Do I Call You “Doctor” or “Professor”?

April 11, 2010
Posted by Jay Livingston

Fabio had a great post a few days ago at orgtheory about how authority structures in a hospital can be hazardous to your health. Even fatal. In the incident Fabio recounts, an anaesthesiologist could see that the patient was having a bad reaction to the surgeon’s latex gloves. But the surgeon refused to switch to non-latex gloves. Surgeons outrank anaesthesiologists, and if the anaesthesiologist had not resorted to extreme measures (threatening to disrupt the surgery in order to call the hospital administrators), the patient would have died.

My first reaction on reading this was: What an incredible asshole the surgeon must be. But Fabio’s point is that the problem is organizational not personal.* The authority structure of the hospital creates an institutionalized arrogance among doctors. The hazardous result is that information doesn’t flow upward from those “on the ground.” (Fabio’s post is here. The comments are also well worth reading.)

Then Fabio asks:

On a deeper level, what sort of organization would allow people to develop such toxic relationships?

And his speculative answer is:

. . . .a combination of high professional autonomy and a garbage can structure. Hospitals, as far as I can tell, aren’t organizations that make one product with a centrally controlled assembly line. Instead, they are a place were “problems” (patients) drift from place to place (ICU, regular, OR, etc) where they might be “solved” (stop showing symptoms) by some random assortment of people who have limited attention (the physicians, nurses, and surgeons). Each physician isn’t in charge of a patient, they do specific procedures and pass the problem along to other people.

Hmmm. Something about that description sounded familiar. So I tried a few “global replace” edits, and it came out like this:

. . . a combination of high professional autonomy and a garbage can structure. Universities are not organizations that make one product with a centrally controlled assembly line. Instead, they are a place were “students” drift from course to course where they might be “taught” by some random assortment of people who have limited attention. Each professor isn’t in charge of a student; they teach specific courses and pass the student along to other people.

I am not saying that universities are necessarily like this. But they do have the potential to resemble what Fabio calls a “toxic culture.”

* The book this anecdote comes from is Safe Patients, Smart Hospitals by Peter Pronovost. Note – not Safe Patients, Good Doctors. The problem lies in the institutional arrangements, not the individuals who work in the institution.