TEDx is a regionalized conference that showcases “ideas worth spreading.” I had the honor to speak at the most recent event in Davenport, Iowa, hosted by Andrea Olsen, an outstanding and dedicated TEDx director.
I originally was scheduled to present at TEDxDavenport in 2020, but Covid-19 postponed the conference until late June 2022. It was worth the wait. The Alder Theater featured an enthusiastic crowd of 500 and an amazing lineup of speakers, addressing a staggering array of topics.
I enjoyed Terry Franklin’s captivating family story titled, “Bending the Arc of History” and tech exec Laurie McGraw’s talk “We still have too few women in leadership. Now what?” I found Jessie Adams’ story inspiring. She overcame many obstacles to become a participant on American Ninja Warrior. Rebecca Bender’s insights into Human Trafficking were heartbreaking. If you’ve never attended a TEDx event, I strongly encourage you to do so.
My talk “Why doctors don’t wash their hands and other medical mysteries” debuted on TED’s YouTube channel as an editor’s pick.
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Each May, in every medical school in the U.S., the graduating class rises as one and swears a sacred oath that can be traced back 2,500 years to the age of Hippocrates. Together they recite primum non nostre, Latin for “first, do no harm.” And yet, harm they will do.
Contrary to what most patients assume, there’s often a huge gap between what physicians know and how they practice. For example, doctors understand the importance of washing their hands. They know that each year in the United States hospital-acquired infections affect 1.7 million Americans and kill 100,000 of them.
Give them a quiz on germ theory and the importance of hand hygiene, and they will get an “A.” Physicians recognize that the bacterium most likely to prove lethal is Clostridium difficile or C. diff. They know it doesn’t travel through the air like the coronavirus, but instead travels on people’s hands. And they understand that soap and water or the alcohol-based disinfectants at the entryway to all hospital rooms are effective at killing this deadly bacterium. Nevertheless, numerous research studies have found that doctors in both community and academic hospitals fail to wash their hands one out of every three times they go from one patient’s room to the next. You read that correctly: one-third of the time.
To make sense of this medical mystery, let me take you back to Vienna, Austria in the 19th century. Ignaz Semmelweis has just been appointed the head of the maternity hospital in the leading academic center in Europe. He is appalled that the maternal mortality rate is 18%. And he’s embarrassed.
You see, across the street, there’s a maternity ward run by midwives where the death rate for mothers is half of what it is in the hospital run by his well-educated doctors.
How can this be? Midwives have less training, less esteem and fewer credentials. And yet they are putting some of Europe’s finest physicians to shame.
At the time, the most common reasons women died while giving birth was puerperal fever, an infection of the uterus that spreads to the whole body. Among doctors in the days of Semmelweis, the leading theory was that puerperal fever was caused by miasmas: invisible particles that wafted up from the streets and sewers beneath the rooms of patients. But if that were true, Semmelweis thought, then why aren’t these same stinky particles killing patients in the unit run by midwives?
Like many great discoveries in medicine, Semmelweis came upon the answer by serendipity. A colleague nicked his finger doing an autopsy on a woman who had just died from puerperal fever, and he went on to develop not just a hand infection, but a systemic disease with a clinical course identical to the women who died shortly after childbirth.
Semmelweis theorized that doctors must be carrying the disease around on their unwashed hands or their filthy leather aprons. He implemented a policy requiring all physicians to dip their hands in chlorinated water and put on a clean leather apron before entering the delivery suite.
Within a month, the death rate in the hospital dropped from 18% to 1.8%. Semmelweis was overjoyed. He submitted his findings to all the leading medical publications of the time. He sent letters to physician directors of maternity services around the world, outlining his incredible discovery.
And do you know what happened? Absolutely nothing. All of medicine’s leaders ignored the findings. Distraught, Semmelweis quit medicine and eventually died alone in a mental institution. It would not be until 50 years later, in the time of Louis Pasteur, that physicians would come to accept germ theory and begin to practice hand hygiene.
Why didn’t change happen, despite the facts Semmelweis brought forward? Change-management experts will tell you that, most of the time, people reject new ideas because they’re too expensive or too time-consuming. Neither was true in the maternity wards of the 1800s. It took only seconds for doctors to clean their hands and swap aprons. It cost next to nothing to do so.
What stood in the way of Semmelweis’ colleagues and contemporaries wasn’t time or money. It was culture. The culture of medicine is a culture of denial.
Patients and doctors alike see themselves as healers, incapable of spreading disease. To suggest otherwise (as Semmelweis did) is to fire a direct shot at a proud profession.
It is the same culture that persists today. Even now, despite all that doctors know about germs and the spread of disease, they still see themselves as incapable of harming a patient. And when a patient dies from a hospital-acquired infection, physicians assume that someone else must have transmitted the bacterium.
The culture of denial isn’t mastered in lecture halls or through textbooks. It is learned in medical schools and residency training, absorbed by observing more senior residents and hearing their stories.
Through the culture of medicine, doctors learn many misguided lessons. Deny your emotions: they only get in the way of objective medical care. Never admit you’re tired: even though data demonstrate that exhaustion leads to medical errors. Never acknowledge psychological difficulties or ask for mental health assistance: even though 400 physician die from suicide each year.
When I was at Stanford, my chief resident told me that if I happen to wake up feeling sick and unable to come to work, he’d better find me in an ICU bed on his morning rounds.
But the culture of denial creates a culture of heroes, a profession of people willing to put the lives of patients ahead of their own.
As a nation, we saw these qualities on full display throughout the pandemic. In the earliest days of Covid-19, doctors lacked the PPE needed to protect themselves from the virus. And yet, despite the overwhelming danger, doctors donned trash bags for smocks and taped salad lids to their faces in place of masks. They came to work for 12 to 24 hours at a time. And when patients couldn’t breathe, doctors passed endotracheal tubes through their mouths into their lungs knowing full-well that as those tubes went through the vocal cords, the patient would cough, spewing virus into the physician’s face. And they did it anyway.
The culture of medicine and the culture of denial helps save lives, but it also contributes to more than 100,000 deaths annually from preventable medical errors and complications from chronic diseases. Knowing this, I concluded my talk by pointing out three ways that patients could avail themselves of the heroic side of the culture while also protecting themselves from the unintentional harms that doctors sometimes do.
Physicians are smart, hardworking, dedicated and committed to their patients. But on occasion, the culture and the system of medicine get in the way. If you want to know what I recommended, check out my TEDx talk above.
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Dr. Robert Pearl is the former CEO of The Permanente Medical Group, the nation’s largest physician group. He’s a Forbes contributor, bestselling author, Stanford University professor, and host of two healthcare podcasts. Pearl’s newest book, “Uncaring: How the Culture of Medicine Kills Doctors & Patients,” is available now. All profits from the book go to Doctors Without Borders.
