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Why are Relationships So Difficult to Address in Health Care?

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When I started my pediatric emergency medicine fellowship this year, after a one-year break from practicing medicine, I walked in with a palpable sense of “impostor syndrome.” My mixed emotions and feelings heightened when I saw a patient with a complex finger laceration that needed a digital block. I hadn’t practiced in a year, and even writing this now some part of me is ashamed to admit I had never performed a digital block.

I was nervous to reveal to my attending that I didn't know how to perform the procedure, and I was unsure how she would react. I managed to squash my hesitation, reminded myself that this is exactly what I was here to learn, and admitted to my attending that this would be my first. 

She immediately reassured me, told me she would walk me through everything I would need to do, and that in the end, the patient would receive the care they needed. I am very proud and fortunate to be a part of an institution that is accepting and encouraging in the face of vulnerability, but I am no stranger to the fact that the culture of health care is not always so forgiving. 

The predominant culture of effectiveness and efficiency in health care has helped to introduce many useful measures and streamline hospital care. On the other hand, our narrow focus on measures, related to those two qualities, has made teamwork and collaboration foreign and challenging in the health care setting. 

Esther Perel, a Belgian psychotherapist, introduced the fascinating concept of relational dowry — the idea that our past relationship experiences and upbringing affect how we communicate, collaborate, and lead in the workplace. Some individuals have a more “central relational dowry,” meaning that they integrate and rely on others in the workplace. Others have a “peripheral relational dowry,” where they are task-oriented and focus little on building connections. 

I grew up in a big, tight-knit Indian family where relationships gave me a sense of purpose, meaning, belonging, and connection. The relationships I built were the goal, not merely a means to an end. Yet, as I entered the world of medicine as a pediatrician, in every stage of my training, relationships were always peripheral; my lectures focused on patient outcomes but not on improving workplace dynamics. Why are relationships so difficult to address in health care?

Many factors make it difficult for individual clinicians to build bonds with one another: pressure to perform; the hierarchy in health care; the in-built competition for resources, prestige, and power; a lack of time; and constantly evolving health care teams. One of the biggest challenges clinicians face is their struggle with vulnerability. Physicians are not comfortable asking their peers for help. For many physicians, doing so can feel like acknowledging that you are not knowledgeable or capable of performing your duty; it brings up a fear that other physicians will judge you as inferior, or even as not fit to care for patients.

Physicians' fears are not entirely unfounded. In my training experience, I have witnessed occasions where a senior physician aggressively berated a trainee for lacking certain knowledge or skills. In this culture, physicians become adept at hiding their weaknesses rather than fixing them.

Organizations rarely focus on addressing relationship dynamics directly. Even world-renowned and powerhouse institutions focus on only two aspects of teaming: team structures and team processes. They want the team to have similar goals to deliver the best patient outcomes and generate the most profit. Restructuring and defining processes can be critical, but they do not directly address the organization’s culture. To accomplish the latter, institutions should consider how teams do the following: disagree, deliver criticism, share and promote ideas, provide transparency, and show accountability.

We can take many steps to promote a more collaborative and vulnerable culture. We must create time and opportunities for relational interactions across departments. Time and opportunities that would allow clinicians to shift their identity from being specific and isolated (e.g., "internist," "pharmacist") to one that's more general and shared: "healer." We can also build collaborative commitments into every clinician’s daily schedule. 

Lastly, transparency is the most important thing we must introduce in the hospital. When our leaders and seniors can acknowledge mistakes, flaws, and gaps in knowledge and capability, it will have a profound trickle-down effect on the organization's culture. Improving the quality of our relationships within the hospital walls can help instill more passion, increase collaboration, improve patient outcomes, and serve as a significant step forward in enhancing clinician well-being.

How do you find the courage to be vulnerable in environments that seem inimical to emotion? Share your experiences in the comments below!

Niharika is a pediatric emergency fellow in Austin, Texas who is passionate about using health communication and innovation to improve patient outcomes and reduce provider burden. She can also be found on twitter @DrNGspeaks

Image by GoodStudio / Shutterstock

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