Monday, May 27, 2013

The Bystander Effect Revisited

My son’s experience with his recent illness (and he is improving) made me go back to read a perspective article in the New England Journal published in January.  Entitled, “The Bystander Effect in Medical Care” the article retold the story of Kitty Genovese who, in 1964, was brutally murdered while 38 witnesses either saw the attack or heard the victim’s screams.  Following this tragedy, much research went into studying the “bystander effect” which was described as the human tendency to be less likely to help when other people are present.  Those studies found that the diffusion of responsibility is a major element of the effect.  If a large group of people are involved in a process, any one person will assume that the responsibility belongs to someone else or they will assume that action has already been taken.  If you think about this in less urgent matters, you can see this effect when a power outage affects a neighborhood.  Who calls the power company and who assumes that since the entire neighborhood is affected, someone else will call?  That is a common example of the “bystander effect” at work. 

The authors of this article related this effect to limits on resident work hours, the increase in subspecialty care, and the large number of health professionals involved in a patient’s care when they are hospitalized leading to a lack of coordination of care and lack of ownership any one doctor feels for a patient.  I would add in the role of the hospitalist which while potentially improving the quality of hospital care removes the primary care physician from the team.  It is the primary physician who will need to help the person through the transitions from the hospital and back to full health.  They point out the important question that is often not answered, and was not answered in my son’s hospitalization, “Who is my doctor?”  I have to add a question, that being “Who is my patient?”  All too often a contributing factor to the bystander effect is that many doctors see each patient as a disease or the “person in room 225”.    The authors of the article noted that “research also suggest that bystanders are far more likely to intervene when they are friends with one another” and then make the argument that the health professionals have to talk more and integrate more to empower more decision-making.  In other words they need to be friends with each other.  They leave out the crucial aspect of seeing the patient as your friend: seeing the patient as a person in need rather than a grouping of symptoms or a diagnostic dilemma.  Teamwork is great but knowing that Mrs. Smith who is now in the bed in front of you, spent twenty years teaching and had three children and five grandchildren and was seen as a rock to all those who knew her may be much more important.  I suspect that if any of those 38 people who heard the screams of Kitty Genovese knew her personally, they would have been much more likely to act in her defense. 

Dr. Kent Bream in a letter to the editor published in April reacting to the January article wrote that the standards and rules that we now pay strict attention to, while certainly improving care in  many ways, also “ensure a polite, rote production of services” and that “our profession should lead us to favor patients over production”. 

In medicine we are often in the business of finding and treating the uncommon event that can be catastrophic.  That can lead to inefficient production of services.  Health care is only effective (even if potentially less efficient) when we take ownership of the person who sits before us in need.  It is always about the person and not only the pathology.  Understanding the unique needs of the individual and addressing those needs as we would for a friend is a key to proper care.  That prevents the bystander effect. 

I learned that lesson many years ago.  As an intern in Chicago, I was in the Cardiac Care Unit and a writer from Chicago Magazine was there and wrote a piece about the work of that unit.  When it came out, a boxed story told of my caring for a 90 year old man in the unit who was unconscious.  I was quoted as telling the writer that the history was that this man had been sharp and active until the day before this event and was active in his community and with his family.  Therefore the idea of doing less for him than for a younger person was just not right.  I am proud as I look back on that that I knew the person and not just the situation of a 90 year old unconscious man in a cardiac unit and that I, even though I was just an intern, took ownership for the care of that person. 

So this is my call to arms.  Medical professionals and all health care professionals cannot be cogs in a machine.  We cannot be bystanders.  We must be the “friends” to our patients and take action when action is needed rather than assume someone else will do it.