Issue 30 / 10 August 2015

I RECENTLY watched American Sniper, a movie nominated for six Academy Awards. 
It is based on the true story of Chris Kyle, who joined the US Navy and was accepted into SEAL (Sea, Air, Land) training. The drill sergeants made it very clear that their task was to weed out the weak and strengthen the strong. 
The SEAL trainees had to suffer physical torture while receiving verbal abuse from their trainers. Only the strong survived. 
In discussions with some procedural colleagues about the movie, I found they had similar experiences during their vocational training. 
Interestingly, although the Royal Australasian College of Surgeons has launched a campaign against discrimination, bullying and sexual harassment, it is the military that is leading the way in tackling a bullying culture in Australia. 
Lieutenant General David Lindsay Morrison famously said: “If you become aware of any individual degrading another, then show moral courage and take a stand against it … The standard you walk past is the standard you accept.” 
The movie made it very clear that SEAL training is not for everyone, but what about medical procedural training? 
I want to be clear that I am not saying inappropriate behaviour is restricted to procedural specialties. It’s a universal issue that extends well beyond medicine. 
However, my procedural colleagues seem to all agree — being a proceduralist can be tough and it is not for everyone. But does that mean that we should treat our vocational trainees like SEAL recruits, and toughen them up or weed them out through our behaviours? 
There are two significant reasons why the answer is “no”. 
First, SEAL trainees know exactly what they were signing up to when they join SEAL training. They provide informed consent. Medical students and vocational trainees do not sign up to be verbally abused or physically tortured. 
Second, SEAL trainees are training to be elite soldiers suffering psychological and physical stress under dangerous conditions in enemy territory. Procedural registrars do need to learn how to cope with the stress of a procedural career, but they should be able to learn that through direct experience and from the role model of supervisors.
There are two problems that we need to address. 
First, medical students and registrars, for the most part, have had a life of academic excellence and achievement. As such, they are not accustomed to receiving negative feedback or failing to excel. 
No doctor wants to know that they are underperforming. Therefore, if a supervisor is not skilled in providing feedback, any negative feedback may be construed as “bullying” or “inappropriate”. 
Many doctors are also perfectionists who do not suffer fools gladly. And many have personalities or temperaments that make them seem curt, brusque or disrespectful to juniors. Some even have anger management problems or personality disorders. 
These doctors may not be intentional bullies, but their behaviour must improve.
Second, compounding this problem, doctors are not trained to give objective feedback, and many are reluctant to provide negative feedback to their peers, even junior ones. 
All of us need to learn how to provide — and how to receive — feedback, whether good or bad. That includes acquiring the insight to self-reflect and to improve our behaviour and the way we communicate.
The real Chris Kyle, the American sniper, after his successful SEAL training, went on to become the world’s best sniper, with 255 confirmed kills, including a confirmed 1.9 km sniper shot. But his personal life suffered a terrible toll. 
He hardly spent time with his children and his wife nearly left him. He developed post-traumatic stress disorder and ended up being killed by a veteran he was teaching to shoot. 
The lesson here for doctors is to prioritise our own health so that we can care for our families and our patients. 
Look after your fellow doctors, particularly junior doctors — encourage them to seek help if they are faltering, and remind them when their behaviour pushes the boundaries of our profession’s values. 
As Nobel Prize winning author Pearl Buck said “the test of a civilisation is in the way that it cares for its helpless members”.
Professor Erwin Loh is the chief medical officer at Monash Health, Victoria.

4 thoughts on “Erwin Loh: Military lessons

  1. Ulf Steinvorth says:

    We can learn a lot from how bullying is tackled in other fields like the military but should not forget that the goal of medical training is our ability for perfect healing whereas the goal of military training is our ability for perfect killing, requiring rather different skills and attitudes that should be and will be reflected in the training process.

    The more shameful if we find brutalization in medicine but much of our surgical tradition and development is entwined with the millitary, maybe something that needs to be looked into.

  2. Sue Ieraci says:

    It’s time surgeons stopped using the “being a proceduralist can be tough” excuse. Being an emergency physician can be tough. Being a NICU specialist can be tough. Being a physician proceduralist can be tough. Being an Oncologist can be tough. Being a GP can be tough. If trained professionals can’t perform tough jobs without systematically brutalising or shaming others, they have not accomplished the requirements for the job. Everyone can get anxious, frustrated, annoyed, or lose their temper in stressful situations. No-one should make a lifestyle out of it.

  3. Dept of Families Housing Comm Svcs and Indigenous Affairs says:

    As far as I know,medicine is about caring for another person. Not to mention the Hippocratic oath & the existence of AHPRA & the medical boards to ensure safety & quality of care. Medical trainees whether in the undergraduate or post-graduate level should be exposed to the realities of their medical careers. That it is their patient’s health & safety that is paramount. It has been shown that a caring & compassionate doctor gets more appreciation from their patients which on many occasions leads to quick recovery of their patient’s health. How does one become a caring & compassionate doctor? Definitely not from bullying nor from any form of harassment or abuse. Applying this to the movie American Sniper, Chris Kyle learned that there are other ways to helping his fellow soldiers. And how did Chris Kyle learned this? From a caring & compassionate doctor! Imagine if Chris Kyle get bullied, harassed & verbally abused by this doctor? What do you think would have happened? Medical students & doctors in training should have good role models. The question lies: should medical schools and training hospitals vet their respective teachers & supervisors so that only those with good inherent qualities being good role models be chosen? What do you think will happen if all doctors would suffer from a form of PTSD from their post-graduate training? Then I would not love to become a patient at all.

  4. SA Health Library Network says:

    “The lesson here for doctors is to prioritise our own health so that we can care for our families and our patients. ”  Actually , it looks to me that the lesson from that SEAL sniper is that he was brutalised till he became a mass murderer and a severely damaged human being. People going though medical training need to come out the other end with their humanity and compassion intact. The increased level of post traumatic stress disorder seen in military personel in recent years may be because modern military  training is all too effective in breaking down the barriers against killing, and as time goes by, the horror seeps through again. I think we need to treat our trainees and students humanely to model the kind of behaviour we want them to display throughout their careers both  to colleagues and to patients. The long hours and mental effort and emotional stresses are still going to lead some to drop out or re-consider their careers.

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