Who’s Running This Mickey Mouse Organization?

The patient wishes it was Disney

The other day, a tweet came into my feed from a nurse who works at a large urban hospital. I’m not going to link to it, because my intent is not to embarrass or fight with anyone. My point has less to do with the tweet than the general tone of the comments that indicate a prevalent attitude in healthcare.

The tweet stated that a patient on her unit complained to hospital management that two nurses were having a private conversation within the patient’s hearing. One of the nurses in the conversation was coming back from maternity leave and the other was asking how she was doing. The original tweeter said she understood the patient’s response, but that people need to know that nurses are human too.

There were 45 retweets and over 1K likes in the first day. The comments were >90% in favor of the original poster’s position, with some going further to complain that there was “nothing to understand” in the patient’s position. The general consensus was that this was the nurses’ workspace, and everyone talks to each other in their workspace.

I may have an unpopular position on this, but I’ve been on both sides of the bed, so to speak. I’ve worked in several hospitals and been a patient in a few.

They call it work

When you show up to work in a place every day, it get’s kind of old. It’s work, you know? You see the same people and the same furniture day in and day out. You have the same routines, do the same paperwork, and get the same breaks just about every day. It’s boring. Yep, I get it. But for the person who isn’t there every day, it’s something completely different.

To the patient, the hospital is a wondrous place. Not wonderful, wondrous. They are scared and often in pain. Everyone speaks a different language than you. They seem to all know what’s going on, while you feel clueless. Few take the time to explain to you what is being done to you. There is equipment that looks dangerous and scary. It is a place filled with amazing and overwhelming sights and sounds in which you have little control over your own actions or what happens to you. It makes almost all patients regress to the younger psychology of a child.

What would Disney do?

This different view of the “workplace” is the origin of the disconnect between the original poster and the patient in the exchange that was described. But this isn’t limited to hospitals. This phenomenon occurs anywhere that people go infrequently but has a regular everyday workforce. Hospitals, hotels, car dealerships, and a court of law are all examples. Another example is DisneyWorld.

Very few people can just “hang out” at DisneyWorld. For most who are lucky enough to go, it is a rare event. Yet people work there every day. Don’t they get bored? Don’t they have the same problems as nurses in a hospital? Yes they do, but the difference is, the Disney cast member is taught to remember why they are there.

Ask yourself, what would be the point of a Disney park if there were no guests? Would Disney employ all those people just to keep the place looking nice? Of course not. The guests, their delight with their experience, and their wish to return, is the point of everything there. The cast members aren’t there so they can have a job; they have a job to ensure the guests have a magical experience.

This is so central to the experience of working there that the words I used to describe it are different than they would be anywhere else. The employees aren’t employees; they are cast members. The vistors aren’t visitors; they are guests. Disney is so aware of the need for cast members to be in their role when dealing with guests, that they have another term that takes getting used to. When a cast member is in an area where they can be seen or heard by a guest, they are ‘on stage.’

Can we do that?

The distinction between onstage and backstage is critical in any hospitality business, and hospitals are a hospitality business whether we like it or not. How the patient feels about their experience during their care has an actual physical impact on the outcome. And none of us went to school to learn the right treatment techniques, only to have the outcome ruined by a poor reaction to the environment of care.

When I owned an addiction treatment center, we used Disney’s onstage/backstage distinction. We taught our doctors, nurses, and counselors that the environment of care was just as important as their technique. Perhaps, that’s in part why we got better outcomes and were able to treat people on an outpatient basis that others thought required inpatient care.

So why don’t the nurses that work at the original poster’s hospital know that? In fact, she mentioned in a comment that the administration responded with reminders to keep private conversations to the break room — essentially backstage. If that hospital is like all the others I’ve worked at, lack of knowledge isn’t the problem. So why did the incident happen, and why was the general response so vociferously not accepting of the patient’s expectation?

Why don’t we?

Hospitals and theme parks are different. We’d all agree. Those of us who work in hospitals would point out the terrible stress of handling the ill, the dying, and their stressed families. It’s enough to make anyone forget why they’re there.

The difference between working at Disney and a hospital isn’t actually the intensity of the dealing with stressed people though. I’ve got to say some of the worst stress meltdowns I’ve ever seen were at DisneyWorld. Stress isn’t more real just because it makes sense to you.

Consider a family on a once in a childhood vacation. They’ve saved for years, and they bring the kid. It’s Florida. It’s hot. They have to get it all done or “we’ll have wasted all this money.” The kid is tired and just wants to lay down for a bit and watch the inviting Disney TV in his cool Disney hotel room. But dad feels the need to pack it all in because they may never get back here. It’s his responsibility to make sure kid has a good time. In spite of his intention dad ends up yelling, “We didn’t come all this way and spend all this money so you could watch TV. We’re going to the park, and you’ll have fun. Let’s hurry up!” I’ve seen cast members at Disney on the receiving end of horrific screaming as a bad as the worst I’ve seen directed at anyone in a hospital.

It isn’t the pain of the patients or the stress of the families that keeps us from remembering the difference between backstage and onstage. In hospitals it is more likely that when we are taught the distinction, we are taught by managers who have never done our jobs. At Disney, the leaders and teachers of new cast are seasoned people who have done and continue to do everything they are asking their students to do. They don’t tell people how to treat guests, they model how to treat guests. At a hospital, the teacher is more often an administrator who went to business school or an outside expert who has never worked in healthcare except as a consultant. They have to tell the employee what to do, but they cannot model it. What we lack in healthcare is a widespread, homegrown cadre of experienced people who understand how scary it is to be a patient. And why is that?

Some of the reason is historical accident, and some is unanticipated results of well intentioned efforts. Old styles of medical education, managed care, government payment for healthcare, and other factors all play a role. The end result is that we in healthcare often feel so bad about our own workplace culture and experience, that we, as all humans will, seek out the increase in dopamine tone that comes with focusing on what we have control of. In the case of medicine, that’s our clinical technique. I can’t control the electronic health record that the hospital picked, but I can focus on how well I hit the vein when starting the IV.

There’s nothing wrong with that, but the result is that we value the technical over the interactive more than it actually should be. Yes, our technical skill matters, but we aren’t executing that technique on a tire or an engine. The object of our skill is a living human being with psychological and physical responses that will happen independent of our technique but will impact its usefulness.

I have no idea if the original conversation between the nurses was benign or not. I have no idea if the patient’s reaction was reasonable or not. It doesn’t matter. The patient had the response to the environment that they had, and the environment was preventable. If you work in healthcare, you may not like my opinion. If you ever get sick of being so unfairly criticized for conversations in the hallway that you want to quit, maybe you should. You could always work at DisneyWorld.

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Howard Wetsman is an addiction psychiatrist living in New Orleans. He maintains a channel on YouTube where he has released his serial Ending Addiction. He is pursuing his goal of ending addiction by educating everyone about the genetics of addiction with this new venture GenEd Systems.

Addictionologist educating the world soon at GenEdSystems.com. Solves problems with TOC. Author of Questions and Answers on Addiction. Twitter: @addictiondocMD

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