Intelligent Disobedience – if dogs can do it, why shouldn’t healthcare staff?
As the relevance of human factors increase to cover more aspects of the safe delivery of healthcare, a deeper knowledge of how our teams work best becomes crucially important for all of us – both leaders and followers – to grasp. Within our multidisciplinary teams, being able to communicate, support, facilitate, follow and challenge appropriately is just as important as being able to lead, manage, direct, delegate and supervise. To be an effective follower requires more than blind obedience and unquestioning loyalty – it sometimes involves speaking up and questioning issues that, if unchecked, could cause detriment to the team as a whole. This is intelligent disobedience, and I’m convinced this is something that every healthcare worker needs to know about.
The term ‘intelligent disobedience’ originates from guide dog training, where a dog spends around 18 months learning how to follow a variety of commands in order to support its owner in their day-to-day life. The dog learns to navigate public areas, avoid obstacles, and perform simple tasks for owners (e.g. returning dropped objects). But the next period of training is dedicated to teaching guide dogs not to follow certain orders, when those orders are unsafe or uninformed – this is intelligent disobedience. A guide dog will not cross the road if it sees an oncoming car (which its owner may not have heard), nor will it lead them into a hole or similar obstacle, regardless of repeated commands to go forward. The dog knows that it has more information than its owner, despite their authority, and correspondingly the owners are trained to recognise these repeated refusals as a sign that unnoticed danger is present and to reconsider their plan.
So how does this apply to medicine? Perhaps much more than you would think. From speaking to friends and colleagues, there is a real reluctance of students and junior staff to speak up when an error or issue is noticed, even when it is potentially serious. These ethical conundrums form a core part of the Situational Judgement Test, the exam all medical students face in final year and which forms half of the FY1 application score. We all know the right answer – to speak out, to raise concerns, to (somehow tactfully) say ‘Ma’am, I think it is the left side we are supposed to be operating on, not the right? ’, despite discomfort and fear of personal or even professional consequences. But how many of us practice what we (so evangelically in our exam answers) preach?
Many will have heard of the famous Stanley Milgram experiment where ‘teachers’ (subjects) were instructed by an authority figure to give greater and greater electric shocks to ‘learners’ (secretly actors), despite screams of pain and warnings of fatality. Those of us who are familiar with this experiment might confess to a guilty sense of self-satisfaction; we would never do that, we think. We would stop, we would say no, we would walk out before putting someone else at risk. Indeed, 95.5% of subjects said that they would stop delivering shocks by 240 volts (300 volts was labelled ‘Danger!’, and 450 volts – the maximum – was simply labelled ‘XXX’). But when tested, less than a third of participants actually stopped at this point when under pressure to continue from a perceived authority figure (65% obedience). Mercifully, this number decreased with variations of the experiment, including having an absent authority figure delivering instructions via telephone (21% obedience), and (actor) peers refusing to deliver shocks (10% obedience).
So what does this say for the values of discipline and of following commands?
I admit, I am still getting the balance right myself. This is not an evangelist’s article where I try to persuade you all to be uncooperative, stubborn and headstrong. Nor do I wish to convey intelligent disobedience as a reason to question every command and suggestion, or to ignore systems and protocols which require compliance just for the sake of disrupting the command gradient. The importance of following appropriate systems and protocols in healthcare is often undervalued, and the barriers to doing so, underestimated. Furthermore, Ira Chaleff, a champion of Intelligent Disobedience, defines it as “finding the healthy balance for living in a system with rules and authorities while maintaining our own responsibility for the actions we take”. This article is, instead, an attempt to raise awareness of the common dichotomy that affects us as students and healthcare workers – we all say that we would speak up, but we may be too intimidated to do so, at least initially.
We say that we would reserve our criticism for a better time or place, but that opportune moment often never comes. It is difficult and awkward, and by disagreeing with your senior (who may have considered many other factors that you do not yet have knowledge of), you may present yourself as a target. Nine times out of ten your concerns are indeed unfounded and you risk ridicule and embarrassment. But that tenth time might be the difference between a patient’s life and death – or more likely (but no less importantly), their morbidity and their health. The important part is to recognise which is the one time in ten when you are seeing something that others aren’t.
This is where graded assertiveness, and the acronym PACE is helpful – it gives a framework for subordinates to raise concerns in a proportionate and respectful way:
Probe – e.g., “Would you like me to re-check the patient’s blood pressure?”
Alert – “Can I point out that the patient’s blood pressure is quite low”
Challenge – “I need you to explain to me why you are not acting on the patient’s hypotension”
Emergency – “This is unsafe, and we must stop and get a third opinion”
In practice, issues rarely escalate beyond P, and this allows everyone (from the consultant to the medical student) to save face without impacting on patient safety. It may even open up an impromptu teaching opportunity, where the senior is able to explain their clinical reasoning to the junior(s), who then come to understand the issue in a new light.
The other side of this debate is how to receive disobedience intelligently; or, more simply, what to do when someone refuses to do what you’ve asked them to do. Are they lazy? Are they being rude? Are they just not a team player? Or, do they know something I don’t? It can be very difficult to invite further criticism and discussion from someone who has just snubbed you, perhaps publicly, even in order to safeguard a patient’s health. Who are you to question my management plan, my treatment, my authority? It is for this reason that we must not just teach intelligent disobedience but also intelligent leadership, where we as healthcare leaders can recognise our subordinates’ discomfort and alleviate their concerns before going forward-whether by simple reassurance or by reassessment of our treatment plans. This flattening of the authority gradient allows junior members of the team to speak up in good faith without fear of negative consequences. A shared mental model is essential; when your team all know the explicit aims and objectives of the day, it is that much easier for them to distinguish between real concerns which call for urgent action, and those issues which perhaps do not require escalation.
We see this in practice when on placement; pharmacists regularly audit prescriptions and treatment plans on the wards, and will raise concerns where necessary in order to safeguard patients (with their pathognomonic Green Pen). Another relatable example comes from Ira Chaleff, who describes a case where a newly-qualified nurse is repeatedly instructed by a senior doctor to administer a drug which she believes is contraindicated and unsafe. He outlines the nurse’s perceived options, from discarding personal responsibility and administering the drug (‘just following orders’), to refusing to follow the order and risking professional exclusion (bringing to mind the famous Rage Against the Machine lyrics). In the end, the nurse found a suitably grey area; she prepared the drug for administration but told the doctor that if they wanted it given, they had to press the plunger themselves. This moved the doctor to reconsider their treatment and prescribe a better drug; the patient (and their interprofessional relationships) were unharmed.
This is intelligent disobedience. Use it wisely.
Chaleff I. Intelligent Disobedience: Doing Right When What You’re Told to Do Is Wrong. 1st ed. Berrett-Koehler Publishers, Inc.; 2015.
Dwyer J. Primum non tacere An Ethics of Speaking up. Source Hast Cent Rep. 1994;24(1):13-18. doi:10.2307/3562380.
Fourcade A, Blache J-L, Grenier C, Bourgain J-L, Minvielle E. Barriers to staff adoption of a surgical safety checklist. BMJ Qual Saf. 2012;21(3):191-197. doi:10.1136/bmjqs-2011-000094.
Briony Keir is currently a fourth-year medical student at Norwich Medical School, and holds a previous first class BSc in biochemistry. She first got involved with medical writing in early 2017 after reporting on the Bawa-Garba case for The Murmur and The Medical Student. Outside of medical school, she is a dedicated volunteer for St John Ambulance, and has a strong interest in clinical human factors. In 2018, she received an award from HM the Queen for personal achievement and benefit to the community. After foundation training, she would like to join an ACCS programme.