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Navigating power structures in medicine

Yale Medicine Magazine, 2017 - Autumn


If you feared that colleagues at Guantanamo Bay might use your psychiatric care notes against your inmate patients, what would you do? After a natural disaster ravaged your hospital’s resources and you overheard colleagues deciding who should live or die, would you speak up?

Sheri Fink, M.D., Ph.D., a Stanford University-trained physician, nonfiction author, and Pulitzer Prize-winning correspondent for The New York Times, described these scenarios based on interviews and research on the military prison in Cuba and the aftermath of Hurricane Katrina in New Orleans in 2005.

As keynote speaker at the 17th annual Power Day on May 12 in Harkness Auditorium, Fink observed that people can feel powerless in structures that they don’t fully control. She referred to such physical structures as hospitals without clear evacuation plans, and to such institutional organizations as the military or medical field with deeply entrenched hierarchies. “One thing to take away today—you do have a lot of power.”

Much of her talk described the moral dilemmas health professionals faced at Memorial Medical Center in New Orleans before and after Hurricane Katrina. Her 2013 award-winning book, Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital, reconstructs each day of the tragedy, sometimes minute by minute. Nurses and doctors weathered the hurricane, only to face a larger crisis as the levees broke and the city was flooded. Memorial’s backup generators, located in the hospital basement, eventually quit, leaving medical equipment, including life-saving ventilators, without power. Helicopter and boat evacuations faltered. Hospital staff—sleep-deprived, overworked, and exhausted—moved fragile patients up and down stairways, and passed them through a tunnel in a wall for access to the hospital’s helipad. Without running water, such basic tasks as helping patients relieve themselves turned into laborious undertakings.

It’s important to remember, Fink said, that at every step in every medical crisis, nurses and doctors have a choice. “Who do you save first when you know you could lose power at any moment? Who makes the choice? What will be the process of making the choice? Who’s in the room making the choice?”

These concerns are related to a primary theme in Fink’s book: how can doctors and nurses ensure that they provide care for patients when structures of command and order break down amid disrupted communications and severely limited resources?

At Memorial, health workers decided that the sickest patients—including those with do not resuscitate (DNR) orders—were those with the “least to lose” and should be evacuated last. A study published years later by the National Academy of Medicine concluded that using DNR orders “as a proxy for triage choice is not a good idea,” Fink said, adding that in general, “it’s hard enough to get people to think about end-of-life issues, and if patients do not trust how DNR will be used, they might not choose it.”

In her talk, Fink highlighted the plight of Emmett Everett, a 380-pound patient who, on the morning of September 1, asked nurses if they were “ready to rock and roll” and begin his evacuation. By that evening, Everett and at least 16 other patients were dead, their bodies filled with high levels of morphine or the sedative midazolam—in some cases, both—according to toxicology reports and interviews Fink conducted with hospital staff.

With some patients—but not Everett—near death, the decision was made to inject the patients. Some doctors and nurses followed orders. At least one doctor spoke up, outraged that his colleagues would knowingly violate the Hippocratic Oath. Were the staff powerless to make another choice? No, Fink told the medical and nursing students. “I urge you throughout your careers to be aware and alive to the fact if something is uncomfortable,” she said.

Originally conceived as an opportunity for nurses and doctors to examine the power in relationships between doctors and nurses and their patients, Power Day’s focus has expanded more recently to examining power structures in which physicians and nurses operate. “Political, economic, social, cultural, and physical structures are decided, and then those structures affect medical care,” said Nancy R. Angoff, M.Ed., M.P.H. ’81, M.D. ’90, HS ’93, one of the founders of the event. She encouraged students to think about how power shapes structure and to examine how they can address these issues in the future. “Because you will encounter these situations—maybe even on Monday,” she said.

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