Issue 46 / 26 November 2012

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

8 thoughts on “Sue Ieraci: Terms of engagement

  1. Rose says:

    Our greatest political ally is the patient. There are lots of patients and few clinicians. We need their feedback unfiltered by health service managers.

  2. Sue Ieraci says:

    Some good points, “Another ex-doc”. In my view, the system that governs a sophisticated clinical service should be at least as sophisticated itself.

  3. Another ex-doc says:

    I am one of an entire specialist surgical department that has recently resigned en masse from their public hospital. Executive management (made up of “clinicians”, they remind us – ex-podiatrists, ex-nurses and other ex-allied health) had brought in new policy directions that actual clinicians strongly advised against. Managers ignored objections and did not engage. Actual clinicians became more frustrated over two years and finally left. Now the entire northern sector of a major city has no public facility. Managers remain in-post, patients lose very badly. Root cause in my view was a management class unable to establish a relationship where the managers respected the doctors’ clinical ability and judgement and the doctors respected the managers’ management ability and judgement. Doctors are held responsible for high clinical standards and managers should likewise be held responsible for high organisational standards. Organisations that are unhappy, dysfunctional or unresponsive should be regarded as management failures and managers should be replaced.

  4. MikeK says:

    An excellent summary of the pertinent issues, Sue. Well done, and I agree with Tim regarding the ‘swathe of incompetent and self-ingratiating managers’. Combined with self-serving political agendas these aspects reek havoc with our health system. It really does come back to ‘leadership with courage’ but, unfortunately, political agendas tend to control everything. We do need a stronger voice.

  5. TIM says:

    Well said Sue, but I have to agree with ‘ex-doctor’ and ‘Anonymous’. We who work in the State Hospital System know only too well what needs to be done. Indeed, we all talk about the problems raised at the recent forum, on a more-than-once-daily basis. Unfortunately, nothing changes. There is also more than one instance on record, of individual doctors sacrificing their careers (unintentionally), by insisting on proper consideration of the clinical practice viewpoint, over and above that spelt out (in no more than 2 syllable words) in those “management manuals and outdated guidelines”.
    There is a WEALTH of highly motivated medical and nursing management expertise ‘out there’, just waiting to be tapped. Unfortunately, much of it is already more than once-bitten and now too cynical (realistic?) to believe that their best efforts will make a difference.
    The current swathe of incompetent and self-ingratiating,(not to mention unqualified), managers with either no or minimal clinical background (read ‘industry knowledge), simply surf the tides of self-serving political momentum, almost invulnerable to any reality check. Is there an organisation with political influence (and if not, can it be organised) for professionals like the respondents to your articles, to interact with and make some real changes happen?

  6. Anonymous says:

    Medical leadership will only excell if medical facilities are run by properly educated and trained leaders and managers instead of halfbaked default managers who use management manuals and outdated guidlines to run hospitals.

    There are medical facilities run by local government clerks and Police Superintendents etc. who unleash autocratic rules on powerless medical professionals.

  7. Sue says:

    Ex-doctor – I agree with your comments about what is required. The purpose of the day was not to preach to each other, but to document the changes required to achieve the culture you describe. If we don’t have it now, don’t we have to do something to move towards it? A good start would be for all readers who agree with these principles to talk about them in their own workplaces and professional organisations.

  8. ex doctor says:

    Sue, isn’t it sad that the “AMA and ASMOF executives, hospital and district CEOs, junior and senior doctors from urban and rural regions and hospital managers, as well as …the ‘Clinical Excellence Commission’ and the ‘Agency for Clinical Innovation'” have to be collected in one room to discover the bleeding obvious? System administration at every level should be dedicated to supporting those the coalface. The key is trust in and empowerment of those with patient contact. Clinicians should feel secure and supported when they “risk” under investigating or under treating or (horrors) incompletely documenting everything. The clinical department’s sole responsibility is surely to achieve a reasonably practical clinical outcome and a satisfied patient. I suspect in your case they were preaching to the converted.

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