We on the two coasts of the U.S. were thumped last week by what is sure to be the ugliest national election of our life-time. Politicians will perform “autopsies” to examine how/why a great country has chosen a President whose behavior throughout the election was decidedly (probably purposely) un-presidential. Aside from the extraordinary intuitions and showmanship of this modern PT Barnum, there may be interesting and relevant parallels in Medicine.
A cogent explanation for our election results is that a large swath of the U.S. population resides in a reality that has not been appreciated by east/west-coast elites and the press. Middle-Americans feel as if government has served everyone’s interests – read minorities, corporations, even foreign governments – but theirs. Meanwhile their wages have stagnated and their tax dollars spent to pursue policies that haven’t benefited them. Or so they’ve been told. In an era of Facebook and boutique pseudo-news media we’ve come to live in “echo-chambers.” That is, we hang with (in the real and internet spheres) people with similar ideas and values. Competing facts are conveniently excluded if they don’t coincide with the site-specific tribal tide of thinking. Echo-chambers amplify and ruminate. Unethical emails transform to criminal conduct deserving immediate incarceration. Tribes get whipped up pretty easily. Smarty-pants intellectuals aren’t immune either. Media, pundits, mainstream politicians and fully a half of the country who see themselves as “progressive liberals” experienced the EXACT SAME PHENOMENON. They reasoned that no sane person could vote for someone who acted, proudly, in such an un-presidential manner. In that competing echo-chamber, the tribe was whipped up to demonize the Anti-Christ and all his worshippers, ignoring reality on the ground, even mis-“measuring” the pulse of the country.
What’s it got to do with Medicine? Since leaving academia three years ago, I’ve been struck how echo-chambers in the form of “local cultures of care” subvert quality care. There is an underlying skepticism or disdain for evidence-based medicine (a populism that is suspicious of academic elitism). The ICU and the office practice where I care for patients are mini-echo-chambers, where what we do is right because that’s the way we do it. In these echo-chambers, well-meaning clinicians violently oppose anything outside local norms of practice. New England Journal be damned. Why? Because in the echo-chamber, the natural human proclivity is to group-think, a self-righteous (sometimes) delusion that “other” practices must harm patients. For example, many nurses and respiratory therapists actually refused to do T-piece trials, convinced that they would harm patients. Ditto applying least sedation. In my office practice, annual physicals are mandatory and labs/EKGs are ordered like water. And 100 other things. Local cultures fester because of laziness and conflicts of interest i.e. no financial reason to improve/evolve.
We convince ourselves that what we’re doing is right and the longer we think it or do it a certain way, the further away we get from being able to hear . . . or listen, to other ideas. Group-think is human nature; a proclivity that undermines progress. In care of patients who desperately need us to listen, to consider alternative new ideas, it is a proclivity that harms those who depend on us.
Constantine Manthous – For over 20 years, Constantine Manthous, MD, has taught, researched, and practiced in the intensive care unit. His research has addressed a panoply of practical problems with a focus on weaning from mechanical ventilation and end-of-life ethics.