Historian Doris Kearns Goodwin highlighted a crucial strength of the 16th U.S. president as he led the nation through one of its most divisive times: Abraham Lincoln encouraged dissent and welcomed opposing points of view, going so far as to appoint three better-known political rivals to top positions in his administration.
That extraordinary lesson in crisis leadership seems to be getting lost in the nation’s battle with the novel coronavirus.
Too many doctors, nurses, and experts in science and medicine have been censored, disciplined, and dismissed for speaking truth to power, warning, for example, about unacceptable conditions for health workers treating Covid-19 infections, news organizations have reported.
Executives at hospitals and other health care facilities like nursing homes have spread the word, by informal and formal means, that their staffers should just, as rough-talking character Archie Bunker used to say, stifle it. As the New York Times reported:
“As the coronavirus crisis has escalated, workers as varied as grocery cashiers, customer-service representatives and flight attendants have clashed with the employers they accuse of failing to protect and properly value them. Amazon drew attention when it fired a worker who had led a protest over health concerns at a Staten Island warehouse. But perhaps the most curious and persistent management-labor tension has arisen between health care providers like doctors and nurses, who are at the forefront of the virus battle, and the administrators they report to. In New York City, the epicenter of the crisis in the United States, every major private hospital system has sent memos in recent weeks ordering workers not to speak with the media, as have some public hospitals. One system, NYU Langone Medical Center, which has more than 30,000 employees at six inpatient centers, dozens of outpatient facilities and the New York University School of Medicine, sent an email on March 27 warning that staff members speaking to the media without permission “will be subject to disciplinary action, including termination.” The email was reported earlier by Bloomberg. Administrators suggested ‘appropriate’ posts on social media instead. ‘Please share positive and uplifting messages that support your colleagues and our organization,’ they said in another email. Similar lines are being drawn nationwide. A doctor in Washington State was removed from his hospital position after speaking publicly about a shortage of protective equipment and testing; the staffing firm that employs him said he was being reassigned. Nurses in Detroit recently walked off the job to protest critically low staffing after a colleague who had spoken up on the issue was fired. A union representing an Oregon nurse says she was told she would face disciplinary action after being quoted in the media, though the hospital did not follow through.”
In the stress and urgency of a medical crisis, it makes some sense for health care workers to exercise discipline and teamwork, focusing on the life-and-death treatments they need to provide patients. Medicine always long had a hierarchical and compliance-focused culture. But telling highly trained pros, who are putting themselves and their loved ones at risk, to shut about crucial safety and quality issues isn’t just small, it’s unwise.
As a fired New Jersey hospital staffer told the New York Times about administrators at his hospital: “As they built these walls, we have less ability to bring concerns forward. It’s like they decided it was martial law in a crisis.”
A nurse wrote in an opinion piece in the newspaper:
“Information came from the top down. Questioning of policies and practices was disapproved of, at times even when that questioning addressed patient safety. No surprise, my former employer has issued a gag order for all of the staff during the pandemic. Clinicians who fear the virus and lack sufficient protective equipment must now work in an environment where they fear the hospital administration as well. The biggest problem with this watertight approach to information and focus on hospital brands is that maximizing health care revenue does not mean patients receive the best possible care.”
A colleague out West offers an example of the differences that can occur with free and open communication, noting that a major academic medical center, in its big push to improve infection control — long before the current Covid-19 outbreak — had to confront sexism, racism, and elitism. The matter at hand seemed simple at first to medical leaders: All health workers had to be 100% diligent in washing their hands, thoroughly (sound familiar?) But the block to this important improvement turned out to be doctors, mostly men and many with big reputations and bigger egos. They heard the evidence-based information about improving patient safety and quality of care with hand washing, and ignored it.
The hospital then turned to its nurses, telling them to feel free to break with stodgy traditions and speak up, with respect and politeness, about scofflaws. The chief medical officer in a staff-wide announcement praised a young nurse for quietly pushing him to wash his hands before seeing a patient. The medical chief of staff declined to berate colleagues. Instead, in the monthly gathering of all doctors, he made it a regular practice to name doctors failing to follow the rules. He also used his power to change their privileges — he got them stuck in distant parking. Hand washing rose and stayed at the highest levels, winning doctors and nurses national attention. Staff morale also went up in marked ways.
This is the 21st century in a democracy with free speech, right?
In my practice, I see not only the harms that patients suffer while seeking medical services but also their struggles to access and afford safe, efficient, and excellent medical care. This has become an ordeal due to the skyrocketing cost, complexity, and uncertainty of treatments and prescription medications, too many of which turn out to be dangerous drugs.
The U.S. health care system was scary and intimidating enough before Covid-19 overwhelmed so many aspects of it. In the days ahead, health care workers can provide the best attention possible under difficult circumstances if their chiefs also listen to and act on their constructive discussions, appropriately. Innovations in care won’t come from MBAs wearing suits in fancy administrative suites. They will happen due to the blood, sweat, and tears of front-line personnel who put themselves and their loved ones at risk to treat others as well as they can.
Even before the pandemic, hospitals and executives acted in unacceptable ways, trying to sweep problems under the rug, to protect institution’s reputations and “brands.” That does not help their hardworking people or the patients who are supposed to be hospitals’ prime concern.
Politicians in the nation’s capital also are taking deserved heavy fire for causing or allowing the muzzling and pushing aside of medical and scientific expertise, whether their careers were built at the federal Centers for Disease Control and Prevention, in national vaccine-development programs, at the National Institutes of Health, or even with the U.S. surgeon general’s office.
Really? We all need to pull together to deal with the unprecedent problems posed by the Covid-19 pandemic. That does not mean we will speak in one voice, nor that we will not disagree. But for health care workers risking their lives for others’ sake, it should not mean sacrificing their professional obligation to dissent — and not have their jobs or careers put at risk. We have got a lot of work to do.