A very long analysis of Doctor Baran Al-Hashimi
(Thanks to my friend that beta read that)
First of all- this is not a bashing rant, this is a critical examination of Doctor Baran Al-Hashimi's first hour in the Pitt, the culture shock she experiences and the ways this shock sabotages her future work relations with Robby and the entire staff.
The main struggle Al-Hashimi faces is that she simply does not understands what it means to be an emergency department attending, and especially what it means to be the head of an emergency department of a level 1 trauma center, which I remind you, are between 220 to 255 of in the US.
Let's start with how she came in: She brought a bagel spread, which is a big win, and she showed up early to meet the night shift. But here is where she started to fail:
took things over immediately, ignoring the night shift attending and pissing off the charge nurse
implemented the patient passports, without warning nor preparations
Took over one of the 2 trauma rooms to have a mock trauma for the 3 med students and the intern.
Scolded the R2 on being behind on charting
all this 4 minutes into the episode. Now, I hope I do not have to explain why coming in and undermining the shift's attending is bad, and why making the charge nurse hate you is a cardinal sin.
now for the next 3 points, starting with the patient passports. the patient passports, while a noble idea and a great tool in certain environments, is just not a good idea for the ED environment. First problem is that it is extra work for everyone involved, from distributing to filling when you already have an overworked staff. Second problem is the privacy issues that can arise from not being able to properly dispose from those forms that have private medical information on it. there is a risk of a passport being misplaced by a patient going into crisis or being in a rush or by a care provider who has to step away urgently because of a trauma or some commotion, leaving this form full of private medical information in plain sight. Third problem is the cost, which with quick math by myself and some friends will cost about 73000$ per year, which is also the yearly salary of a nurse.
Implementing such a radical change to the procedures and policy with so little prep-time for it, on your first day in a new place, in the hours before the person you are here to replace shows up, is a sure way to make people dislike you. now, the clear context to that it that as a Clinical Informatics Expert she led a very successful quality improvement changes in the VA, a thing that probably made her the candidate both Gloria and the board chose to bring in. This change, including all the others she wants to bring are presume included in the packet that was sent to Robby, and were probably approved by Gloria. however, Robby did not read those in the time he did not have and did not respond. Al-Hashimi ignores that, and goes forward despite not getting a conformation from Robby, leaving the entire ED to be blindsided with her showing up and immediately implementing the patient passports. This is very much a hint that management hopes to replace Robby and are using his Sabbatical to try and bring someone they thing will solve all their problems. But, Al-Hashimi is not the head of the department, Robby is, she is only covering for him, and therefore her actions are a sign of huge disrespect in the leader the ED loves, trust and listen to. Combine this with the fact that the grace period before she starts acting as chief, it can defiantly cause tension with the staff.
in most places, there will be a grace period where the new hire will shadow someone of similar or the same rank, so the fact that this is her first shift, not the first shift as substitute chief, but at all, and instead of shadowing Robby she is jumping in is unconventional. instead of taking the time to learn the lay of the land, as getting familiar with the layout and procedures of the Pitt, she came in strong in a way that feels intrusive. I do not know if we will get the backstory of why Al-Hashimi and Robby never met before the shift, but I suspect that it was an intentional play from Gloria.
for the next point- the mock trauma. it might be a great way to test the med students, in a controlled environment, without putting real patients at risk, but this kind of teaching is to be done in clinical learning sessions, not during an actual shift in an actual active ED. Her preforming this little exam pulled 4 people away from caring for patients , occupied one of the two trauma rooms that can be needed in a moment's notice and have to be ready to be used just as fast and kept it from being usable in case of a multi-victim trauma, all while the waiting room is full. A waiting room that will get more busy as the day continues due to the July the 4th celebrations. Funny enough, that little exercise just helped to lengthen the wait time, which we all know is one of the major contributors to patient dissatisfaction. taking away the med students and the intern to do this mock trauma, means that everyone else has to pick up the slack of both her and the med students, rather than being able to rely on her to lead and them to help, which means more work for everyone else. And by starting this before night shift goes home, she initiated this while taking people away from the less-staffed shift, and undermined the shift's leading attending.
this leads to the next point- which was scolding Santos for being behind on her charting. Santos was not part of that mock trauma and had to pick up the workload and gets scolded for being late on charts. Meanwhile she had Javadi, the M4, fill in a mock chart, pulling her from doing charting for actual patients and dealing with the night shift hand offs. As much we can see, only Javadi got this task, and not the M3s who would benefit more from this kind of exercise.
all of those immediately marking her as disrespectful of the ED and their work, which is not a good start. looking at that, the rest of the episode and a bit of interviews, I have come to the conclusion that Doctor Al-Hashimi's biggest blind spot, and the thing that hinders her as a leader in the ED is that she simply does not understand what it means to run an emergency department, even less a level 1 trauma center.
Doctor Al-Hashimi ran a VA, which serves a very specific group- veterans and their families and works in a completely different way. A VA is a clinic, and while they do get walk in emergencies, as stated in episode, they do not get medic runs. While walk in trauma's are a thing and can be complex in their own right, Medic runs can and will be far more severe as the patients often cannot get anywhere by themselves. another major difference is that a VA is built for long tern care, that means patients that will return multiple times for regular care and only come in for a single, specific emergency. Therefore, cultivating a positive relationship that builds enduring trust encourages that patient to both keep returning and rate you well as a physician and medical center, is an important part of the service being offered.
while a long tern or a returning patient is part of the proper routine of the VA, an emergency room is a completely different beast. outside of the outlier of frequent flyers, Emergency rooms rarely see the same patient twice and ideally, EDs take care of the emergency so that the long term care could be moved to the proper specialties for the long time care. this makes patient ratings less critical for the ED, as recommendion from a former patient to someone else needing the ED's services can bring new patients, they are not as important as they are in the VA setting or clinic settings in general. Often an ED is not picked out due to recommendations online but to factors like proximity and availability on relative short notice.
While the VA do have a residency program, PTMC is a teaching hospital, which is a different kind of team management and teaching methods. The VA is much more controlled environment than the ED. They are more likely to have rooms to practice clinical learning on dummies with simulated demos. The VA still handles traumas, but this is still worlds apart Lvl 1 Trauma Center.
The final difference I want to point is the culture. Emergency medicine is full of dark humor, banter and a type of flexibility around the rules, a culture that developed both as a cooping mechanism and as a clash between the pristine protocols and the messiness of life. while this kind of humor is welcomed as a healthy cooping mechanism in the ED, for a VA doctor this kind of attitude is reasonable from the patients, but showing this can be a sign of a bad or negative mentality which would negatively influence the emotional state of the patient and the staff.
this gap in understanding can be shown in the trauma scene. First I will offer you a breakdown of all the moments Dr. Al was out of sync of visibly out of place, with a more complete analyses afterwards.
by the time Al-Hashimi finished to properly gown, Robby was gowned and helped move the patient from the gurney. Al-Hashimi is helped in gowning herself by Ogilvey (the MS3), while Robby and Gargia both gowned themselves with no help and get into it. As well, they both came into the room gloved, while Al-Hashimi did not glove herself up. in the continuance of the scene we will see that she calls for sterile gloves, delegating the fetching of the gloves to someone else.
While Al-Hashimi is polite, Robby, Garcia and Whitaker immediately starts with the banter, that to the outsider can be seen as insults.
"what's your plan, Samira" vs. "Dr. Mohan, next steps?" outside of the comedic factor, you can already see an immediate difference, with Al-Hashimi taking the softer more intimate route with calling Samira by name and asking her for her plan, while Robby takes the professional route, addressing doctor Mohan and letting her determine what will happen.
While not physically active in the care given to the patient, Robby is very much a part of the caring process, calling people in and out, giving them tasks and testing their competence and problem-solving skills, as well as their medical knowledge, but letting them act of their own volition from that moment on, content with staying on the sidelines and be guidance at a remove, unless his intervention is actually needed. Al-Hashimi is very obviously itching to join in and be a part of the process, to take it over and lead it herself, explaining by preforming the actions herself as a way to teach.
"Okay, team, I think we need-" vs. "Samira, next steps" again, Al-Hashimi trying to take a more active leadership role, while Robby is giving Samira, the senior resident, the leadership role, working as a guide who gives her affirmations but no immediate answers.
Robby asks Mohan and Garcia to identify the source, only for Al-Hashimi to give the answer instead of them, prompting him to correct her like he would have corrected Mohan if she gave the same answer.
"you need better exposure" vs "convert to a clamshell" watching the time, Robby sees that there is no progress, so he moves things along by presenting the issue, hoping his residents will figure the solution by themselves. Al-Hashimi sees the problem and give them the answer prompting Robby once again to use the reaction he had ready for his residents on a fellow attending. This time Robby points it out "would've been nice to let them come up with that plan"
when they snap the rib to massage the heart, Robby is unphased, while Al-Hashimi is agape, unused to the banality treatment of the extreme situation.
"I can give it a try" again, Al-Hashimi wants to take an active role in saving that man's life while Robby holds her back, keeping her on the sidelines and letting Garcia and Mohan run the show.
Robby contemplates a moment before offering a treatment plan, doing so only when he is sure non of the residents or Garcia will figure it out.
When hearing the unorthodox and dangerous offer, Al-Hashimi immediately shoots it down and focus on the fact that statistically there is more chance to harm then good. Both undermining Robby and potentially causing Garcia to second guess herself in a way that is usually unproductive in a trauma room. as we know from season 1, the ED is where they try wacky dangerous and borderline insane stuff in hope to buy the patients enough time to be stabilized, with those things are done first discussed later. Now, it is important that she pushed back against this dangerous procedure, but it also serve as another sign of the cultural difference Al-Hashimi is ignoring.
when they hold compressions to check the heart, Robby makes an observation and gives an explanation, but stops there, letting the team make the decision, not giving an order but giving confirmation and approval.
25 vs. 50 Joules- Al-Hashimi gives the textbook answer, Robby gives an answer based of prior experience.
"That's what normal sinus looks like" this is very much my guts about the tone, but it sounds like Dr. Al-Hashimi is saying that to herself as much as she us explaining to the rest of the room. this is contrasted with Robby moments early stating that this is how V-fib looks like. Robby has the confidence of experience, Al-Hashimi does not.
when taking off their gowns, Robby mentions that this is a "hell of a way to start the day" in a way that makes it clear that this is regular enough to not surprise him, but still a bit much for 7AM. Al-Hashimi answers this was "unconventional" clearly making that this is something she does not experience regularly.
now, what does all of that shows us? basically, that Al-Hashimi is not in sync with the rest of the ED. Robby has a very specific leadership and teaching style that focuses on guidance, while Al-Hashimi is very much a hands on teacher- she rather show people and be a part then stand back and let someone inexperienced call the shots. Both are valid educational approaches, defined by the environments they developed their teaching styles.
Robby is very much still responsible, but he is a guide from the sideline, which clashes with Al-Hashimi's instinct to join in and teach by doing. From the dialogue and the acting we know that this whole situation is not new to Robby, he is familiar with the outcome enough to stand back comfortably, intervening only when he feels that there is a need. Al-Hashimi very visibly lacks this pattern (and the specific experience), for her this trauma is an edge case that requires her to join and lead by doing. in season 1 we see Robby lead by doing, but he does so rarely, only when he feels that his active participation is needed, if because he cannot guide others from the side or that they need the extra set of hands.
this class is frustrating to doctor Al-Hashimi, who Robby talks to as if she was his resident and not an equal attending, and holding her back, in a way that can be interrupted as a lack of trust.
from the rest of the episode we can see that this leadership difference continues, Al-Hashimi continues to be a very active and involved teacher, providing answers, while Robby is very much a guide from the side line that prefers to let others reach the answer themselves.
another small example is the exchange with Santos- Robby stays mostly quiet, letting Santos give him the information and her suspicions, asking her for a plan and not giving it to her. Al-Hashimi came in with a question, ready to offer an answer. looking at Trinity we can see the way she defers to Robby, comfortable with his more hands off leadership approach, unsure of what to do with Al-Hashimi more involved approach.
I am not calling Baran Al-Hashimi a bad doctor or a bad teacher, this is a valid approach that can serve her well, but it is out of sync with the rhythm of the Pitt, and her insistence to stick to her own methods and not play by that tune imminently marks her as an outsider, for better or worse.
We do know from interviews that Al-Hashimi did some humanitarian work, and I am curious to what type, but even the most intense stint is a temporary one, in contrast to the never ending high and lows of an emergency department.
Now, the next part is almost entirely speculations based on interviews, the one episode we have and my own experience as a project manager and a regulator among other stuff.
I believe That Gloria and the board brought Al-Hashimi in hopes to use the sabbatical as a trial run so they could justify replacing Robby with Al-Hashimi. We know that the Pitt has under average satisfaction scores and is considered inefficient, with the board considering a management company, so it is not outside of reason that Gloria wanted Al-Hashimi to appease the board. Al-Hashimi showing up on Robby's last day is sketchy but we don't know enough at this moment.
Gloria probably gave Al-Hashimi an introduction to Robby, and a very biased one. I suspect that Al-Hashimi got the impression that Robby is a dinosaur, probably a misogynistic, apathetic asshole that will refuse any improvements to the department or technological advances due to his ego. She came in guns blazing, ready to fight the good fight for the sake of the emergency department, uniting the department with her innovations and technologies that improved the VA and earned her the favor of the board.
instead she got the sassy, petty cowboy, that is respected and loved by his department. She came in expecting to have him try and walk all over her, and she is struggling when the most he does is sass. she came in ready for a fight and does not know how to react when she those not get that fight, instead Robby treats her in a slightly amused unbothered resignation. not only that, the entirety of the staff is not immediately enthusiastic about her reforms, treating her with suspicions and even anger when she expected the open arms she got from Gloria.
TL DR- Doctor Al-Hashimi, despite being extremely qualified, a good physician and a innovator in incorporating new technologies came in to the Pitt under false perceptions of what she is coming into, making her act out of sync and butt head with Robby and the ED as a whole.
