In the excellent study by M. St. Pierre, "Assistant doctors and Caregivers Express safety-related concerns?" published in the anesthesiologist Sept. 2012, he shows how a steep hierarchy and the associated authority gradient endangers patients.

What were you doing?

In a simulator course with 59 doctors, in a scenario the participating senior physician, who was also in the right life, was asked to commit seven mistakes in the simulation scenario in a row. These were increasing in severity and in the last two, which could only be corrected by open verbal utterance of the concerns, he called on the assistant physician to inject a potentially lethal combination of drugs in this situation. The scenario has been exacerbated by the fact that the patient is a "super VIP", chairman of a local company, and long personally on you and you with your own boss.

The senior physician was instructed to decide on any mistake that was made, because of the clarity of the communication, whether it continues or corrects itself. If an error was clearly addressed, he should thank and correct his actions, but then proceed with the next error.

Of the problems that could only be resolved by verbal intervention, 60% were identified, but only in 28% of them were addressed, and only in 40% were pronounced. Otherwise, only hints were made or generally called the problem without becoming concrete.

This resulted in a successful intervention only in less than 10% (!).

Specifically, this means that in over 90% a potentially lethal drug was injected if ordered by the senior physician! 

Asked for reasons for silence in the debriefing,

  • 37% do not indicate why they had been silent
  • 35% did not want to address the conflict
  • 23% took the conflict, but did not want to dissolve it (amazement)
  • 12% due to the authority of the senior Physician (authority gradient) "If he orders this, this is done for me" there was also the statement of the Blind trust "he has never made a mistake"
  • 8% with the experience that senior physicians often do not adhere to SOP ´ s
  • 6% because they did not feel responsible and only 2% because they did not know how they should have addressed the conflict (lack of speech)

What is particularly interesting here is that the fear of Blosstellung of the interns was not the only driving factor, but that even the senior doctors, who are considered particularly good, are abandoned by their team, as their Decisions are not to be questioned. On the other hand, some in many places still consider that subordinate should not question the competence of superiors. In another investigation, 25% of the anesthesia physicians and 40% of the surgical doctors said so. In the same investigation, only 2% of the pilots represented this opinion. We are in the medicine of aviation here ca. 20 years behind. We now know that we have a problem, but we are still years away from developing a culture of communication and security as in aviation.

Mark Weinert