Sue Ieraci: Terms of engagement

A LONG period of discussion about the frustration and sense of disaffection felt by many doctors in our current hospital system culminated last week on an important day for me.

I attended a medical leadership meeting, organised by AMA NSW and the Australian Salaried Medical Officers’ Federation (ASMOF) NSW, which combined presentations with panel discussions in three main areas of medical participation — local innovation, governance and prioritisation, and safety and quality.

Participants included AMA and ASMOF executives, hospital and district CEOs, junior and senior doctors from urban and rural regions and hospital managers, as well as representatives from the Clinical Excellence Commission and the Agency for Clinical Innovation. The day was skilfully steered by respected doctor, manager and clinical governance expert Dr Philip Hoyle.

This article represents my personal take on what was said and what can be done.

At this meeting I heard the stories of doctors providing their clinical service only, feeling powerless to influence either policy or prioritisation of decisions within their health institutions, and being made to feel generally irrelevant to the organisation.

Rural practitioners in particular felt that regionalisation had made them more distant from where decisions are made, and many junior doctors felt excluded altogether.

A few strong themes emerged from the day — not just descriptions of what has gone wrong, but suggestions for improvement. There was a real sense of willingness to re-enter the process in a meaningful way, but with redefined terms of engagement.

Perhaps the most important message of the day was that doctors don’t want to be “engaged” in a tokenistic way — which often implies being presented with a fait accompli and asked to accept it.

What they really want is a partnership between clinicians and managers, marked by mutual respect, appropriate behaviour, and mutual empowerment and accountability.

Another important message was the need for leadership and courage. It was agreed that risk-aversion is a direct impediment to innovation. A risk-averse organisation encourages inaction, and leads to failure to grow and improve. We must measure the risks of not doing — not just of doing.

The hospital clinical department was seen as a key unit for local innovation, prioritisation and cooperation — a place to focus both empowerment and responsibility. When locally appropriate solutions are found to address local issues, informed by specific local data, benefits for patient care are maximised. These benefits must be reflected in real clinical outcomes, not just processes.

There was much discussion about delivering appropriate care. This means avoiding doing tests and treatments that do not add value to patient wellbeing, and not adding unnecessary complexity to procedures and documentation.

Everyone at the forum wanted to provide safe and high-quality medical care. Everyone wanted their motivation recognised and respected, realities understood, trust regained.

We have some way to go. Things have to change. But, with the right motivation, leadership and guidance, change is definitely possible.

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.

Posted 26 November 2012