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What Causes A Toxic Hospital Culture?

Hospital culture is largely influenced by the relationship between administrative and clinical staff leaders. In the “old days” the clinical staff (and physicians in particular) held most of the sway over patient care. Nowadays, the approach to patient care is significantly constricted by administrative rules, largely created by non-clinicians. An excellent description of what can result (i.e. disenfranchisement of medical staff, burn out, and joyless medical care) is presented by Dr. Robert Khoo at KevinMD.

Interestingly, a few hospitals still maintain a power shift in the other direction – where physicians have a strangle hold on operations, and determine the facility’s ability to make changes. This can lead to its own problems, including  unchecked verbal abuse of staff, inability to terminate bad actors, and diverting patients to certain facilities where they receive volume incentive remuneration. Physician greed, as Michael Millenson points out, was a common feature of medical practice pre-1965. And so, when physicians are empowered, they can be as corrupt as the administrations they so commonly despise.

As I travel from hospital to hospital across the United States (see more about my “living la vida locum” here), I often wonder what makes the pleasant places great. I have found that prestige, location, and generous endowments do not correlate with excellent work culture. It is critically important, it seems, to titrate the balance of power between administration and clinical staff carefully – this is a necessary part of hospital excellence, but still not sufficient to insure optimal contentment.

In addition to the right power balance, it has been my experience that hospital culture flows from the personalities of its leaders. Leaders must be carefully curated and maintain their own balance of business savvy and emotional I.Q.  Too often I find that leaders lack the finesse required for a caring profession, which then inspires others to follow suit with bad behavior. Unfortunately, the tender hearts required to lead with grace are often put off by the harsh realities of business, and so those who rise to lead may be the ones least capable of creating the kind of work environment that fosters collaboration and kindness. I concur with the recent article in Forbes magazine that argues that poor leaders are often selected based on confidence, not competence.

The very best healthcare facilities have somehow managed to seek out, support and respect leaders with virtuous characters. These people go on to attract others like them. And so a ripple effect begins, eventually culminating in a culture of carefulness and compassion. When you find one of these gems, devote yourself to its success because it may soon be lost in the churn of modern work schedules.

Perhaps your hospital work environment is toxic because people like you are not taking on management responsibilities that can change the culture. Do not shrink from leadership because you’re a kind-hearted individual. You are desperately needed. We require emotionally competent leaders to balance out the financially driven ones. It’s easy to feel helpless in the face of a money-driven, heavily regulated system, but now is not the time to shrink from responsibility.

Be the change you want to see in healthcare.

The Potential Risks And Benefits Of Vitamins: A Look At The Evidence

The discovery of various vitamins – essential micronutrients that cause disease when deficient – was one of the great advances of modern scientific medicine. This knowledge also led to several highly successful public health campaigns, such as vitamin-D supplementation to prevent rickets.

Today vitamins have a deserved reputation for being an important part of overall health. However, their reputation has gone beyond the science and taken on almost mythical proportions. Perhaps it is due to aggressive marketing from the supplement industry, perhaps recent generations have grown up being told by their parents thousands of times how important it is to take their vitamins, or eat vitamin-rich food. Culture also plays a role – Popeye eating spinach to make himself super strong is an example this pervasive message.

Regardless of the cause, the general feeling is that vitamins Read more »

*This blog post was originally published at Science-Based Medicine*

Priority Problems: The Failure Of Government Aid

I recently saw a teenage boy with headaches.  His father, wringing his hands, said that the headaches had been present for two years; but that the child had never been evaluated for them.  No imaging, no neurologist.  No insurance, of course.

A family friend, another child, had been diagnosed with a brain tumor.  The family of my patient was terrified.  Where to turn?  They were, reasonably, concerned about cost.

Contrast that with the woman I saw on state assistance. Read more »

*This blog post was originally published at*

When Cultural Practices Affect The Treatment Of Patients

In quite a few of the cultures in south africa people tie ribbons, strings and tassels around their own and their children’s wrists and waists. These tassels are imbibed with power to keep evil spirits at bay, I am told. If these tassels come off then the patient is completely unprotected from any and all marauding evil spirits that may be lurking around. Of course, not wanting to be responsible for the unopposed assault by multiple evil spirits, most people are fairly reticent to remove these things. I saw it slightly differently.

As a student I took my lead from my senior. If he removed the tassels then I would be ok with it. If he felt that we should respect the culture of the patient and sort of try to move the tassels out of the way of the operating area or even operate around them, despite the increased infection risk, I sort of reasoned it was his patient and even if I medically didn’t agree with him, the reasoning of respecting the patient’s culture surely held some water at least and I didn’t argue. The fact of the matter was that a number of the sisters would become quite aggressive with the doctor if they thought he was going to remove the tassels and strip the patient of his evil spirit protection, and I think some of the doctors were scared. Then one day something happened that cemented my views and actions for the future. Read more »

*This blog post was originally published at other things amanzi*

The House-Call: Physician Laments The Passing Of The Good Old Days

Nostalgia for the house-call

Not too long ago, I made a house call. As a physician accustomed to working in the emergency department of a hospital, this was quite a change of pace. But it involved dear friends and their sick child, and it was a joy. We had spoken on the phone and I had some concerns about their infant, who was stricken with a high fever. When I went to their home I took only my stethoscope. That and my experience as a physician and parent of four.

When I walked through the door on Friday evening there were candles burning as dinner was prepared. There were no florescent lights. There was none of the chaos of a waiting room. No ambulances idled outside. No bloody, angry drunk screamed profanities. No one was stood by their exam room door, arms crossed in annoyance with waiting. It was a quiet place to be; and the child, on his worried mother’s hip, was quiet as well. He was in a place where he felt safe and was thus able to tolerate my poking and prodding.

I examined him and decided that he was not seriously ill. Because his mother had described him as lethargic when we spoke, I had been concerned that he might have meningitis. This was not actually the case. His parents and I were obviously relieved.

After he was dosed with ibuprofen and put to bed, I chatted a while with his mom and dad, then left for home. As I drove home I realized that Read more »

*This blog post was originally published at*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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