Defending the Expert Culture
Old school and new school ways of thinking often clash into tug of war of who’s right and who’s wrong. Expert culture attempts to merge the two but always questions who is right? The experienced or inexperienced? Is there a possibility to adapt to a new way of thinking? Through an example from mid 19th Century Europe Dr. Cook examined expert culture and the constant struggle for control over all aspects of clinical life. He found that the two factors that can pollute the waters of disagreement are belief perseverance and group think. Physicians of today need to be adaptable to change and evolution while adjusting to the collective culture of nonclinical opinions.
Recently it seems every conversation I have with a physician eventually turns to the never-ending struggle with whatever person or persons are perceived to be controlling all aspects of our clinical life. We feel obligated to push back against what appears to us to be intrusion into sacred territory where the unschooled and unskilled have no standing. We feel it is our duty to protect the clinical realm against those less informed than we while we struggle to find suitable resolution for these disputes. Such disagreement is not new to modern medicine. In this post, I’m going to offer a brief synopsis of one of those disputes which occurred over 170 years ago. Then I’ll offer some thoughts on how to untangle the knot of disagreement, or better still, prevent the tangle before it chokes off any meaningful conversation.
Europe in the mid 19th century was a dangerous time and place for women giving birth. The beginnings of our understanding of infectious disease would not appear for another half century and a curious concatenation of circumstances set the stage for a near epidemic of puerperal fever (aka childbed fever.) Mortality was very high among young mothers giving birth in the new obstetrical hospitals that were appearing across Europe. Ironically, these maternity hospitals came about to address the problem of infanticide of illegitimate children. The women (often prostitutes) would give birth in the hospitals and receive proper medical care. Care of their newborn infants would be assumed by the institution. In exchange, the women would be available for the instruction of medical students.
It was in this setting that Ignaz Semmelweis was appointed Assistant to Professor Johann Klein in the First Obstetrical Clinic of the Vienna General Hospital in the summer of 1846. Semmelweis was in his late twenties at the time, and his position was equivalent to what we would consider a chief resident today. There were actually two OB clinics at Vienna General and they admitted on alternating days. The First Clinic was attended by medical students and their Professors, while the Second Clinic was attended by midwives. Early on, Semmelweis noted that mortality from puerperal fever in the First Clinic was more than five to six times what was occurring the Second Clinic.
These observations were profoundly troubling to Semmelweis and he set about making careful observations of conditions in both clinics in an effort to identify what was different between them and what might explain the discrepancy in mortality for these unfortunate women. In the end, the only difference he could identify was that the medical students would go directly from the autopsy room to the delivery rooms to attend laboring mothers, whereas the midwives had no exposure to the autopsy room. He recommended hand washing with a solution of chlorinated lime before attending delivery in both clinics. He picked this solution only because it reliably eliminated the putrid odor from the dissected corpses. (The germ theory of disease had not yet been established at this point in history.) This simple act of routine hand washing decreased the incidence of puerperal fever in both of his clinics, although the change in the First Clinic was much more dramatic. In both venues, mortality from post-partum sepsis dropped to less than 2% from a previous level of greater than 18%.
At this point, one would expect accolades and awards for Dr. Semmelweis, but it was not to be. His findings and recommendations were met with widespread suspicion and he was disparaged and ridiculed by his colleagues. Even though his changes to procedures at Vienna General Hospital produced dramatic results, the results were simply not explainable using the known science of his day. He was dismissed from his position in Vienna and attempted to re-establish himself in Budapest to no avail. He spent the next two decades attempting to recover his reputation but eventually died about two weeks following admission to an asylum. The cause of his death can’t be known with certainty, but some evidence suggests that he died, ironically, from septicemia…probably from open wounds sustained at the hands of the guards who beat him mercilessly at the institution where he was committed.
We would all very much like to believe such a thing couldn’t happen in the world we know today. But I’m not so sure. In my opinion, the brilliant Ignaz Semmelweis died from complications of “belief perseverance” (aka “conceptual conservatism”.) Simply stated, belief perseverance is the tendency of people to cling to certain beliefs even when presented with compelling evidence that those beliefs are incorrect. Examples are plentiful. There is a small but determined number of people who believe the NASA moon landings were a hoax. Doomsday believers are continually predicting the apocalyptic end of the world on a particular date, only to revise their predictions when life goes on without interruption.
We chuckle at such nonsense, but there are far more disturbing examples. Surgeons in the U.S. continued to perform radical mastectomies years after it was abandoned in Europe and abundant evidence showed that it offered no advantage in controlling breast cancer. Millions of people spend billions of dollars annually on vitamins and nutritional supplements despite plentiful evidence that these products produce no nutritional advantage over a healthy diet. A substantial yet unknown number of parents refuse to vaccinate their children against preventable diseases because of the soundly disproven notion that these vaccines cause mental disorders.
A close relative of belief persistence is “groupthink”, a phenomenon that is perhaps even more destructive than its elder cousin. Groupthink occurs when people make ill-advised decisions in order to remain in harmony with the larger (and usually more vocal) group. The term was first seen in the psychology literature in the early 1970s and is a frequent topic today in discussions of corporate behavior. Frequently cited examples of groupthink tragedy include the 1986 Space Shuttle Challenger disaster, the ill-fated Bay of Pigs invasion, and the 2008 financial collapse and recession of the U.S economy. Groupthink has also been cited as a contributor in erroneous courtroom jury decisions and even aircraft accidents where the “group” consists of only two people tasked with the complexity of airliner cockpit resource management.
Practitioners of the healing arts represent what is known as an expert culture, in contrast to collective culture which is more characteristic of the corporate world. Success of collective cultures is highly dependent upon collaboration and the potential for errors due to groupthink is easier to spot although often overlooked. Healthcare, on the other hand, is a mixture of expert and collaborative cultures and balancing these two competing value systems can create substantial friction among the participants. Such friction is fertile ground for entrenchment and defensive behavior on both sides of the cultural divide. It is in this atmosphere of distrust that those most basic of human psychological weaknesses will take root and flourish. The ancient physician Paracelcus put it this way: “The art of healing comes from nature, not from the physician. Therefore, the physician must start from nature with an open mind.”
It is far easier for the physician to remain open minded toward clinical issues. After all, we were trained to expect the body of scientific knowledge to change and we have watched that evolution with great interest. The intrusion of nonclinical opinions into what we perceive to be “our territory” has been a much more difficult adjustment, however. We will need to learn the language of the collective culture within which we practice. Failure to do so will leave our patients without representation where they need it most.
Wiser: Getting Beyond Groupthink to Make Groups Smarter; Sunstein, CR and Reid H.
Nudge: Improving Decisions About Health, Wealth and Happiness; Thaler, RH and
Quiet: The Power of Introverts in a World That Can’t Stop Talking; Cain, S
To read more of Dr. Randy Cook's blog "The Script Pad" go to https://mymdcoaches.com/blog. Dr. Cook is also host of MD Coaches, LLC's weekly Rx for Success Podcast found at http://rxforsuccesspodcast.com.
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