Doctors are fairly well known for occasionally (often) being challenging (obnoxious) to deal with. This has been attributed to the stress of the job, the culture/climate and, well, our personalities. Much has been made of the hierarchical nature of medicine and how that pervades training. Although I do just like that article’s title, it’s certainly undeniable that conflict and pressure does not make us our best selves. Whilst it is also undeniable that there has been recent forward progress, it remains difficult to make it through a week without another story of distress amongst the medical ranks.
The idea for this piece came to me after attending a conference that discussed some political aspects of healthcare – health economics, funding models, budgets etc. One of the notable reactions was of frustration but also significant was the presence of a strange learned helplessness. This is something that has been bouncing around inside my head for a while, as it seems more and more doctors are feeling increasingly powerless.
This leads me to wonder about how we collectively broke ourselves.
Quite The Dilemma
The well known concept of a ‘prisoner’s dilemma’ refers to a phenomenon by which rational people make irrational decisions. Disregarding the game theory and mathematics, the essential premise is as follows
- You and another person are given the same choice to make
- You will receive the net result of both choices (yours and theirs)
- You can choose to receive a substantial benefit at their expense or for both of you to receive a moderate benefit
It seems so obvious that we should all choose the latter option, but the reality is very different. Some are seduced by the potential for a large personal gain. We might try to rationalise turning a blind eye to the harm they cause. Others may consciously choose to exploit the cooperation of the other party. Doctors still haven’t figured out how to escape this trap (although that’s hardly surprising, since not many of us have a Nobel Prize).
For a more intuitive example, consider the following scenario that tends to play out at many services;
Lisa and Ralph are both doctors, working at the same health service. They, like every other doctor in their hospital, have to cover roster gaps when someone takes leave. A mutually beneficial and reasonable approach to only taking unplanned leave when necessary will minimize their shared burden (and the discord!). If they’re both obnoxious and attempt to manipulate the system as much as possible, then they will likely make each other miserable. Critically, they will likely end up both doing more work and feeling worse about it.
The greatest issue is that if they do cooperate, they will immediately perceive an incentive to undercut the other. The first person to quietly back out of their mutual understanding – that they only ask for help when truly necessary – will be the sole beneficiary. That person gets to avoid work and doesn’t have to cover the other person! Hence, the dilemma.
Where to from here?
The summary of this is not that you have to give everybody else whatever they want. Instead, it is that you should consider the totality of your work environment. It turns out that acting to improve the karmic balance also affects the real-world equilibrium at your job. This shouldn’t be a radical statement for a profession who profess to understand homeostasis, but somehow we managed to forget it. It’s much like fluid balance – if we keep putting more negativity in, it’s just going to cause problems elsewhere even though it might temporarily make the problem look better.
Sometimes people are worried that this change in attitude will cost them something (ie. more work). The ultimate answer is yes – it will. But I firmly believe that this is okay. If my colleague has a bad day, a sick child or a personal crisis then they should feel empowered to lean on the metaphorical shoulder we offer them. That was the crux of the discussion above; that in chasing a large personal advantage we break too much along the way for it to be worth it.
We’re the ones responsible for the medical culture in our hospitals, no matter how easy it is to externalise that responsibility. There is a focus on a solution as cultural shift stemming from a ‘changing of the guard’. I worry that we are giving ourselves permission to disregard our own complicity and avoid the required changes. There’s no magic solution to this, and the metaphor of the ‘system’ as a prison certainly resonates.
The unfortunate reality of medicine is a perennial lack of staff and resources. It would be highly desirable – mutually beneficial, even! – to try and separate our cultural woes from that pile.
Great insights! A system that turns people against each other.