Sunday, December 2, 2012

Stress

     Robert Sapolsky's research on African baboons has formed the basis for much speculation about stress in primates, including humans.  It has also affected the way I run my medical clinic and informed my awareness of how employees experience their jobs.
     Sapolsky observed the dynamics of hierarchy within baboon troops and measured levels of stress hormones--cortisol and glucocorticoids (both produced by the adrenals)--in baboons who occupied different stations within the power structure of the group.  The highest status baboons--equivalent to Type A humans--actually had the lowest levels of stress hormones, whereas baboons occupying lower strata had proportionately higher amounts of cortisol.
     This means that stress is not necessarily associated with Type A personality features, however volatile and aggressive Type A's seem, but to low status within a social group.
     I have spent years working until 2 am in my clinic and carrying the weight of responsibility for the well-being of patients and the solvency of my business.  Nevertheless, being top-dog has conferred on me a degree of freedom from stress that my employees are unlikely to experience.  Since I've had more power than my employees, according to the baboon study I've experienced less stress.  According to Sapolsky's findings, the file clerk in my office is under significantly more stress than me, and so are the receptionists, billing specialists, and nursing assistants.
     Years ago, when I was determined to run a highly efficient medical clinic and make a good living to support my four children as a single mother and put them through college, I was a difficult boss.  I noticed how the staff tensed up when I arrived, and how they stayed "busy" when I walked the hallway.  I was not a very friendly person, even making a rule that employees could not say hello or good-bye to me unless I addressed them first.   My rationale was that if thirty people greeted me every morning and wanted to ask how my day was going, and those same thirty people said good-bye every evening, a great deal of time would be taken up in social niceties, and I would be distracted from my highly concentrated work in a way that could be detrimental to patient care.
      I viewed the office as a big machine that required every person to do his or her part with perfection, so that all the work got done and every patient who wanted treatment would get exactly what was needed, following current medical guidelines (known as "state of the art" medicine).
     "How many mistakes are allowed in a medical office?" I'd quip.
     My employees would answer, right on cue, "None."
     "Why not?"  I'd continue.
     "Because one mistake could cost a patient's life."
     "That's right!" I'd exclaim.  "Zero mistakes!  No one is permitted to make a mistake."
     Back then, I required employees to take quizzes every Friday, and I wrote all the questions and graded the answers.  I tested them on information that was key to performing their jobs with skill, giving them all the answers at the beginning of the week, and requiring them to know them by heart at the end. Sometimes I saw them "cramming" for a quiz over lunch at the picnic tables behind the building, sweating through the ordeal of getting all that data into their heads.  A perfect score was rewarded with a $20 bonus, while a score of 85% got $10--but those who made errors were grilled all week until the correct answers were engraved on the tablets of their memories.
     Quizzes for nursing staff would involve writing prescriptions for the top twenty medications--so that all I had to do was sign one when a patient needed it--or understanding the reasons for centrifuging blood and autoclaving surgical instruments.  Nurses had to explain the procedures for performing gram stains or urine cultures, know the most common organisms causing bacterial infections, describe how to calibrate equipment, explain the reasons for stress tests and echocardiograms, know how to catheterize a patient or debride toenails, understand common x-ray findings, and carry on educated discussions about smoking cessation, low-cholesterol diets, and weight loss strategies.  Every quiz had ten to twenty questions.
     Quizzes for front office staff would require them to understand ICD-9 and CPT coding, co-pay and deductible calculations for various insurance carriers, the proper way to answer and route telephone calls, time-frames for answering faxes and prescription refill requests, putting together bank deposits, entering charges into the computer, and filing documents in the correct sections of patients's charts.
    Billing personnel had to know from memory hundreds of codes for office procedures, explain how to apply modifiers at charge-entry and run daily, monthly, and yearly reports, read and address EOB's, answer patients' questions about their statements, and make sure every person in the office documented everything that was said and done with patients.
     I was a tough boss, but no one complained.  In fact, employees started asking me, "Do you have the quiz questions yet?"--because they wanted to study--or "What time is the quiz today?  Can I take it now?  Please?"  They would waved their bonus money in the air, proud to have gotten all the questions right, and seemed more confident when speaking with patients or performing their jobs.  For me, it meant that I could trust them with greater responsibility, while I did the work that only an MD could do.  We had a highly efficient practice.
     Now, though, I wish I had been a little more personable.  I used to view employees as extensions of myself, and felt the risk of malpractice and harm to my patients acutely.  But my staff members were probably under a lot of stress, in proportion to their status within the office, and knowing that might have made me more sensitive to their situations.  I thanked them with performance bonuses, outlining individual areas of excellence and ways to improve.  End-of-month bonuses were tied to perfect attendance and accurate clock-in times, and no one was "allowed" to get sick--"You're not taking good care of yourself!" I'd say, and admonish them not to drink and party on week-ends.  Their salaries were high, but that might not have compensated for the degree of anxiety provoked by my perfectionism.  Sometimes I wonder if I might have been kinder.
     Except for that, I doubt if I would do things differently as a medical business owner, if I had it to do again.  The medical profession is a very exacting business.  Accidentally dropping a contaminated needle on the floor and forgetting about it is much more serious than dropping a can of peaches while stocking shelves at the grocery store.  Injecting the wrong medicine could have deadly consequences, whereas using the wrong clippers at the hair salon or weeding the wrong flower bed are errors that don't result in serious harm.
     Early in my career, I asked a nurse to place a PPD (TB test) in my left forearm, and she "accidentally" used pneumovax vaccine instead:  my arm was swollen and painful the entire next week--and I felt I had to fire the nurse on the spot, telling her to seek help, because I thought she was impaired by recreational drug use.  After that, I became a crusader for accuracy and double-checking.  I insisted that employees nurture high levels of awareness about everything they did, and I gave them a lot of responsibility when I knew they could handle it.  My employees must be drug-free, extremely alert, and conscious of the risks of everything they do.  On numerous occasions it's they who have prevented me from making errors.  In this way we really do work as a team.
     Stress is a fact of life when dealing with people, and it's more apparent when patients are sick or have high expectations.  An office where everyone is treated with admiration and respect is likely to be less stressful than one where hierarchy plays a big role.  My medical degree doesn't give me the right to abuse or upbraid others.  I have tried to share everything I know with others, both patients and staff--there is no such thing as "special knowledge."
     Robert Sapolsky observed one baboon troop for thirty years.  The dynamics of hierarchy within the troop seemed fixed and cruel, with the lowest-status members suffering greatly from stress, and dying early.  After twenty years, however, something strange happened.
     The baboons gained access to a dumpster with tasty food wastes.  Naturally, only the most powerful baboons--the ones at the top of the food-chain--were able to eat from this "special" cache, since the others were edged out.  But the victuals were infected with TB, and every baboon who ate from the dumpster died of the disease.  That left only the low echelons of baboons to carry on the troop.  None of them asserted power over any of the others, strangely, and soon they formed a peaceful, egalitarian community.  The baboons seemed unwilling to replicate the prior power dynamics, like people who have overthrown a tyrant and thereafter insist on freedom and equality for all.
     When young males arrived from outside troops to find mates and began to bully the others, according to their troop's imprinting, they were quickly put in their places.  In an odd turnaround, they began to accept the new organizational parameters, and the tyranny of the original troop was never reproduced.
     Sapolsky's measurements of cortisol and glucocorticoids among these newly organized baboons showed that every single baboon now had the low stress levels that had, in the prior regime, only been the privilege of the top, Type A baboons.
     Perhaps the power dynamics of hierarchy are not necessary, or even biological, among primates--and this is the basis for democracy.  In every endeavor, including medical clinics, people can work as equals, and thereby benefit from lower stress and longer life expectancies.  What irritates me about the FBI's raid on my clinic and the government's forfeitures of my assets, is that the equalizing forces of democracy are not at play any more in my life and business.
     The presumption, of course, is that when people commit crimes they give up the privileges of democracy.  But without knowing the nature of my "crime," and denied the ability to exercise my rights as someone falsely accused, I am being relegated to the bottom of the baboon-like hierarchy in which some of us (e.g., government agents?) operate.
     Kept in darkness, forced out of business, and isolated by society and my peers, I am now at the bottom and "under stress," in every sense of the term.
    

3 comments:

  1. Dr Dr. Colasante,
    You have a bottle of fine rye wiskey with my name on the lable that I dropped off at the clinic when I left Hawthorn several years ago, and it sounds like you could use a sip.

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