The hazard of the health care common is communication

Both in and outside of health care certain buzz words and phrases become so ubiquitously used that a shared understanding is assumed despite conflicting perceptions of what these sentiments actually mean. Examples in health care include: shared decision making, quality of life, professionalism, patient-centered care, and evidence-based. Each sounds positive and intuitive — what health care provider perceives her/himself as not professional and patient-centered or not providing shared, evidence-based, quality care that helps people? These traits and activities seem inherent to why one becomes a health care provider in the first place, and therein lies the issue. We say the same thing and assume no further definition is required when, in reality, we mean very different things.

I call this social phenomenon the “hazard of the common” and have been surprised how often it undermines professionals’ sincere efforts to communicate and collaborate. It can even generate considerable tension. If we assume a shared understanding and someone else acts contrary to that understanding, we often suspect a lack of professionalism, patient-centeredness or evidence rather than differing perceptions of common values. Below are a couple of examples from my work with a company that characterizes the unique ways different professional groups think to help those groups work together more effectively.

Case example 1: turf wars

Inter-specialty tension tends to come in one of two flavors: conflicting approaches to treating the same condition (e.g., myomectomy vs. uterine fibroid embolization for symptomatic fibroids) or multiple specialties offering the same treatment for the same condition (e.g., endovascular therapies by vascular surgery vs. interventional radiology). Often these providers share a sincere commitment to “doing the right thing” for their patients and suspect that money and ego drive inter-specialty conflicts. Though money and ego can certainly be lighter fluid on the fire, the kindling is often a lack of appreciation for professional, cultural differences that contextualize their common values and goals.

For example, many interventional radiologists (IRs) feel uterine fibroid embolization (UFE) should be first-line therapy for most symptomatic uterine fibroids and worry that gynecologists (OBGs) prioritize their own procedures over what is best for patients. Conversely, OBGs tend not to perceive any tension with IR and exhibit a wide range of approaches to fibroids. Much of the IR identity is based on the minimally-invasive procedures they perform, so the least invasive intervention tends to be idealized, and not recommending UFE is, essentially, perceived as not recommending or trusting IR. OBGs instead describe their roles based on patient populations, focusing more on treatment “definitiveness.” Thus, to an OBG, the least invasive procedure may not be ideal and choosing one procedure over another generates little to no tension as this choice has little to do with their sense of professional worth. Both specialties shared a common interest in helping women with symptomatic uterine fibroids, but there is little appreciation for how their perception of “the right thing to do” is influenced by their specialty cultures.

Case example 2: physician-administration collaboration

There is a greater awareness of cultural differences between physicians and hospital administrators with multiple calls for increasing communication and aligning incentives. Nevertheless, tension can persist. In my recent work at a large academic health care system (unpublished), physicians and administrators nearly unanimously offered the same solutions to improve their relationships: increase communication, align incentives and spend more time in each other’s workspaces. However, there were conflicting connotations behind these seemingly shared solutions that complicated their efforts to collaborate. Some administrators viewed themselves as physicians’ bosses rather than partners, and some physicians viewed themselves as autonomous islands rather than leaders within a team. “Increasing communication” for bosses and islands meant making the other group understand their point of view or telling them what they needed to hear to get them on board. For partners and leaders, communication was more bidirectional with the goal being compromise. Thus, a key issue for the organization involved discrepant power dynamics obscured by the hazard of the common.

To avoid falling victim to this social phenomenon, one must seek a deeper understanding of stakeholders’ diverse perceptions and use this understanding to guide interactions, measures, and initiatives. At a practice or organizational level, effective interventions can be as simple as facilitating regular open discussions about these differences in a safe, non-judgmental environment or team building retreats that bring these issues to light in a non-threatening manner. At a policy level, methods from the social sciences such as ethnography or grounded theory can provide richer characterizations of patients’ and providers’ experiences to guide the formation of initiatives that better resonate with and address the needs of diverse groups. These approaches do take time, but the investment is often well worth it.

It is my hope that this brief viewpoint inspires greater appreciation for the hazard of the common as well as research and initiatives to overcome it and foster better communication and collaboration throughout health care.

Eric J. Keller is a medicine resident.

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