Axing the totem pole

Are you afraid to challenge decisions by senior colleagues – or to acknowledge challenges from juniors? Here Dr Michael Moneypenny asks doctors to consider the consequences of authority gradients

  • Date: 01 October 2013

IN 1999 the Institute of Medicine – an American medical NGO – published an influential paper entitled 'To Err is Human' in which it reported that between 44,000 and 98,000 people die in the US every year due to preventable medical errors. The paper led to a push for patient safety in the US with the goal of a 50 per cent reduction in errors over the next five years.

Sadly this goal has yet to be achieved but the paper is also notable for the first mention in the context of healthcare of a term more commonly associated with the aviation industry – authority gradient (AG). The IOM paper called for the need to "develop a working culture in which communication flows freely regardless of authority gradient".

Today authority gradients are much discussed in connection with patient safety. A seminal paper on the subject written in 2004 defined authority gradient as "a significant difference (between two people) in experience, perceived expertise, or authority"(1). The terms "power gradient" and "power distance" are also used interchangeably with AG.

Just as the authors of the 2004 paper make clear, it is important to keep in mind that the AG is a perceived gradient. It may be that a person has a great amount of authority over another, but the actual authority gradient may be shallow and dependent upon how the two people interact over time.

As all of us who work in healthcare appreciate, the various professions (medicine, nursing, midwifery, etc) are hierarchical and authority gradients exist in many of our daily interactions. AG is important, both as a concept and as a term to add to our vocabulary, because it is a major cause of morbidity and mortality in healthcare.

AGs are important

A child is admitted to the emergency department with chickenpox. One of the doctors is concerned that the child is developing a life-threatening complication. He shares his concern with a senior doctor, but his senior tells him to send the child home. The child dies later that night due to varicella complicated by streptococcal fasciitis.

A junior doctor is pressured by his senior to administer intrathecal vincristine. Despite voicing his concerns and against his better judgment the junior carries out the injection. The 18-year-old patient dies.

A medical student tells two surgeons she thinks they are operating on the wrong side. The student is ignored and the healthy kidney is removed. The patient dies a month later.

In a simulator-based study more than 50 per cent of anaesthetic trainees administered blood to a Jehovah’s Witness at the instigation of a consultant, despite knowing that the “patient” did not wish to receive blood.

These are all real examples where harm or potential harm resulted from a steep authority gradient. Put bluntly, steep authority gradients mean that those who consider themselves subordinate will not speak up or will too readily acquiesce to a senior’s demands. The result is patient harm.

Challenging unsafe behaviour

Steep AGs are dangerous because they may lead to an unwillingness in subordinate staff to challenge a superior’s poor or erroneous decisions. A number of practical tools have been developed to provide a standard, step-wise approach to challenging unsafe behaviour. One such tool is PACE in which concerned staff are encouraged to follow four steps:

  1. Probe: ask for information or clarification.
  2. Alert: point out why you are concerned.
  3. Challenge: Openly disagree with a given decision or action.
  4. Emergency: Act to stop the given decision or action.

Another tool from the aviation industry now being promoted in healthcare is the two-challenge rule. This involves three steps:

  1. Challenge the decision or action. If not happy with result then:
  2. Challenge the decision or action again. If not happy with result then:
  3. Act to stop the decision or action.

Other mnemonics for providing a framework (as opposed to a stepwise approach) to challenging an action or behaviour include:

  • CUSS: I am Concerned. I am Uncomfortable. This is a Safety issue. Stop.
  • DESC: Describe the behaviour. Express your concerns. Suggest an alternative. Consequences are stated in terms of impact on patient or team.

AGs and a safety culture

Most of what you have read so far looks at AGs from the subordinate’s perspective. There are also steps which the senior can take to ensure that AGs do not prevent people from speaking up about unsafe practice. The first step is to acknowledge AGs exist and that the senior’s perceptions of the steepness of these gradients often do not match that of their subordinates. In a 2011 study conducted by researchers in the US,100 per cent of senior surgeons felt that juniors could question their decisions while only 55 per cent of their juniors agreed(2).

It may be useful (and eye-opening) to carry out anonymous surveys of the employees at your place of work with questions such as:

  • Do you feel able to speak up about things which may impact on patient care?
  • Are you afraid to ask questions?
  • Do you feel able to question the decisions of those with more authority?
  • Have you ever seen a mistake which could have harmed a patient but did not speak up about it?

Additionally it may be useful for the senior person to admit to errors made in the past in order to show junior personnel that no one is infallible. Lastly, the IOM report and a number of other studies have emphasised the utility of simulation-based team training in reducing authority gradients and improving teamwork.

Shallow authority gradients

AGs are not all bad; without any kind of AG, roles may become blurred and decisions cannot be made. In the Scottish Clinical Simulation Centre (SCSC) poorly performing teams often lack leadership because participants at a similar level of training may fail to establish an authority gradient. Teams must therefore aim for an optimum AG where effective, timely decisions can be made and followed, while allowing for the possibility of challenging decisions by any member of staff.

Sharpening the axe

Some may wonder how we develop a safety culture which acknowledges authority gradients and appreciates their necessity, while ensuring that they are only as steep as they need to be. It is the responsibility of both ends of any authority gradient to ensure that patient care can still be effective, efficient and safe. This will take courage: juniors must have the courage to speak up and seniors must have the courage to allow their authority to be challenged.

In their 2012 paper 'How can leaders influence safety culture?', Michael Leonard and Allan Frankel state that "culture is behaviour over time…". The behaviour of healthcare personnel creates the culture we all want to see. Just as importantly, we are all or will become patients of the healthcare system one day. Why not make it as safe as possible now? Let’s bring down those totem poles.

Dr Michael Moneypenny is a consultant anaesthetist and expert in the field of human factors in healthcare. He is also director of the Scottish Clinical Simulation Centre


  1. Cosby KS, Croskerry P. Profiles in Patient Safety: Authority Gradients in Medical Error. Acad Emer Med, 2004; 11:1341-1345.
  2. Poor resident-attending intraoperative communication may compromise patient safety. Belyansky I, Martin TR, Prabhu AS, et al. J Surg Res. 2011;171:386-394.

This page was correct at the time of publication. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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