More than most professions, a medical title carries expectations as to how those above and below that status will be treated. Age, merit, and value often take a back seat to professional status and academic rank. In an almost militaristic order, medical faculty line up in front, while attendings, residents, interns, students, nurses, and other staff fall into place behind them. (p 4-7)
—From: Shell G.R., Klasko S.K.: Negotiating. Biases physicians bring to the table. Physician Exec 22:4–7, Dec. 1996.
It’s worthy to note that leadership, by definition, omits the use of coercive power. When a leader begins to coerce his followers, he’s essentially abandoning leadership and embracing dictatorship. (p. 38)
—Donald T. Phillips In Lincoln on Leadership. New York: Warner Books, Inc., 1992.
The most pernicious barriers to communication are those that never allow a conversation to live long enough to allow participants to gain understanding or ask clarifying questions. Of all things that can be used to squelch understanding and stomp a conversation to death, the easiest to call into use and to abuse is power.
There are four general sources of power (Switzler A.: Crucial conversations. Presentation at Provena Healthcare’s Leadership Institute, Chicago, May 4–6, 2006. ):
- Position
- Technical
- Tenure
- Willpower
Positional power is the power that comes from a title, or, as the name implies, position. The chief executive officer has more power than the chief operating office, at least in terms of position. A physician has more power than a nurse and a nurse, has more power than an aide. Residents have more power than medical students. Positional power is not a bad thing, as long as it is combined with some technical competence, good communication skills, civil behavior, and generally effective leadership. Unfortunately, positional power does not necessarily confer upon the individual guaranteed competence, limitless knowledge, or the ability to lead wisely. As long as the leader in a power position understands this and is willing to say “I don’t know,” or “I need your help”—in other words, recognizes his or her weaknesses and is willing to seek appropriate support—positional power is not a bad thing. It is bad when the person does not have such insight.
Technical power is the power that comes from knowing—the individual has experience, knowledge, and technical expertise that confers a certain amount of respect, and, if needed, can be wielded as a weapon. Superior knowledge makes one valuable, and therein lies the power. Individuals whose power comes from their position but who do not have sufficient technical expertise quickly learn that technical power can trump positional power, particulary in times of crisis.
In institutions of higher learning there is the power of tenure. After you have been part of the organization for a while, it is very rare to lose a tenured position. There is a different kind of tenured power, though, and much more benevolent: the power of individuals who have “been there.” This is the battle-wizened individual who has persevered through time and who assuredly carries some, if not a great deal of, technical expertise and is a valuable asset in any organization. Their opinions are often sought, and this makes them powerful, even if they don’t want the power!
The final power source can, in almost every circumstance, trump any other source of power: willpower. One individual’s perseverance (or stubbornness) can drive an organization to great success or derail a Fortune 500 company. A vindictive employee can exercise power through noncompliance, or worse—malicious compliance. There are situations where, if employees truly followed the letter of policy and procedure, the organization would break down. For example, let’s pretend a hospital has a policy requiring medical coders to perform a quality check and audit 15% of all charts monthly to ensure accuracy before the billing department can invoice patients or an insurance company. One day, the hospital’s administration decides that the audit process is too slow and they are concerned that reimbursements are too low due, in part, to inaccurate coding, and they want the coders to speed up the process and ensure better accuracy. Already overworked and understaffed, the coders put in overtime nearly every week, leading the administration to complain (paradoxically) about having to pay time and a half.
The coders are understandably upset. Behind closed doors, they decide that they will no longer work overtime hours, due to “administration’s concerns about overtime costs.” The coders’ accuracy remains excellent, but instead of being able to achieve the 15% audit mark per policy, they are now able to audit only 12%. The coders decided to be compliant with the administration’s concerns regarding overtime, but the reason for compliance was malicious—the coders knew things would get worse. Willpower trumps all other powers eventually, and it is something that can be exercised by anyone.
Physicians are among the few professionals who enjoy all four sources of power. In any patient care environment, physicians are in position power and, right or wrong, they can and do wield that power, particularly when they feel their authority is being questioned. Positional power is something often seen in academic centers, and, like everywhere else, some use it well, and some don’t.
Physicians also enjoy the power of technical expertise. Their knowledge is, in theory, greater than nurses, technicians, patients, and families. These groups look to the physician for answers and guidance related to patient care.
Tenure comes with longevity, and some physicians attain this type of power by staying within an organization for years. But tenure also comes with age itself. If a young physician just out of residency and a 20-year veteran start a new job in a different hospital at the same time, the elder of the two will have some tenure power simply because of age.
Finally, physicians can and do use willpower liberally. Willpower used by physicians can, unfortunately, be used for the selfishness of one. An example is physician resistance to using electronic medical records or unit-based team training for integrated, multidisciplinary care. The literature is replete with articles detailing implementation failures, the most common of which is physician resistance.
The importance of this section is the fact that physicians can, if they choose, start, stop, or alter any communication effort by using any one of the four sources of power available to them. Imagine, if you will, establishing multidisciplinary teams to implement collaborative rounding if the involved individuals will not give up the power they have been granted by position, technical prowess, tenure, or willpower. We must create systems in which any individual—and especially patients—at any level of the organization can confidently confront power that is being used by any individual in an attempt to inhibit open dialogue and effective communication. The way to achieve this end is by creating organizations that are built around people who live the universal Principles of Civility.
Up next in the Communication Series: Civility: The Foundation of Respectful Health Care
All content from In A Blink, by Michael S. Woods. © 2007. All rights reserved.
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