To help then-candidate Bill Clinton remain focused on the No. 1 voter issue ahead of the 1992 presidential elections, political strategist James Carville coined an unforgettable mantra, which he posted inside Clinton campaign headquarters.
It read, “The economy, stupid.”
The quote became famous both for its edginess and wisdom, reminding us to separate the big picture from everything else.
In health care, it can be hard to define the “big picture” issue when there are so many contributors: Unnecessary procedures are raising costs and harming patients, medical errors are killing hundreds of thousands of people each year, and failure to implement useful technology is compromising clinical quality and patient convenience.
To better understand the root causes of professional misbehavior, underperformance, and dissatisfaction, we’d be wise to remember, “It’s the culture, stupid.”
Peter Drucker, one of the nation’s most influential business thinkers, emphasized how culture drives organizational behavior when he wrote, “Culture eats strategy for lunch.” This month, two major news stories brought this truism into clearer focus.
In case you missed it, “the U.S. Attorney in the District of Massachusetts charged 50 people in federal court as part of a long-running, nationwide conspiracy to illicitly gain admission for high school students to top colleges and universities.”
Education experts say the scandal is proof “the admissions system is broken.” But the system is nothing more than a set of criteria and steps designed to facilitate the selection process. The system didn’t engage in fraud or dishonesty. People did. And those people were influenced by the underlying beliefs, assumptions, and norms of these elite schools. In other words: “It’s the culture, stupid.”
In organizations and institutions, culture is defined by the actions, not the words, of leaders. University presidents and deans have always railed against academic dishonesty while ensuring freshman orientations clearly spell out the student code of ethics.
At the same time, university leaders have for decades accepted multimillion-dollar checks for capital investments and endowments, often with the tacit understanding that the donor’s child will be more likely to receive a thick envelop in the mail someday. In a culture that favors (and grants favors to) the wealthy, it’s easy see how some parents and university faculty got the idea it was acceptable to exchange a $500,000 payment for guaranteed admission.
It was the culture, not the admissions system, that blurred the line between what’s unethical and what’s illegal, and it encouraged people, both inside and outside the ivy walls, to step over the line.
Culture has the power to distort perceptions and change behaviors. When it does, the consequences can be devastating, which brings us to the next story. It centers on an institution for which I have great fondness, respect, and professional history.
Technology is corrupting the culture of medicine
For the past decade, a Kaiser Permanente hospital in Northern California has been pioneering the use of “robots” to connect patients with their doctors, even when the physician isn’t onsite.
The concept is superb. Imagine it’s 10 p.m. at the hospital, and the nurse on duty notices a patient experiencing severe anxiety and discomfort. The nurse alerts the patient’s doctor, who’s at home. Instead of simply phoning in a medication order to help calm the patient, the doctor wants to see whether something else might be wrong. Enter the robot, which the nurse wheels into the patient’s room. With a screen for a “face,” the machine allows the patient to see the doctor and, importantly, lets the physician assess the patient’s facial expression, energy level and depth of breathing.
I’ve seen firsthand how these “virtual visits” help doctors make better decisions and avoid potentially life-threatening medical errors. And most patients appreciate these digital connections. But there are times when using the “robot” is inappropriate.
A story about one of these times recently swept the internet. The headline read: Doctor delivers end-of-life news via ‘robot’.
According to initial news reports, a doctor (via a robot) delivered an end-of-life diagnosis to a 79-year-old man and his family. The patient’s daughter, who was in the room at the time, told ABC7 News in San Francisco, “There was no bedside manner, there was no compassion.”
A senior administrator with the hospital clarified that “the evening video conversation was a follow-up to earlier in-person physician visits and was not used in the delivery of the initial diagnosis.”
Although we don’t know exactly what was said, I suspect the doctor on the “other end” of the robot-enabled conversation had good intentions. By explaining that evening, rather than the following day, that the patient’s most recent radiology findings had worsened, the doctor wanted to give the man more time to say goodbye to loved ones and get his affairs in order.
Of course, what precisely the doctor said or his intent isn’t the most important issue. The “big picture” is about how technology is influencing medical culture.
On one hand, information technology in health care saves lives, allowing doctors to achieve higher quality while making medical care more accessible and convenient. We need a lot more of it. On the other hand, technological innovations have pushed many important elements of medical practice into the background.
Throughout most of human history, there was little doctors could do (medically) for a dying person. In the absence of antibiotics, vaccines, and telemedicine, physicians relied on the only tools available: their compassion and empathy. Standing at the beside of their patients, doctors delivered bad news with sincerity, kindness and a human touch. Artists of the past have beautifully captured these moments, which depict the doctor-patient relationship at the very heart of medical culture.
Regardless of the moment – then, now or in the future – empathy and compassion are best practiced in person, not through a digital monitor. When doctors lose sight of what’s important, when they prioritize the convenience of technology over human touch, it’s not a failure of technology. It’s “the culture, stupid.”
The culture of medicine, like the culture of academia, is built on good intentions. But recent news stories remind us that all cultures can be corrupted. It’s a lesson university presidents and medical leaders would be wise not to forget.
Robert Pearl is a physician and CEO, Permanente Medical Groups. He is the author of Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong and can be reached on Twitter @RobertPearlMD. This article originally appeared in Forbes.
Image credit: Shutterstock.com
