Hierarchy in medicine is something almost no one talks about in the medical field. The general axiom in medicine is that the more senior the doctor, the better he/she is in the practice of medicine. This unwritten rule is generally true in most cases since with experience comes judgement which is a key skill in medicine. However the culture of not questioning decisions of seniors in medicine hurts both medical professionals and patients in the long run. In India the word of a senior physician is gospel for patients as well as for their much junior colleagues. No one is allowed to question it. We as medical students and residents are taught not question authority in medicine and sometimes punished for it too.
As a doctor who is still in the first half of his career, I come across senior doctors putting across their wrong opinions and treatments all too often. Some of them are even daring enough to present their atrocities in big conferences and some even manage to publish them in journals – pulling their weight because of their seniority. Most are due to plain ignorance or failure to keep up with the latest but some are due to more sinister reasons. A few prominent examples which come to memory:
- Ignorance: I had advised a patient to undergo Dacryocystorhinostomy- (tear duct bypass surgery)- a longer, complicated, more modern and successful procedure. The patient’s family physician who was to give a surgery fitness certificate strongly advised the patient to go for a older antiquated procedure called Dacryocystectomy (removal of the tear sac)-A much easier, quicker but with high long term complications. Obviously the elderly family physician was advising from what he was taught 30 years ago in medical school which no more holds true. I’m the sub-specialist who advised the surgery and he had no business putting doubts into patients citing outdated knowledge.
- Malpractice. There was this Radiation Oncologist who advised a 3 year old kid with Bilateral Retinoblastoma with Radiation whereas the appropriate treatment was chemotherapy followed by local focused treatments. That would have saved the child’s life as well as vision in one eye. When the patient finally landed up at my clinic, it was already too late to save the kid. Personal greed and possibly pressure to reach targets got the better of the Radiation Oncologist. It was with a lot of anguish that I came to know that the family had ignored the much younger Ophthalmologist’s correct opinion and decided to go for the wrong treatment suggested by the Radiation Oncologist – because you know he’s so “experienced”!
- Mediocrity : A 4 year old turned up in my clinic with droopy eyelid since birth along with deprivation amblyopia – which is reduction of vision due deprivation of light to the eye. The amblyopia was obviously caused due to the droopy eyelid preventing light from reaching the eye. I was surprised why a child born in a posh corporate hospital did not have his droopy eyelid corrected. The family then told me that the “very senior Ophthalmologist” working in that corporate hospital advised that droopy eyelid surgery has very high failure rates, so it is better not to do the surgery till the child was an adult-which is rank bad advice. The obvious explanation was that the “senior doctor” didn’t know how to do a droopy eyelid surgery (Ptosis correction surgery) but unwilling to admit that to the child’s parents. I tried in vain to salvage the situation by advising urgent surgery to save the child’s remaining vision but the parents were very convinced that first ophthalmologist was right and viewed my urgency with suspicion.
- Propaganda : Many national and state conferences in India are being used by the big shot doctors in their respective fields to brag about their all important self-claimed preeminence. Their presentations have not changed in 10 years time and they keep harping on and on that what they do are the best practices. Nepotism is rife and these same doctors promote their kids by providing them platforms denied to genuine candidates. Many of them are scientific frauds who pretend to be academics. While this happens, medical research coming out of India continues to be poor because of the never ending regime of these pseudo-scientists. Many established institutions publish papers with obvious fake data with erroneous conclusions but still make it past peer review because these are authored by powerful senior doctors. I’m sure this is not a problem endemic to India only and it’s varying forms must be seen in other parts of the world. These may seem inconsequential but these actually affect life, health and deaths of patients. Of course I should mention that good scientific work still gets done despite all this but discerning true scientific content is getting harder by the day.
The above examples are few among the many I come across in my practice. I have often grappled with this dilemma between respect for seniors’ opinions and the ethically right thing to do. There seems to be no mechanism in medicine where one can safely call out the senior physicians’ obviously wrong decisions/opinions/treatments. I have personally been lucky to have mentors who viewed me as an equal colleague rather than a rank inferior but many of my friends in different specialities have been punished for opposing the wrongs of their seniors. So most people stay quiet and don’t talk about it. They probably feel guilty for not speaking up. If they do speak up, they may end up suffering for it, so they go along with a path of least resistance. Most people would avoid confronting a bully- inside school or in the real world.
In the 1990s, Korean Air was having more plane crashes than any other airline. The reason-it was later found-was not due to some technical insufficiencies but due to the culture of hierarchy in the cockpit. The first officers were hesitant to point out the mistakes of the much senior commanders of the aircraft. Malcolm Gladwell talks about it in his book Outliers
But Boeing (BA, Fortune 500) and Airbus design modern, complex airplanes to be flown by two equals. That works beautifully in low-power-distance cultures [like the U.S., where hierarchies aren’t as relevant]. But in cultures that have high power distance, it’s very difficult.
I use the case study of a very famous plane crash in Guam of Korean Air. They’re flying along, and they run into a little bit of trouble, the weather’s bad. The pilot makes an error, and the co-pilot doesn’t correct him. But once Korean Air figured out that their problem was cultural, they fixed it.
Malcolm Gladwell on Culture, Cockpit Communication and Plane Crashes
What plagues modern medicine is quite similar and something needs to be done from the inside to fix it. I don’t know how this problem can be tackled completely but I do know that physicians with a conscience need to speak up. Hierarchies are important in medicine but what is also important is safeguards to bypass the entrenched systems.
This is a difficult thing to talk about for me because I’m speaking about the ills of my own profession- which I love so much. However some things need to be said or this will never find a voice.
DR. RAGHURAJ HEGDE 