Why Are There so Many ___________s in Medicine??

flying cadeuciiAn article containing some ideas from The No Asshole Rule appeared in The McKinsey Quarterly some time ago and was summarized in The Economist.

This post is motivated by the question with which The Economist ends its little story: “If jerks cost firms so dearly, why are so many them employed?”

I think that it is a good question, and one that I have puzzled over a lot. To their point:

A study of American workers released in March found that 44 percent of Americans reported they have worked for an abusive boss. This study was conducted by the Reed Group for the Employment Law Alliance.

They surveyed a representative sample of 1,000 American adults within the past two weeks, which resulted in interviews with 534 workers.

Things are even worse in some occupations, notably medicine. A longitudinal study of nearly 3,000 medical students from 16 medical schools was just published in The British Medical Journal. Erica Frank and her colleagues at the Emory Medical School found that 42 percent of seniors reported being harassed by fellow students, professors, physicians, or patients; 84 percent reported they had been belittled and 40 percent reported being both harassed and belittled.

The full report is here. Similarly, a 2003 study of 461 nurses published in the journal of Orthopaedic Nursing found that 91 percent had experienced verbal abuse in the past month. Physicians were the most frequent source of such nastiness, but it also came from patients and their families, fellow nurses, and supervisors.

The No Asshole Rule suggests a few reasons why there are so many.

1. In our society, we value winners so much that, even if they are jerks, we tolerate, or even glorify, them because — so long as they keep making money or winning games — we think they are worth the trouble. Exhibit one is Coach Bob Knight and his long tenure at Indiana University. The administration didn’t have the courage to get rid of him because he won so many games, despite a history of atrocious behavior.

See this story and the associated 1997 video clip: It sure looks to me like he is choking the player. Knight brags that he “did it my way,” but I don’t want people doing things that way in my organization, no matter how great they “perform.”

2. Tough leaders sometimes create a climate of fear, so that those who surround them are afraid to challenge them or take action against them. If you have seen The Last King of Scotland, the Academy Award-winning film about Idi Amin, you can see an extreme form of these dynamics on display.

The same dynamics (albeit in milder form) sometimes surround corporate leaders, as their underlings are afraid to challenge them.

3. Power can turn anyone into a jerk. A large body of evidence (hundreds of peer-reviewed studies) shows that giving ordinary people power over others can make them selfish and insensitive. I wrote a detailed post about this research on my other blog.

The upshot is that giving people power causes them to be more focused on satisfying their own needs and less focused on the needs and reactions of those around them, especially those with less power. They act as if social norms don’t apply to them.

4. There are advantages to acting like a jerk, such as when an organization is set-up as a pure “I win, you, lose” game. If you work in an asshole-infested organization, being nasty to others is probably the only way to survive, let alone get ahead. Indeed, that is why I grudgingly wrote a chapter called “The Virtues of Assholes” in the book.

But if you are winner and a jerk, you are still jerk, and so you are still a loser by a more important standard. Not everyone thinks that way.

I wrote the book, and the article for McKinsey, because there is a strong business case against allowing assholes to flourish, and my hope is that if organizations begin to come to grips with the evidence, they will take stronger steps to enforce the no asshole rule.

And as I have noted here before, there are growing group of executives who believe that enforcing the no asshole rule can help them attract and keep the most talented employees.

What do you think? Why are there still so many demeaning jerks in organizations if they undermine performance (and damage the mental and physical health of others)? Why do so many of these creeps get away with it?

Robert I. Sutton is the author of “The No Asshole Rule: Building a Civilized Workplace and Surviving One That Isn’t.”  He is a fellow at IDEO and has taught at Stanford Business School in one capacity or another since 1983. He blogs at Work Matters, where he writes about business, management and __________s.  He also blogs for HBR.org,  where this post first appeared.  

9 replies »

  1. And as someone who is not in medicine like yourself, what would YOU know about good medicine? When shit hits the fan you won’t be blaming the team but the doctor.

  2. Which is more effective in achieving compliant behavior in health care, being liked or fear of being called out by a jerk ? In some cultures, the nice people verifying that a pre-surgical checklist was followed may be ignored, whereas the jerk who holds every team member accountable and calls them out when they don’t follow the checklist is an unpleasant experience everyone works hard to avoid triggering.

  3. ” Maybe we don’t have enough of the “I win-you lose” types?”

    Those people went into law.

  4. “What is an asshole exactly?”

    It appears you have provided some important answers to this question with your own behaviors. You may be the greatest surgeon in the world for all I know, but quality health care is delivered by teams, not individuals. The kind of petulant behavior you describe contributes to breakdowns in team communication and process which can directly lead to medical errors and adverse events. I wonder how many of your patients have been hurt by your behaviors? But then by your own words, you can live with it.

    It’s really quite sad that you and so many others think you have to abuse people to achieve some outcome.

    Last, you should have the guts to use your own name for this post.

  5. When Spielberg was filming Jaws, at first the shark wasn’t working so he couldn’t film it straight on. Instead, he had to shoot footage from the point of view of the shark, whcih of course turned out to be the best part of the movie, hearing the Jaws music without seeing the shark.

    So let me do something similar, and offer a defense of jerks from the point of view of the jerk. Not just any jerk, but the worst kind of jerk, a jerk with data.

    People in the places I target (the wellness industry, Community Care of North Carolina) do things they know are wrong, driving up costs and occasionally harming patients, in order to line their own pockets. They don’t really report to anyone, or if they do, they can easily fudge the numbers to make it look like they are making dramatic improvements.

    Asking nicely doesn’t work. Tried that. So what are the options other than being a jerk, which seems to be working? Under pressure from THCB’s jerk-in-residence, CCNC’s consultant admitted lying, and in wellness a whole rat’s nest of liars-and-their-cronies was unmasked (WELCOA, Health Fitness Corporation, Ron Goetzel’s Koop Committee) and admitted lying as well. Others (Mercer, Staywell, Shapeup, Propeller, Vermont) tacitly admitted guilt by not defending themselves.

    When I taught economics, I used to tell the kids (this being Harvard, most of those “kids” make a lot more money than I do today), that in economics the answer is almost never 0 or 1. Meaning, there is always an optimum. that goes for the number of jerks too — they perform a role.

    What I read in the article is some people are jerks without data, and also perhaps there are more than the optimal number of jerks in medicine. Both could be valid statements but the answer is not to eliminate jerks, but to understand and channel their value in those circumstances when they do add value.

  6. I think it is simple: people are more narcissistic and antisocial, and they are the living example of “hear the lie enough and it becomes truth”.

    Frankly, people of leadership, influence, and example in this society the last 15 or so years are characterologically impaired until proven otherwise.

    Maybe the author should follow up with “Why are people so tolerant and accepting of these a–holes?”

    Perhaps because too many identify with the a-holes to begin with?!

  7. I am a surgeon. In retrospect, there have been times throughout my career when I have been an asshole – or more appropriately for me, a bitch. But I wasn’t sorry then. And I’m usually not sorry later.

    When I am, I apologize and try to do better.

    But what is an asshole exactly? Is it being blunt to the point of rudeness, or is it being demanding? Is it being impatient on a busy day when people are being ineffective and creating an impossible backlog that is going to disrupt many other poeple’s day?

    If it’s throwing a petulant two year old’s temper tantrum (and yes, unfortunately, I’ve done that too), then certainly that behavior should be checked. If it’s over-entitlement and expecting everyone to bow down to you, ditto. But if it’s pushing yourself and others to be better and more capable, then I can live with whatever name is given for it.

  8. Being belittled seems like a low threshold. From my own experience as a medical student I can recall being the recipient of the following statement (framed as sarcastically as possible): “Do you think that a chest x-ray might have been useful?” I was embarrassed at the time and it occurred in front of a team of medical students and residents. On the other hand I was just starting out, we were rounding on 20 people, we had to get going and the attending who made the remark was entry level staff. I would consider all of those to be risk factors for sarcasm and hostile remarks.

    On the other hand I was attacked more vigorously one day when my chosen speciality was mentioned and an attending physician decided to take me and the speciality to task – even though he clearly did not know much about it.

    Since those incidents 30 years ago, I have not encountered any courses for physicians on how to lead or behave in leadership or senior positions. I have seen many great examples of physicians who were scholars, teachers, and knew how to lead by example and encouragement. None of that seems to have been formalized and I think that business strategies that set a low threshold for “disruptive” physicians simply give those in the “I win-you lose” game more leverage in getting rid of people who don’t agree with them.

    The question I would have is if there were that many physicians who were “assholes” – why has medicine in general been politically ineffective against those who have taken over the field? Maybe we don’t have enough of the “I win-you lose” types?

  9. Smart, aggressive people working long hours under stress dealing with less smart people and each other. Bad things result.