In the 1950’s, a psychologist named Leon Festinger studied the bizarre behavior of a doomsday cult called the Seekers that strongly believed in an imminent apocalypse. Once the date they predicted for destruction of the world came and went, Festinger noted that few cult members openly acknowledged the obvious failure of their prophecy. Instead, they doubled down on their idea and acted in a variety of irrational ways that reaffirmed their original beliefs. This famous research led to the theory of cognitive dissonance to explain the aversion caused by two opposing ideas and the strong motivations that we all feel to resolve this discomfort. It illustrated the immense grip that core beliefs have on us all – even the persistence of the world was not enough evidence to shake the unbroken unity of those cult members.
There has been a gradual paradigm shift in cardiac surgery, called the Heart Team committee, that also causes cognitive dissonance for those accustomed to the status quo. The purpose of this committee – as it has been described in the literature – is for experts in the management of cardiovascular disease to proactively discuss cases that are being considered for high-risk surgeries. In the past, case selection has been the sole domain of the surgeon with little input provided or requested from others. However, there has been a growing recognition of the value of teamwork in complex surgery – not just in the actual performance of the cases but also in the selection of candidates. Evidence suggests that using the Heart Team approach for case selection builds communication and trust among stakeholders, breaks down silos between the departments involved in the care of these patients, and helps shift the culture away from individualism and autonomy and towards better teamwork.
Our hospital administration reacted to the potential of a new Heart Team in a way that made me think about Festinger’s research. The personal interest of our administration in this type of Team is most likely based on the reality that case selection it not just important for optimal clinical outcomes, it also influences the bottom line. Cases that are too high risk for a given facility can strain its available resources, an issue that has come under the spotlight with COVID surges and the widespread cancellation of elective surgery to preserve resources. Increased need for resources also makes high risk cases less profitable, an issue that is not irrelevant at a for-profit hospital like Mt View Regional. Since profits were at stake, one opposing idea was that those with fiduciary responsibility – members of the hospital administration – should drive the Heart Team process.
The other opposing idea is that only experts in cardiovascular disease are intellectually equipped to improve case selection and resulting quality. It is axiomatic that the Heart Team that focuses first on quality will see profits inevitably follow but the one that instead prioritizes profits will end up with neither quality nor profits. Assigning hospital administrators like the CEO, CNO, chief of staff with no past expertise in cardiovascular disease as voting members of the Heart Team raises many red flags about the legitimacy of the case selection process used by the committee.
One rational way to solve the dissonance between these two opposing ideas is to learn what other Heart Teams have done. (Spoiler Alert: None has included hospital administrators on their teams.) The University of Ottawa Heart Institute recently published the protocol for their Heart Team. They presented the results of activities and expenditures to the senior management team semi-annually as an acknowledgement that this idea was in development and not yet fully evaluated/vetted. Discussion with management allowed the team to consider changes in direction, undertake new initiatives, or see changes to their financial support. However, including administrators as part of the team to select which patients should undergo high risk surgery breaks new ground.
All of this leads us to the following question: What does it hurt to include hospital administrators on the team? It is fair to acknowledge that most quality improvement projects need the skillsets and the input of both physicians and administrators to be solved. However, selecting the best cases for surgery is decidedly not one of those projects. To elucidate what makes this “collaboration” so unholy, we should start by articulating its underlying assumptions. The main unspoken assumption is that the goals of the Heart Team – to improve quality and profitability – are equal and that both these goals cannot be achieved by focusing on quality alone. If this is true, it leads to the second assumption that physicians cannot be trusted on the issues of hospital costs or profitability. Administrators resolve their discomfort from granting power to a new committee by holding fast to a comforting old idea: physicians do not care about finance. If this new committee has any hope of guiding more responsible resource use, it must come under the control of hospital administration. It’s a pattern of flawed thinking as old as Aesop’s Fables –we feel the need to micromanage and be suspicious of the goose if we want to get more golden eggs. Pointing out that other Heart Team committees do not have administrators in attendance is no more convincing than realizing the world survived the day after the Seekers predicted its demise.
The solution to cognitive dissonance is not to seek out ways to become more comfortable in our thinking. In fact, it is the opposite. The Heart Teams that are the most effective are those that learn to become comfortable with the uncomfortable. The Heart Team asks surgeons to give up their autonomy to select cases and to be willing to hear negative feedback on their proposed choices. That has the potential to cause anger and conflict. An important point is that this meeting should not be expected to reach its peak immediately. The process requires patience. In the beginning, it can feel like we are children – lashing out criticisms that come across more like personality conflicts and acting defensively. Passion to present your ideas in the best light can spill over to being pushy and unconvincing.
Eventually, the child gains experience and grows into adulthood, granting the wisdom to recognize the difference between a critique that is reasonable compared to an unfair blanket criticism of one’s personality. One of the most important skills in medicine is learning to navigate a difficult conversation with just the right amount of assertiveness and minimal defensiveness. To accomplish this, we must learn to balance advocacy of our position and inquiry into what reality looks like from others’ points of view. This is not a skill that can be mastered intellectually or individually. It requires sitting in a room with your peers, going about things in the wrong way, and reflecting honestly on what went wrong so that it can be done better the next time.
So now the final question: Why do really smart people rely on flawed assumptions? The root cause of this shortcut is a failure of trust. It is hard to rethink assumptions about those we do not really trust. It is far better for patients if we deal with the cognitive dissonance caused by bad decisions by taking time to seek out the correct facts. That’s what good decisions are made of.
