In traditional organizations, hierarchies are the normal state of affairs. While this may chafe those at a lower level of the chart, there is usually no thought to getting rid of a hierarchy, it’s more about finding ways to get on the top of the pile. However, in more progressive organizations and societies, hierarchical structures are much flatter, looser or may not exist at all. In many ways, medicine in all forms has some aspects of both types of systems, which can plant the provider squarely in that uncomfortable transition zone.
Hierarchies are very much the norm in many types of locations and systems. Thin, for instance, of the military, the legal system, or more rural or conservative portions of the US. It’s hard to imagine a judge asking the bailiff what she thinks about the case at hand! The lawyers argue their cases, the rules of evidence are enforced by the judge, and either the judge or jury dictates the outcome. Although the case may have a lot of gray in it, the outcome is black or white. This type of system is centuries old, present in many different cultures in different forms and is unlikely to change.
Medicine, however is different in a few key regards. As licensed providers, we are still responsible for safety, clinical pathways, outcomes, documentation, etc. However, the hierarchies have loosened. Doctors no longer give orders, they make recommendations. Patients have access to a wealth of information about any set of symptoms or conditions, some of it accurate, some of it not so much. Patients now have fast and easy access to their own medical records through EHR portals, and are permitted to edit the records if they see fit. Just a generation ago, medical records were viewed as the property of the treating doctor, but now the patient and the insurance carrier have unlimited access to these records. There is a newer, more collaborative movement in some medical circles where the patient is viewed as more of a partner than a consumer.
The bind here is that at some level, patients expect to be treated as peers or collaborators, whether or not they have the judgment or experience to match. This is also seen to some degree with employees, but let’s focus on patient relationships for this post.
Much of the flattening of hierarchies can be traced to the information explosion and the fragmentation of the traditional work place and work environments. There are more people than ever working as solo agents, sole members of a company and virtual contractors or employees (yours truly included!) This is also seen in society at large by the continuing outcry about income inequality, minimum wage levels, etc. I don’t think income has ever been equal in this or any other country, but that’s a subject for a different blog post.
What can we do as doctors to adapt to a cultural shift that we re in the middle of?
- Acknowledge the flattening and loosening of hierarchies that is taking place nationally, not just in your office. Meaning, fighting and resisting it to the Nth degree is a losing battle.
- Identify where command and control is critical to patient outcome, safety, or anything else that represents your core business and is the primary reason the patient visited you in the first place. These are specific arenas where you must exert top-down control. An example would be the length and duration of a treatment regimen. This is something that the patient cannot know best about, because there is no commensurate training or experience to make rational judgments with.
- Identify aspects of the patient’s care that can be modified, assigned to patient responsibility or set up as a pilot project to see what the response is. An example would be an injured athlete’s return to participation. When, how and to what degree can be experimented with (within ranges), feedback given and treatment modified accordingly.
This sort of cultural transition has some aspects of the classic recipe for stress: we are still held ultimately responsible, but the control over the operating factors is fuzzier and weaker. The search for the parts that cannot be a doctor patient collaboration is one method of keeping the best outcome in place while not swimming against a cultural tide.