It has been over a week since a jury in Minneapolis found former police officer Derek Chauvin guilty on all counts for the murder of George Floyd. This was an important moment which delivered accountability, and I sincerely hope it will bring some measure of healing to his family and community. Nevertheless, it is impossible to ignore that during this trial and in the week which elapsed since this verdict, news reports related to the shooting of Black and brown citizens by the police have not abated. In fact, studies have shown that police violence is the sixth leading cause of death of young Black men in the United States. Full and inclusive justice for all members of our society cannot be achieved without confronting the structural racism that is present in every component of our society.
Several key moments emerged during the course of the trial which resonated deeply with me, as they relate powerfully to a key structural component embedded in many facets of our society, including the health care system. Namely, the role of hierarchies. Hierarchies in health care are intended to support patient safety. It is the belief, particularly in high-stakes situations, that the most senior and experienced individual should lead the health care team to provide the safest and most effective care to patients. Nevertheless, if hierarchies result in other members of the team not feeling empowered to speak up when they see issues, or if they experience not being listened to when they do, then the consequences can be severe — with potentially deleterious impact on patient care, the experience and education of learners, and the psychological safety of the health care team. In the case of George Floyd’s death, three other police officers, two of them in their very first week on the Minneapolis police force, were present as George Floyd died. One cannot help but wonder what role the power differential played in their decision not to speak out against the senior officer, or intervene, even with the most powerful evidence of suffering taking place directly before their eyes?
Silence in response to significant problems or issues was identified as a key factor leading to poor health outcomes by the patient safety movement, which commenced over 20 years ago with the publication of the Institute of Medicine report, To Err Is Human. One of the key reasons for organizational silence? Powerful and entrenched hierarchies, in which the unequal power relationship of medical students, residents, nurses and other health care team members towards senior clinicians encourages a focus on maintaining good relationships rather than speaking up or raising concerns. In such instances, all the value that the hierarchy might bring — namely the leadership of a senior, experienced individual overseeing team members of various levels of training — is lost through the preservation of a pernicious power differential. Such a relationship is that of a superior to subordinates, rather than the relationship of a senior clinical educator interacting with colleagues and trainees. The latter relationship emphasizes collaboration and learning, thereby ensuring the psychological safety that all members of the health care team must feel to meet the important goal of providing safe, effective, and life-saving care for patients. And yet, those on the front lines of providing care are too often the ones who feel the least psychologically safe and the least able to speak truth to power.
As the trial unfolded, I was particularly awed by the courage of the young people who recorded the events of that horrible day and bore witness to what really happened. Without their courage, the world would not have the full story of how George Floyd died, and Derek Chauvin would not have been held accountable for his actions. The pain that the youth experienced while witnessing murder, they then had to relive during the trial. This is a burden far greater than anyone should carry. But without their resolution in bearing witness, the outcome of this trial might have been very different. It is also telling and significant that in the minutes during which these events were unfolding, it was those very young people who saw the situation with the greatest clarity and who spoke up for George Floyd as forcibly as they could in an effort to save his life.
In so many moments during my career as a physician, I saw students, residents, nurses, social workers, pharmacists, and others on the health care team make important observations that changed the course of a patient’s care and brought about a better outcome. It is also my experience that students are often in the position to see what is hiding in plain sight with the greatest clarity, including the bias and discrimination which exist in health care and health professions education. We need their voices to successfully flatten the hierarchy and eliminate entrenched racism and inequities.
The Josiah Macy Jr. Foundation has been funding grants, programs, and projects with the goal of improving interprofessional teamwork, communication, and collaboration in health care for over a decade. In 2020, the Foundation launched a new strategic plan and funding priorities — including promoting diversity, equity, and belonging in the clinical learning environment — with the ultimate goal of improving health, safety, and opportunity for everyone. Without a willingness to listen to hard truths, we will not achieve these goals. The events of this last year have led us to embrace our mission with a new urgency, but also with humility and a deep appreciation and gratitude to all those who speak up in order to create a more just and caring world.