Snooping at Britney’s Chart: Why Should Docs and Nurses Have Different Rules?

Robert_wachterShould doctors and nurses be subject to different penalties for
precisely the same infraction? Of course not. Are they? Sure. Just ask
Britney Spears.Britney was hospitalized at UCLA at least
twice in the past few years –
once when she gave birth to her first son in 2005, and again in early
2008 for psychiatric care. Both times, dozens of UCLA staff members
peeked at her medical records, despite having no clinical reason to do

This voyeurism, of course, is hard wired into our DNA, and
we aren’t about to purge our inner paparazzis any time soon. But even
celebs have a right to keep their medical records private. Although the
Health Insurance Portability and Accountability Act
(HIPAA) has caused some real mischief, one of its beneficial effects is
that it put the issue of medical record snooping on our radar screen.
Whether the victim is a Hollywood starlet or your next-door neighbor,
it is just plain wrong.

Most organizations have hired HIPAA
police and done extensive HIPAA training with their staff.
Nevertheless, all the UCLA snoops were documented to have passed an
on-line HIPAA tutorial. When Britney hit the door, Inquiring People
just wanted to know.

Lest you think this is a UCLA thing, we had
a similar situation (with another famous actress) a few years ago, as
have dozens of other hospitals. In fact, human nature being what it is,
I can’t imagine this not happening – unless the rules are clear, widely disseminated, and strictly enforced.

That means for everybody. As Charlie Ornstein reported last week in the LA Times,
of the 53 people caught snooping, 18 of the non-doctors resigned,
retired, or were dismissed, while no physicians left the staff. David
Feinberg, UCLA’s chief exec, correctly noted that, “historically,
doctors have been treated in a way that may be more lenient than

Well, yes. But why?

Hospitals have
always hired nurses, respiratory therapists, pharmacists, and other
staff, paid them a salary, and established an employer-employee
relationship. Such relationships are governed by strict rules, overseen
by a Human Resources department.

On the other hand, relatively
few hospitals have hired physicians, at least in the past. Instead,
docs were usually in private practice, using the hospital as their
hobby-shop – in doing so, “bringing in the business” that kept the
enterprise afloat. This meant that hospitals needed to play nice-nice
with physicians, since the latter could always threaten to take their
business (sometimes known as "patients") elsewhere if they weren’t
treated with kid gloves. In fact, many old-time CEOs have told me that
a decent chunk of their schooling was in “how to keep the doctors
happy.” This is not a mantra that leads to the development and
enforcement of standards of behavior.

On top of this
organizational framework is medicine’s posture as a self-governing
profession – which led to the system of peer review. Whatever its
merits (and there are some – medicine is sufficiently complex that, for
many clinical decisions only another expert can reasonably judge the
conduct of a colleague), the peer review structure also meant that
discipline could only be meted out by a colleague – who, naturally, was
reluctant to be too harsh.

These forces quite logically led
hospitals to develop two parallel systems of governance, rules, and
enforcement: one for physicians, and another for everybody else. For
the staff, rules fell under an employee-employer framework,
transgressions were handled by HR (often in the context of negotiated
ground rules, sometimes involving unions), and punishment was
frequently swift and merciless. For docs, the rules (such as they were)
were fluid, enforcement was negotiated through the peer review process,
and decisions were made in the context of the organization’s strong
desire to remain “doctor-friendly.” The result is UCLA’s present
pickle, and many other similar situations.

If this seems wrong
to you, you’ll be pleased to learn that it is changing, for several
reasons. First, the nursing shortage has made it clear that nurses
really are very valuable – perhaps not as valuable as the rock-star
neurosurgeon, but valuable nonetheless. Second, more and more doctors
are being hired by their hospitals, or receive significant support
payments – creating a new environment of accountability that is less
benign than a system in which one is judged by golfing buddies through
the process of peer review. Third, and perhaps most importantly, the
patient safety and privacy movements have created the need for a
uniform set of standards that are not particularly clinically nuanced.
It doesn’t take a jury of one’s peers to understand that peeking into a
celebrity chart is wrong, nor to determine that the caregiver who
refuses to wash his or her hands before seeing patients needs to be
disciplined. It is just common sense.

This issue is particularly
important in patient safety, since all of us are trying to establish a
“safe culture.” One key element of such a culture is that there be “no
blame” for honest mistakes made by competent providers. Yet in
organization after organization, the CEO’s cheerleading for a no blame
culture is undermined (in a nanosecond) when front line staff members
realize that there are different rules for doctors and nurses. (Yes, I
know that we physicians have our own cross to bear in the form of the
medical malpractice system, but it generally addresses – poorly – a
different set of problems.)

Moving forward, we continue to need
peer review for clinical decisions, since it really does take an expert
to figure out whether a decision to anticoagulate or to operate was
clinically appropriate. But for violations of unambiguous rules and
policies (remembering that some rules and policies are dumb and need to
be broken in the name of efficiency or safety, a process known as a workaround),
there is no reason that the standards for physicians and other staff
should be different. If, as organizations consider the implications of
uniform enforcement, it looks like the physician staff will be rapidly
depleted, then perhaps the enforcement policies for the other staff
were too harsh and should be softened a bit. Both the goose and the
gander need to be treated appropriately and fairly.

In the end,
providing high quality, safe, and patient-centered care must be a team
sport.  We’ll never get there if team members are playing under
different sets of rules.

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7 replies »

  1. I have noticed as a physician another dichotomy. There exists a very clear, standardized set of steps for reporting doctors for being mean, not washong hands, etc all at the discretion of the nurse. However, when an order that I enter into the EMR and give verbally goes undone for hours while I am operating and that patient suffers, I really am clueless about how to proceed. I want to discuss it with the nurse, but then I am being mean. I suppose the answer is to “write them up”, but I’m an adult and quite busy, so the error just falls to the wayside.

  2. On the topic of privacy advocates and the current moment: I recently heard Marc Rotenberg of EPIC cite a story from Ralph Nader’s “Unsafe at Any Speed,” which eventually prompted automakers to install seat belts (among other reforms). As Marc re-told it, one automobile executive testifying before Congress said he and his family do not need seat belts: He practices reaching out his right arm to brace his children (seated in the front) when he saw danger ahead! The executive urged other people to practice the same method to protect their own families. Rotenberg went on to say, “I think we’re having a similar discussion this morning. I think we do not yet understand the responsibility that properly falls on America business when it collects and uses personal information about American consumers.”

  3. Even though I am a physician and sometimes do enjoy preferential treatment (like the one ticket I avoided during residency, I was a little relieved hearing that this often works for nurses as well), I do not really see a good basis for these inequalities pointed out by Dr. Wachter … other than what Ira B. points out, and the fact that recruiting costs for doctors are generally much higher than for RNs, even though both are in demand.
    As a side note, I have also seen it the other way around: at a large public hospital in Chicago where patients and infrastructure were neglected by nurses and ancillary staff, I heard that nearly all staff was unionized and it was impossible to fire anyone. (I cannot believe that I with my European union-friendly attitude would ever say something against aspects of unionizing.)

  4. Of course, even if they were employees, doctors are still the “faces” that get patients in the door of the hospital: I may go to a hospital to see a doctor, but not a nurse. sort of like lawyers in a firm. No one goes for the paralegal

  5. Wow, I’m astounded to learn of this dichotomy. I’m not surprised to learn it goes on, but that there exists a double standard. Thank you for highlighting this.
    I’m glad this is in the process of changing.

  6. “We’ll never get there if team members are playing under different sets of rules.”
    But this isn’t a game. Doctors operate in a more collegiate environment, where Nurses are more production-oriented. Doctors need to be relatively free to take the “blameless” risks that medicine, not being an exact science, sometimes require. Nurses need a firm floor to stand on, so they can call it like they see it, too. This, I think, is where we trip up.
    Or, Ok, I could use a sports metaphor. In football, there IS a difference between offensive and defensive lines. Such is there here.
    I agree that many elements – patient privacy, for example – should be equivalent. You break the deal, you face the wheel. This is where there should be parity, absolutely.
    I only disagree when we start to argue that somehow we can find one True List Of Rules. That promotes lazy thinking, in my experience, and, worse, encourages work-arounds. We need a sane approach to fairness, not a one-size-fits-none blanket.

  7. Love the post. I am a nurse and have seen this double standard played out many times. It is frustrating. At the hospital I work at there have been countless times a doc has verbally abused staff, practiced poor medicine, or disrespects the patients, and nothing was done. Even with video evidence, multiple complaints, and patient reports, there was little more then a hand slap.
    It has even gone so far as the trauma docs have kicked out all non-physicians from the M&M conference. Tell me where the team work in in that. A few of the administrators that do have access to this secret meeting tell me that many docs begin blamming poor outcomes on nursing. Glad we can defend ourselves.
    Thank you for the post… I am excited that accountability is being applied to the not-so-all-mighty doctors… its about time!