
00:02:35.120
the person I was reporting to. So, you know, luckily I did my residency at a hospital
00:02:39.940
where most of the residents were just exceptional. So it, for the most part, was really easy to
00:02:44.940
respect the hierarchy. But the problem was when I encountered somebody and I didn't think
00:02:49.080
that they were good enough or smart enough or knew enough, I wouldn't hesitate to just
00:02:55.220
steamroll them. And that gets you into a lot of trouble.
00:02:58.220
I saw that in you when you were a medical student. I remember it. It was one of your
00:03:01.840
characteristics that I actually respected a lot. Because again, like you said, and you kind
00:03:06.860
of described our team pretty well. And the person at the top was fairly narcissistic.
00:03:10.760
The one in the middle was kind of a non-entity. Then there was me, who was the class clown.
00:03:14.640
And then there was you. And it speaks to our medical training in general that it really
00:03:21.140
is about kissing the ring of the authority figure. So one day you will be the ring that's
00:03:25.840
kissed. That's the majority of our training. The first two years, we're fed a bunch of information,
00:03:30.200
50% of which is wrong, but they don't tell us which 50%.
00:03:33.180
And then the 50% of the residual will be outdated by the time you finish.
00:03:36.880
Exactly. So it's 100% bullshit. And yet we're expected to kind of suck it all in and regurgitate
00:03:42.340
it with respect for this hierarchy. And we don't ask questions. We don't step out of that. And
00:03:47.120
you're right. You have to respect your authority figures, which is important when you trust and
00:03:50.760
respect them. But when you're questioning things like, why are we doing this? Why are we giving
00:03:54.760
Lasix to this person? Or what's going on with this renal failure? Actually, what about the root cause of
00:03:59.020
that? You start asking this question. No, no, no, no, no. That's when I was told, hey, you speak,
00:04:02.620
then think you should reverse that. They don't want to hear that from a medical student. And
00:04:07.000
we had the short white coats and everything. You guys had the long white coats. It wasn't as
00:04:10.320
It was very unusual. Yeah. I didn't realize how, quote unquote, special that was until I saw that
00:04:16.400
there were many programs where even the interns were still in short white coats. And I didn't
00:04:21.120
realize what a big deal that was, how much obsessing went into the white coat thing. I feel like an idiot
00:04:27.860
even just voicing this right now, because I've never thought about this for like 20 years.
00:04:32.240
But what a big deal that white coat is. And I feel bad. Maybe I should be more respectful of the
00:04:36.380
white coat. You know, when I came from UCSF, nobody wore a long white coat except for fellows and
00:04:41.860
attendings. So even the residents wore short white coats. I think Hopkins was that way. They're just
00:04:46.260
starting to change it. When I came to Stanford, I saw you wearing a long white coat. And my conditioned
00:04:52.720
unconscious wanted to smack you. Like how- I haven't earned it. You haven't earned it. I haven't earned
00:04:57.940
the long white coat I'm wearing as a R1 as an intern. It's such an interesting process. It's almost
00:05:03.620
militaristic. It's a very military hierarchy. And the question is, is that good? Do we need that? I
00:05:08.340
think some degree of organization hierarchy is important when people's lives are on the line. Same
00:05:12.080
within the military, right? Yeah. You're friends with Jocko Willink and these guys. I mean, what would
00:05:15.740
he say about this? I don't know. I'd hate to speak for anybody, especially Jocko. But the challenge
00:05:20.640
comes when you have to make a decision that is probably not the best decision for the patient,
00:05:29.920
but it's the one that's coming down from the person just above you. And I always found the
00:05:33.860
stickiest situations were, and I had an example and I want to be very careful. I don't reveal too much
00:05:39.020
because this was such a vivid example in my residency. But there was a time in my residency when
00:05:43.840
I was an intern and it was a small surgical service. So it was me and a chief resident only.
00:05:49.200
So you didn't have all like the 17 layers. So it was, you know, you basically had attending fellow
00:05:54.620
chief resident intern. So there was only like four people in the chain of command.
00:05:59.420
And there was a situation that was in my mind, clearly a case of someone that needed to go to
00:06:05.000
the operating room. I don't think you even needed to be a physician to know that this person needed
00:06:09.780
to go to the operating room. I think if you walked into McDonald's and just polled a hundred people
00:06:14.800
there, 97 would say, yep, that's a surgical case.
00:06:18.400
Yeah. And the third would be like, I want extra.
00:06:20.380
Right. The other three, they might miss some finer detail. So I called the chief resident and this was
00:06:26.460
a weekend that I was on call. And I said to him, hey, I got this case and you know, blah, blah, blah,
00:06:32.840
blah, blah. It needs to go to the OR. And he was like, just deal with it yourself. And I said,
00:06:38.040
look, I know you're upset at me. I've already called you twice today. This was 8 PM. And I had
00:06:43.400
already called him twice on the Sunday and he had had to come in both times because of the injuries
00:06:47.820
were so severe that I was calling him about that they had to be taken to the OR. So he'd already
00:06:52.020
been to the OR twice that day. It's a Sunday. He's pissed. It's his day off. So now I'm calling
00:06:56.920
him at 8 AM or 8 PM to say, this is a surgical case. He's saying you fix it yourself. I'm saying,
00:07:03.840
look, I technically could address this in the ER, but that's not the best thing to do.
00:07:10.440
And he was like, stop being such a fucking pussy.
1.00
00:07:19.960
So again, I don't want to get into the details of it because it could kind of give away the
00:07:24.200
identity of any of the people involved. In the end, I did deal with it in the ER. And I dealt with
00:07:30.140
it the best I could, admitted the patient. The next day, everyone's rounding and they see the
00:07:37.060
patient and they're like, God damn, how did this not go to the OR? So what I realized in that moment,
00:07:44.700
and I was very early in my internship, I mean days into my internship actually, what I realized was
00:07:50.500
the mistake I made was I didn't call the attending directly.
00:07:55.600
Yeah. Again, it was so obvious that this chief resident was wrong. It's so obvious he was being
00:08:01.340
a lazy sack of shit. So I should have just called the attending. Now, at the time, that wouldn't
00:08:07.400
even occur to me. I mean, that's like, you can't break the chain of command. But I look back at that
00:08:12.380
and I view that as probably, certainly one of probably my five biggest failures in residency
00:08:17.240
was the weakness, the inability to break that chain of command and deal with the consequences of
00:08:22.900
it. Because there would have been consequences of that. Even though it was the right thing to do,
00:08:26.260
and even though that patient would have gotten much better care, I would have paid an enormous
00:08:29.600
price for that through the duration of my residency, at least in that era. And I don't know, I feel like
00:08:34.100
in some ways I was just a coward, you know, or deer in headlights. I just didn't know what to do.
00:08:40.140
You know what? I want to dig into that because this story is at the center of what we're now calling
00:08:45.560
burnout. And I don't think it's burnout. I think it's moral injury. And Talbot and Dean and others
00:08:51.120
have written about this in STAT and other places. You were in a position where all the system was
00:08:57.240
arrayed to make it very difficult for you to do the right thing for the patient. You knew it was
00:09:01.140
the right thing. You knew the patient needed to have this done. And you knew that it would cause
00:09:06.740
serious consequences to you to have it done. And you erred on the side of, okay, well, maybe the
00:09:12.320
system is this way for a reason and it'll be okay in the morning and it may not have been.
00:09:15.740
And then you had to live with the shame and the guilt of not having done something that was
00:09:20.880
self-destructive, that was not in your best interest to help this other person. And to this
00:09:25.740
day, I can tell sitting across the table from you that this bothers you deeply. You're saying it's
00:09:29.420
one of the five things- This bothered me so much that for at least 12, 15 years after, I would
00:09:39.320
contemplate asking one of my friends who was still at Hopkins. You know, by this point now,
00:09:43.740
a few of my friends who had finished were still attendings at Hopkins. I had contemplated asking
00:09:48.700
them to dig through the medical records to find out what happened to that patient because I couldn't
00:09:52.640
remember the patient's name, but I remembered the date. So I was going to say, hey, go back to this
00:09:56.780
date and look at everyone that came in the ER on that day. And I will be able to figure out which
00:10:02.280
this person is. I want to know what this person is doing today. And I kid you not, this is actually a
00:10:09.420
really funny story. I mean, funny in this one twist. I know you're a huge fan of Dr. Oz, right?
00:10:17.240
Right. So I was on that show and a little embarrassed, truthfully, because I felt silly
00:10:22.080
and I didn't think it made sense for me to be on, but nevertheless, I was on. And I didn't know
00:10:26.720
when it actually aired, but when it aired, I heard from the patient's mother who was also there.
00:10:36.280
And to make a very long story short, it reconnected me with the patient who was doing
00:10:39.680
exceptionally well. And it was, you know, in a way, maybe it's wrong that I could alleviate some
00:10:46.100
of the guilt by knowing that the patient turned out okay. But it was unbelievable because even this
00:10:51.460
patient said they'd never watched this show before, this Dr. Oz show. They just happened to be in the
00:10:56.840
waiting room, I don't know, getting their car fixed or something. And they saw it on TV and they're
00:11:02.460
That patient recognized you across the years on TV.
00:11:06.160
Yeah. This would have been 15 year Delta. And then connected with me through my blog or
00:11:11.540
Really, we have to let that sink in. That at the heart of all of this, and you're, you know,
00:11:15.900
listen, you're an amazing scientist. Your podcast is unbelievable. Like I listened to it,
00:11:20.600
I'm enthralled by it because I'm also a huge nerd. But the fact is that was a human connection
00:11:26.080
that you made that also was a victim of a system that was so broken that it caused you moral distress
00:11:33.820
that lasted for years and was only partially ameliorated by reconnecting with that human at
00:11:40.400
the center of that. Now, let's take that, that you suffered, and scale it by a thousand times every
00:11:47.220
single day when we have to take care of patients. We know full well what needs to be done. We know where
00:11:52.020
the fuck-ups are and where things have gone wrong and where our system has failed, and we have
0.86
00:11:55.440
powerless, not only powerless, if we do the right thing, we will lose money, we will lose time with
00:12:00.900
our family, we'll be charting all night, and it still may not work for the patient.
00:12:05.820
Hope you enjoyed today's special bonus episode of the Quali. New episodes of the Qualis are
00:12:11.000
released Tuesday through Friday each week and are published exclusively on our private member-only
00:12:16.460
podcast feed. If you're interested in hearing more, as well as receiving all of the other
00:12:20.480
member-exclusive benefits, you can visit peteratiamd.com forward slash subscribe.
00:12:26.260
This podcast is for general informational purposes only and does not constitute the practice of
00:12:31.360
medicine, nursing, or other professional healthcare services, including the giving of medical advice.
00:12:37.620
No doctor-patient relationship is formed. The use of this information and the materials linked to this
00:12:42.820
podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for
00:12:49.220
professional medical advice, diagnosis, or treatment. Users should not disregard or delay in
00:12:55.880
obtaining medical advice from any medical condition they have, and they should seek the assistance of
00:13:01.260
their healthcare professionals for any such conditions. Finally, I take conflicts of interest
00:13:07.500
very seriously. For all of my disclosures and the companies I invest in or advise, please visit
00:13:13.540
peteratiamd.com forward slash about where I keep an up-to-date and active list of such companies.