SUMMARY KEYWORDS
risk management, risk, patients, people, managers, healthcare, bioethics, policy, manager, protect, legal, happen, identifies, area, case, ethical, physicians, ethical duties, families, moral disengagement
Jennifer Cohen 00:04
Welcome to the Voices in Bioethics Podcast. I’m Jennifer Cohen and it’s my great pleasure to welcome bioethicist, risk manager, and professor Josh Hyatt to the podcast. Thank you so much for joining us today.
Josh Hyatt
Thank you very much. I appreciate the opportunity to be here.
Jennifer Cohen
Josh Hyatt has been in healthcare and risk management for more than 25 years. His academic interests include the relationships between health law and bioethics, risk management, and ethical and legal considerations, and LGBT health care. He’s been an adjunct and visiting professor was several universities, teaching health law, bioethics, health leadership, health policy and analysis, health informatics, and strategic management. He’s published pieces on LGBT healthcare disparities and workplace issues, social media and health care, and bioethics. He has five years of clinical experience as a psychotherapist, and he is a 2021 graduate of the Harvard Medical School Center for Bioethics. Josh, let’s begin with your work in risk management. I think most people have a sense of what type of risky behavior they’re willing to engage in, what type of risks they don’t want to engage in, but for people unfamiliar with this as a professional and academic field, what is risk management?
Josh Hyatt 01:20
Thanks. That’s a really great question and it’s really hard to nail down. In healthcare settings, it’s kind of funny, the joke is when the health, when the healthcare Risk Manager is in the hallway, people dive into the rooms to hide. And Risk Managers really are there to help facilitate safe patient care, as well as protect the institution and our providers and patients from harm, litigation and so forth. So, it’s a broad base but new profession similar to bioethics. Bioethics, as a profession itself hasn’t really been around very long. So, they’re both kind of nascent professions and there’s a lot of similarities between bioethics and risk managers. So, it’s really there to be a guidepost for providers, institutions, and to provide consultation and support to help patient safety and reduce litigation over time.
Jennifer Cohen 02:15
Okay, I want to go through a lot of what you’ve just brought up. Firstly, what does it mean to, quote, manage a risk, as opposed to collecting data on risks or communicating information about risks?
Josh Hyatt 02:30
When you’re managing risk, there’s a balance between proactive and reactive in risk management. Proactively, what we want to do is to have enough information and know what are the things that are likely to happen, that we have historical knowledge about, or we have data about, that we can prevent, actually, from happening down the road. For example, falls, you know, we want to look at, if we know that patients are likely going to be falling off of tables in radiology areas, we want to make sure that there are safety protocols in place to prevent those particular falls. On the flip side, there’s the reactive side, what happens when something does happen? Healthcare and medicine are very complicated systems, and they’re strife with error, we know that errors are going to happen. We know that mistakes are going to happen. When we look at human factors research, when we look at safety research, we know that there’s likely going to be things to happen. So, we have to have a good response and how do we manage that? How do we learn from that? So that’s really kind of how a Risk Manager looks at controlling risk as much as possible. They try to prevent it when they can, and they try to respond appropriately. When it does happen, take the lessons learned, move forward, and make systems changes to prevent further issues from occurring.
Jennifer Cohen 03:45
Okay, so risk management must be something that’s constantly adapting to facts on the ground, very evidence based.
Josh Hyatt 03:52
Yes, in fact, we joke in risk management, we call ourselves firefighters, because every day is something different and something new, you don’t really know what’s going to happen from minute to minute sometimes. And within risk management itself, you are looking at a lot of different pieces to kind of pull together and then triage what are the things that I really have to deal with? So, when people in healthcare, think about risk management, one of the very first things they think about is incident reports, something happens, you fill out an incident report. That’s really the first step by which a risk manager is often notified that something has happened and they then go into a reactive mode. Well, how do we respond to this? How do we protect our patients? How do we protect our faculty, our staff, and our institution? And what is the right thing to do on the other side of that? So, there’s that component of kind of learning from there, but then you also get consultations. So, Risk Managers are really known as consultation people. We would get phone calls all the time, from physicians, nurses and so forth saying this is happening and I don’t know how to handle this. And so, we kind of become collaborative conciliators for our colleagues, so that we can help divert and mitigate risk before it actually happens and to provide education and guidance.
Jennifer Cohen 05:16
Okay, so you’ve alluded to this already, but it’s my understanding that the field of healthcare risk management, and we should say, you can explain this, if you feel it’s relevant, that risk management is in many different fields. It’s in the financial sector and it’s, as you say, sort of a newly applied field in health care. Would you say that’s fair?
Josh Hyatt 05:37
Yeah, that’s very fair. In fact, risk management really did start in the financial sector. So, insurance companies hire or develop risk management programs to mitigate the loss of money. That’s really what they want to do. So, they would look at factors if you’re looking at commodities, right? They have Risk Managers that look at commodities, what’s likely going to happen is there going to be a big freeze and orange juice is going to tank or whatever. So, Risk Managers are always looking from a financial perspective in those areas, they’re trying to divide and mitigate the loss to the institution’s. Healthcare risk management actually started really taking root in the 1970s during the medical malpractice crisis.
Jennifer Cohen 06:20
Okay.
Josh Hyatt 06:22
So, what was happening is in the 1970s, there were these enormous medical malpractice claims and judgments that were coming out, and insurance companies were pulling out of insuring physicians and hospitals. And so, hospitals started, and insurance companies started, saying we need to have some way of reducing our risk, and then having it somewhat predictive, so that we know how to price premiums for physicians and hospitals, while at the same time protecting the overall institution of healthcare. And so, Risk Managers really were financial, initially, in the health care sector, they were really looking at insurance policies. So of course, they were very reactive so they were looking at big losses, they were looking at claims data. As you moved into the 80s and 90s, risk management started to take on a flavor of more clinical focus. They’re starting to realize, wait a minute, you know, if we reduce our risk from a clinical perspective, then it’s going to reduce the risk and the back end and the financial side of it. So, Risk Managers went from kind of a financial focus and a legal focus into more of that clinical focus. Which is why today, many Risk Managers, I’d say good majority of healthcare risk managers are nurses. And so, they’ve gone into this because they have expertise in clinical standard, they have expertise in clinical safety. And so, a lot of nurses kind of moved into that risk management side and these are often nurses who enjoy both the clinical and kind of the legal or regulatory pieces of healthcare. And so, now we’re kind of evolving even more into thinking broader about risk management, and what are the things that we can do from an analytics perspective, using artificial intelligence, all of these different technologies now to really reduce patient harm overall?
Jennifer Cohen 08:16
Fascinating. So, how does this look on the ground? Do most hospitals then have a designated Risk Management Department?
Josh Hyatt 08:25
So, I would say yes, I would say probably most hospital systems would have a Risk Manager. But Risk Managers are really different and depending on where they are, you know, people ask, like, what does a Risk Manager do? I say, well, it depends on where you work, a Risk Manager’s job is not consistent, it’s very different from place to place. Risk Managers don’t always report to the same types of people. So, in some facilities, a Risk Manager, for example, may report to the chief nursing officer. So, their focus may be more clinical, or they may report to a chief legal officer, where their focus is going to be more on claims, or they report to a chief financial officer where they focus more on getting insurance policies and setting up captives and stuff. So, really, how you practice risk management is really unique. Academic medical institutions are very different than community hospitals in risk management. They may have very similar types of risks, but the way they approach it might be very different. So, one Risk Manager is not like any other Risk Manager.
Jennifer Cohen 09:28
So, you’ve alluded to this as well that the Risk Manager has sort of two broad writs. One is protecting patients, patient safety, and the other is, in a sense, protecting the institution. They’re attending to all of these different groups, as you say, clinicians, administrators, patients, families, they have ethical duties to all those groups. Are there times when Risk Managers can find that those ethical duties conflict?
Josh Hyatt 09:54
Yes, and that’s kind of been my interest area around integrating risk management and bioethics. Most of the time, Risk Managers and bioethics think very much alike, their goal is to do the right thing. Most Risk Managers will say the right thing to do will hopefully mitigate an opportunity for loss, right, an opportunity for a lawsuit. But in order to do that, you need to have ethical constraints put into place. Not all ethical issues are going to align with risk management principles or legal principles. Sometimes ethical standards are above that of a legal standard. So, depending on the perspective of the Risk Manager, they will lean, often one way or the other, between legal and kind of the ethical side. And so, I would say that many Risk Managers that I’ve worked with in the past, they tend to lean more in the legal side, because that’s kind of more of a comfort zone. It’s more regulatory, it’s more line by line by line, right, you can follow the logic. Whereas with ethics, it does get a lot mushier, and so, you want to protect the organization and the patients, and sometimes those are going to be in conflict. That’s why it’s really important for the Risk Manager and the ethicist to really coordinate and collaborate when you come to these types of ethical and legal intersections. I encourage my colleagues and risk management to look at ethical issues as an opportunity to learn and to evolve with the ethicist, and realize you don’t have to take this on yourself, you do have a perspective and an important point of view. However, there may be other things that are happening that might even supersede that.
Jennifer Cohen 11:42
Is there a professional code of ethics for risk managers?
Josh Hyatt 11:47
There is a professional code of responsibilities.
Jennifer Cohen 11:51
Okay.
Josh Hyatt 11:52
So, the field of risk management is basically under the umbrella of the American Society for Healthcare Risk Management, and that is a affiliate group under the American Hospital Association. And so, ASHRM, which is American Site for Healthcare Risk Management, ASHRM, has set up professional standards, but not really a code of ethics. And it’s been intentional to not put in the term code of ethics, for reasons I don’t really know. There has been a lot of discussion within ASHRM about changing professional responsibilities to a code of ethics, but it’s a little different.
Jennifer Cohen 12:30
Okay, let’s turn to this main focus of your work this relationship and integration of risk management and bioethics. As you said, a lot of traditional risk management is identifying a risk and quantifying it, putting $1 number on it. And in a recent piece of yours, you wrote, ethical and just decision-making models for risk management can be a professional paradigm shift. What are the challenges, do you see, as thinking of risk management in terms of ethical decision making?
Josh Hyatt 13:01
First, it’s really the fact that the Risk Manager has a lot of stakeholders around them that have a lot of different opinions, and sometimes very strong opinions. Risk Manager can often get kind of caught in the middle of doing the right thing, but also trying to please other people, like your chief financial officer, or chief legal officer, or the physicians involved, or you know, the staff or the patient, or regulatory agencies. So, they can get pulled into a lot of different directions, which creates its own internal conflict, so to speak. And so that can be a challenge, because when you are in the position of being, as I alluded to earlier, the firefighter, right, because you’re dealing with constant change, constant events. I will tell you that as a Risk Manager, I’d be sitting in my office, and I would be looking at incident reports, I’m getting a phone call, we have a retain for an object in the OR, and somebody’s hit the water main, and somebody’s car got broken in, and so, within a matter of five minutes, your entire day is completely destroyed. Thinking through, having the time to really think through some of this stuff is a challenge for the risk manager because they’re constantly in this motion. And so, they often will need somebody on the back end to help them. And so, ethical decision making is not always at the forefront of the mind. Because oftentimes, in my experience, ethical decision making requires an opportunity to sit and reflect and think about and collaborate. And Risk Managers maybe may not have that opportunity because they have a lot of different forces that are pulling them in many different directions.
Jennifer Cohen 14:44
In your work, thinking about risk management and bioethics, are you thinking about sort of how risk management might apply to the bioethical principle, of say, patient autonomy, and how much information clinicians provide so patients can weigh risks and agree or refuse treatment. Is that the type of work that you’re doing?
Josh Hyatt 15:05
So, it’s really interesting. There’s a professor in San Diego and he wrote a paper about the management of ethical risks and the ethical management of risk, and they’re two different pieces. And so, what I did is predicated a lot of my work on these two elements. The management of ethical risks are the things that we often think about, like autonomy issues, surrogate issues, discontinuing life sustaining treatment, the things that really often will end up in a ethics committee, but also have potential litigatory, or regulatory components to it. So, these are the really highly complex clinical issues, where Risk Managers often become the de facto ethicist. If the organization doesn’t have a bioethicist, or they don’t have a strong coordinated ethics committee, many times the Risk Manager is stepping into that role, and it’s not always an appropriate thing to do. The Risk Manager is trying to manage a complicated situation many times. So that’s one area. The other side of that, though, is the ethical management of risk, which is different because, as we mentioned, there is no code of ethics for Risk Managers, and Risk Managers come from a variety of backgrounds. So, we have Risk Managers who are nurses, attorneys, physicians, administrators, and so forth. And so, they all have different points of view in how they approach risk management, and what they want risk management or think risk management is to them. And so, that is where I kind of went into that spot saying, let’s as Risk Managers, let’s step back and think about how do we make ethical decisions? How do we make decisions that are right for people? How do we demonstrate that what we’re saying makes any sense at all? Because we don’t know, we don’t really have any proof that says that our recommendations as risk managers is any better than anybody else’s. So how do we quantify that? And so, I would challenge my colleagues and say, well, can risk management be replaced with AI? Can we just develop an amazing AI program and just put that in there and let that be the Risk Manager, because obviously, that AI program, will probably be much better at pulling out preventative things, proactive stuff, breaking down root cause analysis and FMEAs and system, it may be really good at all that stuff. But does that constitute what we do? No, we do a lot more, we provide a lot of context and so, we really want to kind of think about what does it mean to be a Risk Manager? And why do we think the way that we think? And part of the problem is, is that you have so many different disciplines, in one discipline, thinking in very different ways. So, if you’re an attorney, who’s a Risk Manager at a hospital, you think about things from the perspective of the hospital is my client and so, I am representing my client. Whereas if you’re a nurse, and you’re in a risk management position, you may think more about patient safety. I’m having more empathy, so my direction is going to be more towards patient care. There’s no real one direction and so, I ask this question from time to time and I say, to whom are you beholden? As a Risk Manager, to whom are you beholden? And when I do consultation with Risk Managers, I ask them this question, and it makes people very uncomfortable, because they’ve not really thought about that. And so, when you’re looking for guidance, and I ask, to whom are you beholden? Are you beholden to the patient? Are you beholden to the doctor? Are you beholden to the institution? Are you beholden to the profession? Who are you beholden to, in this particular circumstance? Sometimes it’s circumstantial, sometimes it depends really, on the circumstance, sometimes there are overriding legal things that we just have to swallow and we may not like it or may not agree with it, but we kind of have to swallow it. But in general, risk management lives in a really big gray zone, to get us to that place of the ethical management of risk is really kind of getting us to that place of how do we make these decisions? And why do we make decisions and there is no literature on this. When I was doing my work, I did extensive lit reviews, and there’s really no literature on this area. And then I started seeing kind of an alignment with bioethics, the practice of bioethics and healthcare as having the same kinds of problems. How do you demonstrate value? How do you demonstrate that what you’re advising or recommending really is the right thing to do? And, thereby, getting support that you’re doing that because there’s a lot of things that come into play, when you’re making recommendations. If you don’t believe that your recommendations are good or strong recommendations, it’s going to create moral distress for the provider or for the Risk Manager or for the Bioethicist, and there’s always this kind of sense of doubt. Am I saying the right thing? Am I doing the right thing? And you don’t really know, and there’s really no training for Risk Managers. You don’t go out and get degrees in risk management, healthcare risk management, there is nothing like that. I’d say most Risk Managers are actually kind of put into positions and have to learn on the fly. Which is why organizations, like ASHRM, are so important because they provide the education and mentorship and foundations that are necessary, but even then, it’s still oftentimes just one person in one facility, who’s just basically trying to keep it all together.
Jennifer Cohen 20:44
Wow. Is there an ethical framework, a set of principles, that you think can be used in this project of ethical management of risk? Can, can bioethical principles of beneficence, non-maleficence, justice, can those be used, or adapted rather, to this, rather than management of ethical risk? Ethical risk of management?
Josh Hyatt 21:09
Yeah, so I mean, I think in some cases, you use the framework of the bioethics principles, right? So, you’ll use the autonomy and so forth, you’ll use that principalistic framework to have conversations about things. But does that really drive bioethical thinking? No, it really doesn’t drive bioethical thinking from a process perspective. It contextualizes cases and it’s really good for that. It’s good if you’re discussing a case, if you want to frame it in principle, and great, go ahead that works. There are other ethical constructs that I like to teach bioethicists to utilize. So for example, I like to use the Precautionary Principle. I like to teach the Precautionary Principle to Risk Managers to explain, okay, Precautionary Principle says this; if there is a circumstance by which harm can come to people, and you may not have all the information that you need to have to make a decision, you still have the right, in the obligation, to make a reasonable decision to protect people. That changes, however, when you get new information, but you don’t refrain from doing something that’s going to protect people in the long run if you don’t have all the particular information. I use that example with COVID and I was doing a presentation with some Risk Managers about withholding visitors during COVID. And so, I said in the Precautionary Principle, it makes sense that, as we’re learning about COVID, in the beginning, we’re going to limit the amount of people coming in to see patients. Our patients are sick, they’re vulnerable, we have a legal and ethical duty to protect them. It makes sense to limit that, however, we have to understand on the back end, that there is a consequence to this. So, the consequences are going to be to the patient, the patient’s not going to have the support systems they need, there’s going to be consequences to the family members, there’s going to be issues about trust and honesty, and things like that, when they’re not able to be there with their family, because this can tie into guilt and other things. And then there’s also the impact on our staff, the staff have to manage this as well. And there’s a lot of moral distress, they’re going to get yelled at, they’re going to get screamed at, they’re going to be basically watching patients dying without family members there. And there were lots of newspaper articles and stuff about nurses who would go in off duty to sit with patients who were dying because families weren’t permitted that sort of thing. So, when we contextualize Precautionary Principle in that way, it makes sense that we want to do things to protect our patients and our staff as much as we can. However, as times change, as we get new information, as we figure out different ways of doing things, then we need to adapt. Unfortunately, what happened in healthcare is not a lot of facilities adapted and they maintained this process, creating more and more and more distress to patients to family members and to staff. I think is a huge contributing factor to the moral distress and decline and why people are leaving the nursing and medical professions. This has had really significant impacts. I’ve had family members I had two family members who both passed away from COVID without having family members present or able to see them from the time they were admitted to the hospital the time that they died. And I did have my brother, his dad had been admitted into a nursing home in November of 2019, pre-COVID has dementia, his wife was a registered nurse who was retired, but still had an active license in March. Of course, when everything got shut down, they basically said you can’t come in and see him anymore, and his dementia was so advanced that he would get violent if she wasn’t able to see him. And so, she said, look, I’m, you know, I’m an RN, I’ll come in and I’ll pass meds or I’ll sweep the floors, I’ll do whatever, just so that I can – nope, we don’t, we don’t want you into the facility. And so, he decompensated so severely throughout the year. He never had COVID and it was really just dementia, he had escalated, he had gotten very violent, they had tried to do activities for him that failed, and ultimately, he kind of gave up, and he went into a really deep depression, and then eventually, he died. I believe it was either October or November of 2020. And so, from March until that time that he passed away, his wife was never allowed to see him. I find that to be unconscionable. And they tried the iPad thing, right, but with his dementia, he couldn’t understand what the iPad was and he sees his wife’s face, but he doesn’t know what was happening. And so, the stuff that they tried really, actually aggravated and made the situation worse. So, from the Precautionary Principle, I step back and say, Okay, it’s so at what point do you stop and say, okay, this isn’t working anymore. Let’s reevaluate and try something different. That was one area that I had significant distress around myself.
Jennifer Cohen 26:29
I’m so sorry for those losses, that sounds like terrible situations. And a perfect example of a policy put in place, as you say, to mitigate risk that then had downstream effects that might have been foreseeable. How much of this problem with the visitation policy do you think centered, maybe not so much around the policy, but around communication issues or a lack of collaboration with patients, their families, and even the staff around the policy? Do ethical considerations come into play there? When it comes to communications of policies.
Josh Hyatt 27:06
Oh, absolutely. And I think it starts off with the right intent, right? People understand why you’re doing it.
Jennifer Cohen 27:12
Right.
Josh Hyatt 27.14
Family members understand why you’re doing it, they get it, they understand it. But when you pass that point of what seems to be just and reasonable, then it becomes a question of this is going to not only create ethical problems, right, but it’s now going to also create legal problems, and it’s going to create risk management problems. And we’re just beginning now from the malpractice side, to start to see some of these things unwinding. And so, you know, we anticipate on the malpractice side that this is going to unwind for years, and there’s going to be a lot of stuff that’s going to be tied into this Gordian knot of what happened during COVID. And I think part of that will be how families and patients were treated, the perception of how they were treated. And this would have been a perfect opportunity for Risk Managers and Bioethicists to work together and say, we know that there are going to be downstream effects that are going to have both legal and ethical ramifications, we need to intercede now. It’s kind of the same thing happened with the rationing of health care when it came to ventilators and tests and medications. How did they get there? I spent probably six months meeting with many different health care organizations, helping them just kind of structure a conversation around how do they allocate respirators? Because on a rare occasion, you may not have enough, and then you get one from another facility or you transfer a patient. But when everybody’s down, and everybody needs them, this was not one of those kind of anticipatory things. And so, all of a sudden, they’re like, wait a minute, we can’t just rely on our normal systems, we now, actually, have to think about we’ve got five patients and three ventilators, what do we do? We have no choice, two people aren’t going to be able to be on a ventilator and these are not risk management issues, these are not legal issues. These are purely ethical issues that have legal and risk management implications. And that’s kind of the areas where Risk Managers and Bioethicists really can collaborate. And so, I was working a lot with my Bioethicist and risk management colleagues and saying, you now know that this is a thing, that this is something that can really happen, put this into your emergency management plan, work together to develop planning for this sort of thing in case it happens in the future. It’s just stuff that you don’t really think about until you kinda get hit sideways with it.
Jennifer Cohen 29:50
You wrote in a recent piece on this topic, quote, it’s often easier to act from a morally neutral place, ignoring the moral issue and defaulting to the ubiquitous and enigmatic, quote, policy than to engage in morally courageous perspective advocating for a reasonable accommodation to the policy. So that, is such an important insight and hospitals need policies, as we’ve been discussing. Yet, in what ways can it end up in being a crutch and a way not to make individual decisions that are required to make ethically?
Josh Hyatt 30:26
That’s a great point. And that’s exactly the reasoning behind that. I think that risk managers will often lean towards legal and the regulatory side, because it’s easier almost it gives more structure and guidance. I don’t mean easier in that it’s an easier decision, but it’s more natural to incline in that direction. And this particularly happens when, for example, the visitation thing. When we know in our gut, there’s a problem, we know that this is not the right way necessarily to do this long term. When we know that there are going to be problems like that, and things are going to happen, falling back on those policies. Sometimes, I mean, to the point where you almost falling on a sword where you know, you’re just gonna kill yourself by doing this, there’s no reason to do it, rethink this approach. Because we kind of in healthcare in general, Risk Managers do this. But I think in general, and healthcare, we do this, we fall back on what is comfortable, and what is in policy thinking that this policy is going to protect us. And in some cases, the policy may protect you in certain ways. But what I have found with bad, and I call them bad policies, policies that really ignore the humanity behind what it is they’re trying to do, it creates a moral distress to people, it creates, and causes harm in a lot of cases. And so, what will happen is those kinds of policies will often have lots of workarounds. And people will say, well, you know what, I don’t really want to do it this way, I don’t want to really do it that way, and they start working around it. So, sometimes just scrapping it, thinking it over, and then saying, if we’re going to make an exception to our policy, and as a Risk Manager, I did this quite frequently. I would say, you know what the policy says this, and I know that we’ve all agreed on this, but, in this one particular case, there are mitigating circumstances. And I would have to make a case to say these mitigating circumstances mean that I don’t think that this is in our best interest. And then I would escalate that into my executive leadership teams and discuss it and kind of come to some resolution. And oftentimes, not always, but often, I would be able to make exceptions to policies. But I would be clear as to why those exceptions existed. If I just defaulted back on policies all the time, there would be times that I wouldn’t have been able to sleep that night, because the policy itself was wrong, given the circumstance in which it exists.
Jennifer Cohen 32:57
I want to pick up on something you’ve mentioned a couple times now, moral distress, provider burnout, mental health. I think your mental health background really has given you some fascinating insights. You first wrote in a recent piece, something that is so straightforward but it rarely stated and so important, the need to validate ethical behavior, both of family and patients, and of staff. And you point out that validating ethical behavior will deepen the relationship, it will deepen a sense of collaboration. And crucially, the lack of validation might result in what you call behavioral slippage. Can you expand on that?
Josh Hyatt 33:40
Yeah, so for me, it’s really about aligning your values. So, if patients or your staff or your team members they feel heard and validated, that goes a long way. You don’t have to always agree with everybody’s perspectives or points of view, you don’t have to align perfectly with that, but just being heard sometimes in and of itself goes a long way. If you align with people, you get their trust, you build that trust, which both as a Risk Manager and a Bioethicist is crucial when you’re dealing with families, and patients, once you have worked to establish and build that trust based on values, because you’re looking more about what does this patient value? What does the family value? And what can we do to kind of help move this forward for them? If you don’t continue that validation process, then people will start going back and behaving in ways that are counterintuitive, or actually, actively sabotage what you’re trying to get to, because Risk Managers and Bioethicists are often trying to get to an endpoint. And an endpoint is the resolution of whatever this particular issue happens to be. And in resolution that’s going to satisfy as many people as possible with kind of a utilitarian bent, right, but still maintain the values and missions and support of the organization, the staff and the patients. When you stop validating people’s values, or you stop being consistent in your approach, that behavioral slippage will start happening, you’ll see it within families, you’ll see within patients, you’ll see it within staff. That’s why it’s, you know, I feel that you have to stay consistent and have that consistent message going forward. That we respect, honor and value, who you are as a person, what you value as a person, and we want to make that right to the best of our abilities, and keep that message kind of moving forward. And it’s much easier said than done.
Jennifer Cohen 35:49
It’s so important. I think the example I remember you using is saying something as simple to the family, if you’re the provider, I’m noticing that our last few discussions didn’t result in screaming matches, and that’s great. You know, and let’s keep that going, and just to acknowledge that and to validate that goes a long way.
Josh Hyatt 36.08
Agreed.
Jennifer Cohen 36.09
It easily goes unremarked on, so I thought that was such an important point. Another thing you’ve written about is, quote, moral disengagement among clinical staff and the danger that poses to patients. Can you discuss a little bit what you mean there?
Josh Hyatt 36:21
Yeah, so moral disengagement, it’s a phenomenon, it’s linked more to almost a defense mechanism. So, people undergo moral injury, so they experience things that caused them some kind of a moral injury, right? It doesn’t necessarily mean anything bad, it’s just it can be anything. It can be stress, it can be seeing a bad case. I did some consulting work with a hospital emergency room and they had a group that they asked me to meet with, for moral distress purposes, because they had a case that came in and it was a five year old child who was in a driveway, and the parent didn’t see them and backed over them. And it wasn’t just that the child was injured, but there was like disfigurement to the face and it was a really heinous case. They got the child, and they were able to save the child’s life, but the child was disfigured, and will have significant long term medical impacts. But the case itself impacted the provider so deeply, that they were having a hard time even focusing and concentrating on their work. And if you think about it from the perspective of like, if you work in trauma, or you work in ED, you see this all the time, and these little moral injuries really start to build up in you. And so, they create that kind of moral distress where it starts to come out and it starts to come out in different ways. It starts to come out in your behavior, it can be anger, it can be self-destruction, there’s lots of different ways it starts to bleed out, and then you see it kind of as burnout. But ultimately, where it gets really dangerous is moral disengagement. And moral disengagement is when there’s so much anxiety and so many moral injuries that have accumulated that the person almost dissociates themselves from the moral things around them. And so, it’s easier for somebody to do something unethical when they are under this kind of moral disengagement, because they’re not really connecting to the actual moral issues tied into this. And you see this in small ways and in large ways. One of the things that drives me crazy if I’m on a unit, and I hear the nurse say, oh, change seven B’s diaper, right? Drives me crazy. I’m like seven B is a human being they have a name. That is a miniature way of doing a type of moral disengagement. And so, there are little things that can lead up to bigger crises in the long term. But it’s not reflected that the provider themselves are bad. It really is a defense mechanism because they are dealing with so much past trauma. This is the only way that they can actually cope and survive, and it’s not something that they enjoy, if this was a natural state for them, they’d be a sociopath. But in these particular cases, this is behavior that’s engaged to basically survive. And it runs the gambit, like I said, can be all the way from you get home and you kick the dog all the way up to, you’re using drugs and stuff like that.
Jennifer Cohen 39:38
So interesting. Okay, let’s switch gears entirely because I want to make sure I get your views on another area of your expertise, that of LGBT advocacy within the healthcare space. What are some of the issues that you’re working on now to prevent discrimination and unfair treatment? I know you’ve done some work on medical documentation and protecting the privacy for minors. What other types of things is your expertise being applied to?
Josh Hyatt 40:05
Well it’s funny in the early 2000s, I’m an openly gay man, I’ve been out since 1988 and from then to today, the landscape has changed dramatically in a lot of different ways, in both good and bad. Towards the mid 2005, 6, 7, there was this big movement about education on LGBT issues, and so, I got tapped for doing a lot of this and I’ve done hundreds of presentations for healthcare providers on a variety of topics. But one of those I kind of fell into really is the risk management side of LGBT issues. There are risk management issues around that in the early part, it really dealt with things like visitation and fair treatment and that sort of stuff, but it’s evolved a lot. And then I would say, then it became more about transgender, and so what was interesting is that LGBT get all lumped together. LGB, lesbian, gay and bisexual is sexual orientation. Transgender is gender, they are completely separate worlds. They are completely different things, but unfortunately, they kind of get lumped together a lot, and so the issues are often very different. So, I’ve actually kind of almost taken LGBT out of my vocabulary, and I’m replacing it with sexual and gender minorities, because that’s really what we’re talking about. When we start looking back at how people viewed gay and bisexual and lesbian individuals, that has changed significantly, sociologically, I mean. There are still obviously haters, but I mean, in just reality, it’s it has changed tremendously. The Supreme Court, a very conservative Supreme Court last year, included sexual orientation and gender identity under Title Seven, to protect it under sex, which was monumental, in my opinion. So, I think that that exists, but there are still microaggressions that occur within the sexual minority community. For example, as a gay man, I can tell you that when I’ve seen a new physician in the last 15 years, only one, and there’s been many have not asked me almost immediately about my HIV status. And it’s because I’m very open about who I am, and so I would say, within the first five minutes, I get asked about my HIV status. Now, I know that that’s not common if it’s not a gay man, I understand why it is a microaggression, but it’s one of those things that exists. Transgender, on the other hand, have a completely different calculus. And they’re not necessarily coming out, they’re more in the transition process, they’re coming out as transgender, but then they have a whole different component to what they do, is this transitioning their life. They become a different person and it’s not just an element of their life. So, there’s a lot of social injustice inequities that lie within these two different domains. And then as you look at the younger groups, the millennials, and Gen Zers, and stuff like that, they’re adding in more and more terms that are things that I can hardly keep up with non-binary and queer gender, and all sorts of things. So, the definitions are expanding out tremendously. So, when I speak with providers, in fact, I just spoke with a provider group a couple months ago, I brought in somebody who identifies as non-binary to talk to them about what that means, and what does non-binary mean to that person, and so it’s really kind of reteaching that. Then if I look at it from the risk management side, there are patient safety issues. There’s things like how do you identify people on a medical record, not just for the purposes of being nice or being correct in how you address them, but for safety purpose. When you’re in the emergency room, and this has happened, I’ve seen these cases come in, you have a transgender woman come in with abdominal pain, and they take an x-ray, and they have male genitalia, but they’re a transgender woman. They’re identified as a woman in the medical record, radiology stops, they’re like, oh, we’ve got a mis-identification, because they’re seeing sex as one thing, sex is the biological sex of the individual, whereas you have gender is how the person identifies how they see themselves. And so, you know, you get mismatches on that sometimes, and that can create patient safety problems. Medications, there are some lab values that are aligned directly with gender, and so there are things like that that can cause injury and harm through misdiagnosis, delayed diagnosis. And then other things such as if you’re a trans man, they are at high risk for getting breast cancer because they often don’t have breast exams, or if you’re a trans woman, you may not ever get a PSA or have your prostate checked, but you still have it, and so there’s high rates of prostate cancer in those communities as well. Because on top of all that, you’re heightening it, oftentimes, with hormone treatments, and so forth. There’s a lot of risk management things to look at, because you have a lot of potential for making mistakes. But there’s also the social justice component, how you treat them, how you engage them in the decision-making process, involve their family and community.
Jennifer Cohen 45:32
I was reading recently that the average age for nurses and doctors in the US is 51. And I think that speaks to your emphasis on education that these concepts and this changing landscape might be something that older people are just completely unfamiliar with.
Josh Hyatt 45:49
100%, I had an argument one time with a physician at a facility I worked with, because we had a employee who used the pronoun they, and that’s how they identify was they, instead of he or she. And so, this physician was just like, I’m not calling him they, he’s a he, they is a they, and we got into this argument. I said this, it doesn’t hurt you to call them they, it may not be something that you agree with, that you understand. But, in reality, this is how this person identifies and how we treat each other means a lot. And there’s a lot of people call themselves things that I don’t necessarily agree with. But out of respect, I will do that.
Jennifer Cohen 46:32
So well put. My last question, Josh, what is next on the horizon for your work?
Josh Hyatt 46:38
I’m still doing a lot of LGBT work. I’ve just co-authored a paper around new graduate registered nurses who are being put into healthcare settings without proper mentorship and training and the safety issues to the patient, but is also to them. So, and this is in response to COVID. So, nurses are leaving the field, they’re getting these new grads, they’re not giving them proper mentorship, they’re putting them in very complicated areas, and so they’re actually endangering patients, they’re endangering themselves. Same thing is going to probably be happening with residents, I haven’t seen the data on that, but I suspect that there will be. And I’m really kind of hoping to expand internationally and look at healthcare risk management internationally, and bioethics internationally, to see where we kind of have some collaboration and overlap.
Jennifer Cohen 47:27
If people want to find more of your work and writings, where can they go?
Josh Hyatt 47:31
academia.com I do publish some of my works on that particular site. I don’t know that I necessarily have a particular place where people can go, but they can always feel free to reach out to me, my email is Hyatt, hyatt.josh@yahoo.com and you can always feel free to reach out to me there. I’m also on LinkedIn, so you can find me on LinkedIn and some of the stuff I’ve published is posted there as well.
Jennifer Cohen 47:56
Josh Hyatt, thank you for a fascinating discussion and best of luck in your future work.
Josh Hyatt 48:01
Thank you so much, I really appreciate the opportunity. This was great.
Transcribed by otter.ai