A Series - Friction: When Medical Culture Resists Patient Safety. The Introduction
A series about improving quality on labor & delivery and the obstacles being placed.
When I took over in charge for a Labor and Delivery unit over three decades ago, our outcomes were unremarkable, not terrible, not excellent, just persistently average in ways that meant preventable harm was quietly, steadily occurring. Our cesarean rate hovered at 35%. Our NICU admission rate for term infants without clear indication was double what the evidence suggested it should be. We had the occasional uterine rupture that might have been avoided, the shoulder dystocia managed differently by every attending, the tachysystole from oxytocin that went unrecognized too long. One maternal death in the prior year.
Our liability premiums had just increased (it had actually tripled) after a few bad outcomes, including an over $10 Million case, and the hospital was feeling the financial pressure.
We knew what the evidence said. We had the studies, the guidelines, the data from units that had implemented standardized protocols and seen their outcomes improve.
What we didn’t have were clear guidelines, clear instructions that everyone had to abide by.
What we didn’t have was buy-in from the people who mattered most, the high-volume attendings who shaped unit culture, the nursing leadership protecting their staff from “more paperwork,” the anesthesiologists who saw L&D protocols as obstetrics overreach, the residents caught between our new standards and their attendings’ old habits, the hospital administrators who feared losing their biggest admitters if we required physical presence in L&D or implemented protocols senior physicians openly opposed.
This “Friction” series chronicles the resistance I encountered across the entire medical system as we transformed from a three-star to a five-star safety unit.
These weren’t bad people. Most were technically skilled, deeply committed to their patients, and armed with concerns about quality improvement that turned out to be more valid than I initially wanted to admit.
Senior physicians worried about cookbook medicine. They did not know how to use electroniuc medical records.
Nurses resisted documentation requirements they saw as meaningless box-checking.
Anesthesia questioned whether our escalation pathways respected their judgment.
Hospital administrators calculated the revenue risk of alienating physicians who delivered 400 babies a year.
Residents struggled to implement changes their attendings openly undermined.
Their stories reveal an uncomfortable truth: the people most resistant to evidence-based change are often the ones who force us to implement it more thoughtfully. The attending who fought our standardized oxytocin protocol identified real gaps in how we’d designed nurse empowerment. The anesthesiologist who dismissed our hemorrhage pathway exposed flaws in our interprofessional communication. The hospital CFO who blocked funding for quality metrics revealed how we’d failed to make the business case. The senior attending with the 400-delivery-per-year practice who insisted standardization would slow her down revealed assumptions about efficiency that didn’t hold up under scrutiny.
I was told it was impossible to implement this in a reasonable time period to make an impact. By the time we achieved sustainable improvement, 5 years later, cesarean rates around 30%, appropriate NICU transfers, systematic approaches to shoulder dystocia and hemorrhage, and yes, lower liability premiums, I had learned as much from the resisters as from the evidence base itself.
This is not a morality tale about heroes and villains. It’s a field guide to the messy, human work of making hospitals safer when the people you need most are the ones fighting you hardest.
Each week, I’ll share one story of resistance from across the system, physicians, nurses, midwives, anesthesiologists, neonatologists, clerks, administrators, residents, what drove it, how we navigated it, and what legitimate concerns lay beneath even the most frustrating opposition.
Because the truth is: if your quality improvement initiative isn’t encountering friction, you’re probably not pushing hard enough to make real change.