More/Much More on the Complexities of Helping

Some more reasons why accepting offers of help aren't easy

By Suzanne Gordon and Susan Somerfeldt

You would think that accepting offers of help is a no brainer, not only for those who work on high functioning teams, but in any workplace or professional relationship. Somebody either directly or indirectly expresses the need for help and, if a team member offers that help, it’s readily accepted. (Similarly, you’d think that offers of help to patients are also eagerly accepted). Ask anyone in the so-called helping professions, and you find that offers of help – whether of helpful advice, help getting access to needed services or resources, help accomplishing tasks or help getting medical treatment are not always accepted or may even be gruffly rejected.

That’s because accepting help is very complicated. First, people may not agree that help is needed or that the kind of help that is offered will, in fact, be helpful. Some offers of help come with so many strings attached that they are deeply suspect. Some may be perceived as serving the needs of the helper than the person who needs assistance.

Even when offers of help seem to be unambiguously positive, they may be viewed as unwelcome and spurned. That’s why the staff at the Women’s HIV Program (WHP) at UCSF in San Francisco spend so much time strategizing about how to offer help to patients who might otherwise (and sometimes still do) reject those offers. A patient may perceive an offer to help them get to an appointment, deal with an elderly parent or child, or fill out application forms (to name only a few of the offers of help we’ve observed) as belittling. The patient may believe that the doctor, nurse, therapist, is suggesting that “I can’t do it myself.” This may in turn, reflect a deeper sense of shame born of the belief, all too common in our society, that people should be able to take care of themselves even when they don’t have the skills, resources, or ability to do so.

This isn’t only a problem for patients in the program. It can be a problem for staff as well. That’s because team members socialized in our highly individualistic, status and hierarchy obsessed healthcare culture, may interpret requests for help as a sign of weakness or a negative assessment of their knowledge, and skill. It may also be perceived as a direct or indirect challenge to their authority. Asking for or accepting help can be viewed as an unacceptable (and shameful or embarrassing) admission that one has gaps in knowledge, can’t do everything by themselves, can’t be the boss, or can’t handle anything thrown at them at any time.

It’s hardly surprising that people feel this way. Healthcare training often involves countless years of learning how to master – on one’s own – significant amounts of information and data, make on the spot decisions, and display -- to patients and colleagues alike --that one is a respected expert in one’s field. While this definition of mastery takes on different forms depending on the healthcare profession, it is ubiquitous.

Medicine may exercise a legal hold on diagnosis and treatment, which it sometimes grudgingly shares with “allied” or “mid-level” professionals (a dubious formulation that should be immediately discarded, see SG’s essay in the BMJ here). Nurses, however, make an equally strong moral claim to caring, compassion, and a deep understanding of the patient’s innermost being and needs, thus asserting superiority over social workers or psychologists. Whatever the profession or occupation, healthcare education is almost always conducted in silos and includes some variation of ingroup versus outgroup, us -against- them (we are better than they are) socialization. None of this encourages collaboration or interdependence during the educational phase of professional training.

While it’s true that there is more focus on interprofessional or interdisciplinary care in healthcare education, it is often superficial, episodic or lessons are given that are out of the context of real life experience, which is often very different than examples used in a training session or one off experience with learners from other disciplines. When learners move into the professional setting, the structure of our healthcare system does not reverse, but instead tends to reinforce, siloed practice or even competition. In too many practice settings, the kind of helping that is born of true collaboration and interdependence is subverted. It’s held hostage to concerns about the maintenance of toxic hierarchy and status, an emphasis on revenue maximization, scarcity of time, or punitive pedagogies that are grounded in the notion that humiliating a learner will produce an expert and safe clinician.

Consider, for example, the story a nursing student recently shared with Suzanne. The student was in an endoscopy suite observing a resident and gastroenterologist attending as they scoped a patient. At one point in the procedure, the attending turned to the resident and asked him to make a complex mathematical calculation in his head. He froze. The attending asked the nursing student if she could make the calculation, which she did. The attending then turned to the resident and snidely remarked, “see even a nursing student could do it.”

When Suzanne heard the story, she shuddered to consider the downstream consequences. Unless, he had a whole lot of different experiences during the rest of his training, when that soon to be practicing physician was on his own, Suzanne wondered if would he ever admit to gaps in knowledge, ever ask for help from someone he considered a subordinate, or a superior, or even from a peer? Suzanne worried that he wouldn’t and that a patient might be harmed, or even die, as a result.

Or what about the common complaint we’ve both heard from some attending physicians as they supervise residents. These physicians wonder why residents don’t call them more often when they are in the hospital at night or on the weekend dealing with complex patients without the presence of an attending who obviously has far more expertise. We know, the attendings tell us, that the residents must have many, many questions but they never call us to ask them. We’ve often suggested that attendings call the unit and ask the resident how things are going. “We know this patient is very complex, is there anything we can do to help? Any questions you might have that we could answer?” That kind of offer of help would perhaps overcome the residents’ reluctance to admit to gaps in knowledge (which many residents believe would count as a mark against them).

The complexities of offering -- and encouraging people to solicit or accept offers of -help is something that staff at the WHP understand not only as they work with patients but with each other.

In our next column we will describe some of the ways that WHP staff grapple with these complexities, offer help, and help one another to accept those offers.

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