Hospitals Must Let Doctors and Nurses Speak Out

This post was originally published on here by staff writer Conor Friedersdorf.

Nicholas Christakis says that “clamping down on people who are speaking is a kind of idiocy of the highest order.”

Throughout the United States, doctors and nurses at the forefront of the fight against the coronavirus want to share what they are seeing and hearing with the public. But some fear that doing so could get them punished or fired by hospital administrators or medical-staffing agencies. Recent press reports document that many institutions have formally warned employees against speaking out, while some have already terminated various medical professionals.

NYU’s Langone Medical Center is among the institutions that sent a written warning to its health-care workers. It later asserted in a public statement that limiting the speech of its doctors and nurses is a long-standing policy intended to protect patient and staff confidentiality. “Because information related to coronavirus is constantly evolving, it is in the best interest of our staff and the institution that only those with the most updated information are permitted to address these issues with the media,” the statement said. “We have a responsibility to the public at large to ensure that the information they receive from our institution is accurate.”

Does that rationale stand up to scrutiny? To think that through, I called Nicholas Christakis, a physician and professor who directs the Human Nature Lab at Yale. For 15 years, he has studied different contagions, including the H1NI flu. One study probed what happens when a biological contagion such as H1N1 unfolds alongside a behavioral shift, or a so-called social contagion, such as wearing masks. How quickly must a social contagion spread through human networks to arrest a biological contagion?

“When the pandemic began, I never imagined that two topics I have an intellectual or philosophical interest in—processes of contagion and issues of free expression—would overlap in the United States,” he told me. “I realize there’s a world of a difference between speech suppression by the Chinese Communist Party or a government entity. But it’s just not a good look for hospitals—and especially for academic medical centers, for which many of the doctors and nurses are on the faculty, and which have a commitment to free expression—to be disciplining their doctors and nurses in the middle of a pandemic.”

What follows is a condensed and edited version of our conversation.

Conor Friedersdorf: What specifically is wrong about policing the speech of doctors and nurses?

Nicholas Christakis: It is bad for morale. It is inefficient in the sense that we’re taking health-care workers out of commission at the time we need them the most. It is absurd that administrators are spending time surveilling the social-media posts of their personnel rather than trying to actually fix the problem by addressing inefficiencies in their hospital or sourcing [personal protective equipment]. And finally, we are not going to kill this germ with censorship! The idea that we can hide from inconvenient truths or close our eyes and pretend that the situation is not the way it is by clamping down on people who are speaking is a kind of idiocy of the highest order. I find the whole thing absurd. The sharing of information is extremely useful and important to optimize efficiency. And don’t these administrators have anything better to do? Hospitals are scrambling. Why try to run around and shut up your staff when you could be fixing supply chains or sourcing ovens to heat PPE or preparing to divide wards to separate the sick from the not so sick? There are so many urgent things to do right now.

Friedersdorf: You’ve studied a lot of pandemics and epidemics. Is there any compelling public-health reason for restricting information flows?

Christakis: I cannot see any legitimate reason for such practices. I can imagine that people will say they’re trying to tamp down on panic or to provide a consistent message to a confused public. But if anything, in my view, the ham-fisted way this is being done is going to contribute to public disbelief in experts.

Friedersdorf: One can imagine an irresponsible doctor or nurse somewhere who says something that’s false or needlessly inflammatory.

Christakis: The way we gain credibility and show our expertise is by forthrightly addressing false information or taking ownership when uncomfortable true information is released. I get the idea that there could be rumors, there could be false information, there could be inconsistent information. In fact, our own government has been inconsistent in a number of its recommendations.

Now imagine for the sake of argument that back in February, when the government was reassuring everyone that everything was okay, if people like me and other epidemiologists trying to sound the alarm had been muzzled, or told that we were giving inconsistent information when we were telling the truth. I don’t accept that we are better off silencing people saying things that we don’t agree with. I totally, fundamentally reject that, not just from a principle of free expression, but also wanting to optimally meet grave challenges. So let me tell you what I would put in its place.

If a hospital is concerned that wrong information is spreading, the way to gain credibility is to stand up in a meeting or release a public statement once a day saying, “We have heard the following things: Our nurses are reporting a shortage of PPE in our hospital. This is true! And here is the challenge we’re facing as a nation. This is what we’re trying to do about it. Or, “This is false, and here’s why we reject it. Here is the evidentiary basis.” This increases credibility when we need it. It provides the public with confidence that the people leading them or who are responsible for their lives are telling the truth. Whereas if you try to suppress it, I’m thinking, What else is the hospital hiding that they don’t want me to know? Why should I trust anything they say?

Friedersdorf: What useful things might we learn if doctors and nurses are able to speak freely?

Christakis: We might learn, for instance, that doctors and nurses need housing because they don’t want to go home to their loved ones, that they’re willing to work but would welcome it if a local hotel owner gave them a place to stay. We might learn that they need child care, and be motivated to figure out how to provide it. We might learn that they need meals or want food delivered so that they can be more efficient at work and work harder. We all know now about the shortage of PPE. The more we hear about it, or the more anecdotes or stories that people in different communities get, the more people might be motivated to share the PPE that they’ve previously been hoarding.

We might learn about hot spots that we didn’t know about, or that even though the governor of state X says nothing is wrong, actually workers in a hospital there say we have an outbreak. There are so many ways in which the frank exchange of information and the forthright confrontation of falsehoods that may circulate, perhaps as rumors, enhance our ability to fight this epidemic. A hospital that corrects a false rumor has an opportunity to enhance their credibility.

Friedersdorf: But surely some false rumors do harm.

Christakis: We have all these hucksters in our nation—including some TV celebrities, some religious figures—who are circulating falsehoods about the efficacy of certain treatments. And they’re just making a buck. These people should be despised. They are in the worst tradition of snake-oil salesmen. So much so that they were caricatured in the movie Contagion by the man who was selling forsythia.

These people are awful. They have no basis for their claims. They are lying. And they are exploiting the fear of the public. But I would not stop them from saying these awful and wrong things. Instead, I would get up and say that they are lying, as I am to you now, and why they are lying, that there is no evidentiary basis for their claims.

So what I am saying is that I am not familiar with a case where the flow of information has been shut down in ways that have been beneficial even when we are sorely tempted to shut some people up.

Friedersdorf: Because the free flow of information also bolsters public trust in experts who deserve to be heeded?

Christakis: Yes. Look what’s happening in China right now. The populace doesn’t know what to believe. There are all these indicators and rumors that deaths in Wuhan were four times as large as official figures, judging by the number of funerary urns being delivered. And when officials say yes or no, nobody believes them, because they don’t have any credibility. It is so important to not be seen as squashing the flow of information and to acknowledge your mistakes so that when you get up and say something, people believe you. That kind of credibility is incredibly important when you’re trying to organize large groups of people. Look at the send-off Captain [Brett] Crozier just got when he disembarked from the Theodore Roosevelt. His sailors knew what was going on. His credibility was enormous.

Friedersdorf: Institutions often censor their employees reflexively. Still, I’m a bit confused about the institutional incentives that are causing hospitals to crack down on employee speech, even in this anomalous emergency. If a nurse at a hospital were to tell a local newspaper, “I’m not getting the protective equipment that I need,” or to post on Facebook, “God, we’re overwhelmed. This is really tough,” that doesn’t seem like it would hurt the hospital’s consumer brand in the long run or affect who goes there two years from now for a knee surgery. Would I have found this same approach from hospitals before this pandemic?

Christakis: Yes, this managerial posture is long-standing––this effort to clamp down on information. So I don’t think it’s a new thing. I think the coronavirus heightened it. I also think it reflects a shift in the last 20 or 30 years from doctors being perceived as professionals to doctors being treated as corporate employees. The idea that some administrator is authorized to tell doctors what they can and cannot say and do comes from a shift in vision of the function of doctors in our society. Nurses too. Instead of being treated as independent professionals who swore a Hippocratic oath and are carrying out a moral calling—I mean, these health-care workers are literally risking their lives. It’s hard to imagine a more important calling than one that requires this of you. And they’re doing it for us. The idea that they can simultaneously be shut up is just offensive to me.

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