Jae Won Joh is a classmate friend of mine from Stanford. He’s a super smart, super nice guy who in his third year of medical school at Baylor. He’s also written over 400+ high quality posts on Quora.

I recently shared the Why Chewing People Out for Mistakes is a Bad Idea post with him and he got some passionate about the topic that he wrote up the following post and I felt I had to share it with the readership here. Hope you enjoy it! – Jason


Hey Jason, I loved your post about the surgeon chewing out his nurse. After reading through the post and its subsequent commentary, I strongly suspect that anyone who sides with the surgeon has never personally been in surgeries with both calm and temperamental surgeons; the difference is vast, and anyone who supports the latter type can only be doing so out of ignorance, so let’s set the record straight.

Myth #1: The 10 minute delay put the patient at serious risk.

False. Delays happen all the time in all stages of surgery–10 minutes is nothing. Surgeries that are estimated to take 3 hours regularly last 5, 6, 7 or even longer. The increase in chance of infection in 10 minutes? Probably quite minimal given the big picture–many surgeries involve giving the patient a dose of antibiotics beforehand anyways.

As for the patient’s general status, that’s what the anesthesia team is there for–they manage heart rate, blood pressure, fluid status, etc. If the anesthesia team is seriously concerned about a 10-minute delay, chances are the patient should never have been considered a surgical candidate, as I’ve seen a good anesthesia team keep someone under for well over a day.

Myth #2: Surgery is very delicate and there is no room for error.

This belief stems from the unrealistic expectation that the medical profession should always be perfect. Hate to say it, but all surgeons, no matter how experienced, make mistakes. Period. Everyone’s got slightly different anatomy, and sometimes, stuff that’s supposed to be there isn’t, and vice-versa–it’s confusing business, and yes, sometimes there are slip-ups. Thankfully, the beautiful part about surgery is that the patient’s already cut open, so you can generally fix whatever went wrong (about the only possible exception I can think of is neurosurgery). The argument that a mistake in surgery “could kill someone” and therefore justifies berating is ludicrously hyperbolic to the point of fallacy–it would be like saying a germ in my Subway sandwich “could kill me” and therefore justifies me berating the employee for not drowning his gloves in alcohol in between every customer.

Myth #3: It’s the nurse’s job to check supplies before surgery.

No, that’s not her job. Please stop thinking of nurses as monkeys responsible for all scutwork. Stocking the supply room is a tech’s job. Even if it was her job, she can’t, because…

Myth #4: It’s always known what will be needed, or possibly needed for each surgery.

When a surgery case is posted on the schedule, the surgeon is required to write the basic equipment he wants available. Beyond that, it’s whatever the specific case ends up demanding. Surgeons call for additional/different equipment all the time in the middle of surgery, because again, every case is slightly different, and has different needs that the surgeon must adapt to on-the-fly. Most of the time, the stuff is close by; occasionally, it might well have to be transported from another hospital. Anyone who thinks they can successfully predict that mess should (a) enter the stock market, (b) become a weatherman, and (c) play the lottery.

Myth #5: The surgeon’s behavior ultimately maximizes patient care.

No, it doesn’t. It just earns him a bad reputation, which actually degrades the quality of care, because now no one will want to work with him. His residents will shy away from surgeries with him, meaning they might get less experience in the long run. The staff will no longer do the small things they did as favors even though it wasn’t in their job description. And as you pointed out, his attitude stifles creativity…and anyone who thinks surgery doesn’t have a significant creative element is a fool. There is absolutely nothing about his behavior that would possibly increase the quality of care in that hospital. It would only decrease it. All because he was just impatient for whatever reason and projecting his frustration on the target with the least amount of power.

Myth #6: The surgeon was the leader of the team, and was therefore acting like a football coach yelling at a player.

No, the surgeon is actually much more like the quarterback. He may be responsible for making plays happen, but he is nothing without the rest of the team: the circulator, the scrub nurse, the resident, hell, the people who clean the OR after each case and make sure it’s sanitary. Everyone needs to work as a solid unit for things to go well. Nota bene: surgery involves tons of teamwork. People who suck at teamwork suck at surgery. Actually, that’s true of medicine as a field.

To put it musically: the surgeon is less like the director of the orchestra and more like the first violin. He might be able to pull off some sweet solos on his own, but it’s only with the backing of the full orchestra that he can deliver a majestic performance.

I have seen great surgeons at work, and they treat everyone with respect. They are loved, things get done quickly for them, and everything in general just runs smoothly because everyone involved feels that they are a part of something amazing. It is an incredible moment to see a resident thankful to be with a particular surgeon because they know the 16-hour procedure (all done while standing, mind you) will be less grueling. That resident is going to be less stressed. That resident is going to be less depressed by the fact that his dear 4-month-old daughter won’t even see him that day. And yes, this will make a difference in how he performs. :-)

Myth #7: The asshole, perfectionist surgeon is better than the nice, forgiving surgeon.

People have clearly been watching too much House. This is a true story:

An administrative official was looking through the complication rates for each of his staff surgeons, and noticed that one stuck out. He spoke to the surgeon’s colleagues, and indeed, they were quick to out this surgeon as an incompetent buffoon. Furious but curious, the official dug a bit deeper, and on a whim, played with various factors with regards to surgeries. Completely by accident, he noticed that the surgeon in question was always operating out of the smallest OR. Oddly enough, it was only when he operated in this OR that he had complications arise; whenever he was in any other room, his record was literally perfect. The official went to the staff and asked what was going on.

Turns out, no one enjoyed working in that OR because air circulation was poor and it often became warmer than was comfortable. This particular surgeon was nice enough to always let his colleagues have the nicer rooms whenever they wanted as he toiled away in the small OR with the crappy air.

The official immediately shut down the OR in question and had it renovated. Once that was done, the surgeon’s complication rates shot far below his colleagues and set a new record/standard. The colleagues who had thought him a talentless fool were having complication rates 4-5x this guy’s.

Because he was nice, the multi-million-dollar hospital nearly fired the best surgeon it had seen in decades.

~~~~

Conclusion: You were absolutely correct in saying that the surgeon should not have needlessly berated the nurse. It’s unprofessional at best and damaging to patient care at worst.

Cheers,

~The Medical Dork

I had a conversation recently with a few friends about chewing people out for mistakes that I wanted to share.

My med school friend had been observing a surgery where the surgeon had asked a nurse to get a specific item from the storage closet for use in the surgery. When the nurse got to the closet she found that they had ran out of this particular item, so she had to go all the way across the hospital to retrieve the item. She rushed back quickly, but it still took about 10 minutes – which is an eternity during surgery when the patient is already “open”, because it increases the risk of infection.

After the nurse returned, the surgeon went off on the nurse, berating her for failing to get the item back sooner and threatening the safety of this patient – even though it was not her fault that the storage closet was not properly stocked (that job laid with some third person who was not present). The surgeon chewed out the nurse so hard that she started crying and had to leave the room for almost the entirety of the surgery – meaning the operating team had make do with one less person available to help.

Some disagreement ensues

I felt that the story really underlined the reputation that surgeons have for being assholes and that his behavior was destructive and uncalled for. Surprisingly, both my trader friend and engineering manager disagreed. Their opinion was that the nurse (who was not a newbie by any measure) should have double checked all the supplies prior to the surgery and by getting chewed out, she’d learn her lesson and never let this happen again. Thus, even though the surgeon brought the nurse to tears and caused her to be ineffective for the rest of the surgery, he ultimately did the right thing in terms of maximizing patient care in the long term.

I strongly disagreed with their assessment and spent some time unsuccessfully trying to explain why.

I was so distressed by this conversation that it’s still on my mind now and I decided to write this post. So here are the 4 reasons I feel that yelling, belittling, insulting, threatening, and otherwise chewing someone out for a mistake is a really bad idea.

1. Stress inhibits initiative/creativity and encourages mindless obedience

The number one issue I have with this situation is that the nurse wasn’t even in charge of stocking the storage closet. That was someone else’s job. The surgeon wanted the nurse to take extra initiative and double check the closet – which is a great thing to encourage.

But you can’t berate some into taking initiative.

Sure, they might double check next time, but in general, when you are afraid of making mistakes, you are unlikely to take initiative to try new things. This nurse is less likely to go above and beyond the call of duty – not more. As a data point: it’s been shown that innovation efforts struggle after a firm announces restructuring efforts (a known stressor).

If you want your people to take initiative, putting them under a ton of stress for “screwing up” is not going to work.

2. When you lose control, you lose respect

When you chew someone out – it is often because you are pissed off and unleash your anger on anyone who is involved in the situation (and sometimes even unrelated people!) When you lose control of your emotions as the leader or most senior person on the team – you lose the respect of your team. You lose credibility and you lose influence.

How are you supposed to have the discipline to make the tough-but-important calls when you can’t even discipline your own emotion?

If you’re upset, it says much more about your character if you can stay calm and collected when discussing then incident – which will earn the respect of your team, making them more likely to follow your directions in the future.

3. You breed resentment which leads to turnover & passive aggressive behavior

Besides inhibiting creativity, chewing people out and making them feel bad leads to resentment, which leads to a host of negative consequences. When you resent someone, you tend to resist helping them and look for little ways to screw them. I’m sure you’ve all seen this sort of passive-agressive behavior play out in your home or work. It is toxic – you don’t want that in your workplace.

Additionally, resentment leads to people quitting. This nurse had been working at the hospital for many years – she was no dummy and had a wealth of valuable experience that can make a huge difference for patients in many ways. But if she left due to resentment or just plain burn out, that is a net negative for the hospital and for patient care.

4. You don’t get to the bottom of the problem

When you yell at someone for making a mistake and simply tell them to “never let this happen again” you are demonstrating a lack of intellectual curiosity. Most problems don’t have simple solutions – or else they would have been solved already. You need to get to the root cause of the problem.

Instead of chewing people out, a better approach might be to use the 5 Whys – a technique developed by the founder of Toyota. As the architect of the Toyota Production System describes it:

“the basis of Toyota’s scientific approach . . . by repeating why five times, the nature of the problem as well as its solution becomes clear.”

Chewing people out assumes that the problem lies with their intelligence or motivation – and if that’s really the issue – you have a bigger problem on your hands.


I guess now I have to write a post about the right way to deal with mistakes or problems with people – that will come in time but in general, two good tips would be: ask a lot of questions and work hard to set clear and agreed upon expectations.

Chewing people out doesn’t work and it’s unprofessional. So don’t do it.

UPDATE – A med school friend of mine has written his thoughts on the surgeon’s behavior: Further Thoughts on Chewing People Out