Too Many Doctors Can Hurt a Patient in 'Bystander Effect'

Jan. 3, 2013— -- An acutely ill man with mysterious symptoms -- a nasty rash, kidney and lung failure -- was admitted to Yale-New Haven Hospital where he was treated by 40 of its finest doctors.

But because so many cared for him, two of the attending residents say, the 32-year-old patient actually got sicker. That is because of the so-called "bystander effect," they say in an article published today in the New England Journal of Medicine.

Authors Dr. Robert R. Stavert and Dr. Jason P. Lott argue that because of changes in health care, more specialists get involved, leading to "decay in coordination of care."

The psychological phenomenon, also known as "Genovese syndrome," was first coined in 1964 after Catherine "Kitty" Genovese, 28, was stabbed to death in New York City as others appeared to have been aware of the attack and did nothing, although the number of bystanders has become a matter of dispute.

One witness told police at the time, "I didn't want to be involved."

A large body of research now shows that humans are less likely to offer help in an emergency when others are present. The key factor is "diffusion of responsibility": the larger the group, the less likely an individual will act.

"We have talked a lot about the broader issues of healthcare -- and not just within our field -- and it really struck a chord," Stavert, a resident in dermatology at Yale, told ABCNews.com. "We came to realize that the people involved were really excellent doctors and all worked with really good intentions but it became apparent the pitfalls people could fall into."

The patient the Yale team treated spent 11 days in intensive care, but nine sub-specialty units were tending to his case, causing "more of a handoff" of responsibility, the authors wrote.

"Our inability to easily name his disease process quickly created ambiguity about 'ownership' of the patient," they say.

"While our team sat in a remote rounding room pondering potential causes of the patient's rash, another team of intensivists gathered in the ICU hallways to debate his ventilator settings, while yet another consultation team sat at a distant ICU desk, struggling to understand his multi-organ failure."

The patient had more than 25 diagnostic lab tests and two imaging procedures daily, many of them "duplicative and unnecessary."

"This cloud of medical purgatory lifted only when acute decompensation occurred, forcing the doctor-of-the-moment to act decisively," they wrote.

"This happens all the time in medicine," said Lott, who, in addition to being a resident in dermatology at Yale, is a clinical fellow at the Robert Wood Johnson Foundation. "You make your best guess and keep your fingers crossed and it turns out for the best."

The "bystander effect" is often seen among witnesses to crimes.

For two hours in 2009, as many as 20 people watched or participated in the gang rape of a 15-year-old girl outside a homecoming dance at her school in Richmond, Calif.

Hundreds of students who had gathered in the gym nearby took photos and some even laughed.

Ervin Staub, founding director of the doctoral program in the psychology of peace and violence at University of Massachusetts, has devoted his career to the study of how a person can become an "active bystander," the witness who is in a position to take action.

He is now just finishing the book "Roots of Goodness," about moral courage and heroism. In it, he attributes the phenomena to the bystander effect: diffusion of responsibility and plural ignorance.

In diffusion of responsibility, a person who is alone is more likely to act in an emergency.

In a group, the individual will often assume someone else will take action. "In an unfamiliar and strange situation … taking action is challenging," Staub said. "You have to step forward and expose yourself to public scrutiny."

Research has also shown that when a person is in a position of leadership or specific role, they are more likely to act.

In pluralistic ignorance, individuals privately reject the group, but are afraid to speak out.

"People don't show their emotions in public," he said. "They kind of put on a poker face or wait for others' reactions. As they look around and see others don't react, they decide not to react."

In studies of children in kindergarten to sixth-grade, Staub found that the youngest children "naturally say something" when they heard a "crash and distress" in a neighboring classroom, eliminating pluralistic ignorance.

"It causes attention and kids engage in a discussion and move jointly to some kind of action," he said. "By second grade, that disappears."

More research of children in the seventh-grade has shown that those who are given permission "for an irrelevant reason" to go into another classroom are more likely to respond if they hear distress.

Those with no instruction from teachers responded only 30 percent of the time. In those who were told they could leave the room, 90 percent reacted to the "emergency."

"Kids learn all kinds of rules of everyday behavior that inhibit them from helping people," Staub said. "They don't learn that under certain conditions, moral or caring rules override the rules of every- day behavior."

"I wonder if the same thing is present in the medical profession?" he asked. "There are all kinds of implicit rules: Don't interfere, it's another's domain."

While teaching a class at Stanford, Staub asked students where it was better to take action when it is uncertain whether it was needed.

"The worst that could happen was that it was not needed," he said. "The undergrads said basically they prefer no action so as not to expose themselves to embarrassment.

"People have powerful influence over each other," he said. "It's not just the presence of others, but what others say. They define the meaning of the situation and the appropriate action. We look to others for cues."

E. Scott Geller, director of the Center for Applied Behavioral Systems at Virginia Tech University and author of a book about medical errors, "Actively Caring For People," said the "bystander effect" does influence medical decisions.

"We are so busy these days that if we can pass the personal responsibility off to someone else, we are going to do it, especially if it seems justified," Geller said. "One way to decrease the bystander effect is to make sure responsibility is assigned."

In studies of a phenomenon known as "social loafing," researchers found that when measured, individuals in a rope contest would pull harder than when in a group.

When pulling alongside another, a person thinks, "They got my back," he said. "If I think you are going to hold me accountable for how I contribute, then I am going to hold up my weight."

The issue of competence also comes into play in the medical world, Geller said.

"If the observer knows what to do, you don't get the bystander effect," he said. "In this medical example [from Yale], it seems there were so many unknowns."

Although the Yale patient recovered, his illness was never deciphered by the large team of physicians. Study authors Stavert and Lott say medical school education and health-care protocols need to be improved.

They say some research suggests that bystanders are more likely to act if they are friends with one another. The hospitals should encourage more collegiality across the disciplines.

"People can have a greater level of comfort and sense of ownership to increase their confidence to act or share an idea," Stavert said.

New federal health safety programs like TEAMSTEPPS (Team Strategies and Tools to enhance Performance and Patient Safety) are also critical to improving communication between doctors, they said.

"I think we are doing such a better job of taking care of disease in general, but the level of acuity of patients admitted to the hospital is so much higher than it was 40 or 50 years ago," Lott said.

"The problem becomes it's more difficult to coordinate care and also to keep your eye on the ball. We are not doing as good as we could."