Hierachy in Communication

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Photo by David Yellen

I’ve recently read a book by the infamous Malcom Gladwell, a best-selling author of various books at the intersection betweens sociology, psychology and cultural phenomena. The book I read is called Outliers, The Story of Success and has already been published in 2008 – so I am kind of late. The book itself is quite OK. One chapter in particular caught my attention and made we want to write this post.

We’ve recently argued that there are several things that physicians can learn from pilots, and the chapter I am speaking of in Galdwell’s book also deals with this topic. It does not talk about medicine at any point, yet Gladwell points out several unbelievably interesting findings in airline history that are all centered around how communication and cultural differences can lead to plane crashes.

In particular, Gladwell writes about the tragic plane accident of Korean Air 801. To give you an insight in what Gladwell writes about and where his arguments are leading, here is an excerpt of an Interview with him in FORTUNE magazine.

F: You share a fascinating story about culture and airline safety.

G: Korean Air had more plane crashes than almost any other airline in the world for a period at the end of the 1990s. When we think of airline crashes, we think, Oh, they must have had old planes. They must have had badly trained pilots. No. What they were struggling with was a cultural legacy, that Korean culture is hierarchical. You are obliged to be deferential toward your elders and superiors in a way that would be unimaginable in the U.S.

But Boeing (BAFortune 500) and Airbus design modern, complex airplanes to be flown by two equals. That works beautifully in low-power-distance cultures [like the U.S., where hierarchies aren’t as relevant]. But in cultures that have high power distance, it’s very difficult.

I use the case study of a very famous plane crash in Guam of Korean Air. They’re flying along, and they run into a little bit of trouble, the weather’s bad. The pilot makes an error, and the co-pilot doesn’t correct him. But once Korean Air figured out that their problem was cultural, they fixed it.

The entire chapter of more than 30 pages exclusively examines the reasons for that plane crash, and eventually the reason is a cultural one. The plane was fine, technology worked, but to reduce this to its most substantial element: the co-pilot didn’t have enough courage to let the pilot know of his failure. Why? Because it’s simply not a polite way to communicate in Korean cultural terms.

There are several other similar examples he describes, all have to do with cultural differences in language and hierarchical differences in communication.

Since this post is already getting way to long, let me get to the point. I am pretty sure these elements equally happen in modern medicine, mostly in hospitals, where teams ought to work together, yet there are strong hierarchical differences. I can mostly speak of Austria, respectively Europe, but I doubt it’s any different in the U.S. or other parts of the world.

Imagine a very senior and experienced surgeon, doing his 4th appendectomy in a row on a monday morning. Then there’s this young resident or the nurse, who are eager to be in the O.R. and thrilled to be able to work with the head surgeon. Great. But wait. What if, no matter why, the experienced surgeon does something fundamtenally wrong, that might threaten the patient’s life. Would the resident or the nurse tell the doctor “Hey boss, that’s not the way to do it”? Their career is at stake. Also, they would run the risk of embarrassing their boss in front of the O.R. staff. They think twice and oops – there was the wrong cut.

In most cases it’s not about life and death and the consequences not always imply the patient’s death, but it’s about the nuances of languages. At first, these things follow an “all or nothing rule” (either you tell the head surgeon to stop what he is doing or you don’t), but in the long run it’s also about HOW one handles such circumstances. There are mulitple stages of telling somebody that he’s wrong. Ranging from “Could you explain what you are doing?” to “Stop what you are doing, because it might kill the patient”.

It’s a complex topic. It gets even more complex when people from different cultures are working together, when co-factors such as fatigue and respect come into play, yet it’s mesmerzing and it’s so important that I really feel the urge to dig into this more.

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