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WHEN Korean Airlines Flight 801 departed Kimpo Airport in Korea on 5 August, 1997, there were 254 passengers and crew on board. The plane crashed on Nimitz Hill in Asan, Guam, while descending to land in bad weather conditions early the following morning. Two hundred and twenty-eight people died, most of them at the crash site. Finding 13, from the Federal Aviation Administration’s report into the disaster, lists excessive hierarchy as one of the reasons for the crash: “The first officer and flight engineer failed to properly monitor and/or challenge the captain’s performance, which was causal to the accident”.
Eight years later, on 29 March, 2005, 37-year-old Elaine Bromiley was wheeled into an operating theatre in England for routine sinus and nose surgery. After sedating her, the anaesthetist couldn’t fit an endotracheal tube to establish an airway and struggled to ventilate her lungs – a “can’t intubate, can’t ventilate” emergency. Despite the presence of multiple senior doctors in the room, Mrs Bromiley was starved of oxygen for so long that she suffered irreversible brain damage and died 2 weeks later, after life support was withdrawn.
In the ensuing investigation into this mother-of-two’s death, it was found that the nurses had quickly realised that an emergency tracheostomy was required, and had even brought the requisite equipment to the doctors’ side. The nurses were unsuccessful in challenging the operating theatre hierarchy and couldn’t interrupt the doctors to help them save the patient’s life. As it turns out, Mrs Bromiley was married to an airline pilot. Martin Bromiley has since campaigned widely to improve patient safety in the United Kingdom.
In April 2017, Professor Sir Liam Donaldson, the World Health Organization Envoy for Patient Safety and former Chief Medical Officer for England, visited Sydney and addressed a patient safety seminar, lamenting the lack of progress we have made in health care to reduce avoidable harm. In particular, Sir Liam drew a comparison with the airline industry, noting that they had worked deliberately to counter a reluctance of co-pilots to challenge senior pilots, a factor in multiple accidents and near-misses. “Hierarchy is alive and well in health care and it needs to be addressed in a similar, robust way,” he implored.
Any doctor-in-training working on the coalface of the public hospital system knows this all too well. I remember trying to query a psychiatrist’s request to order a non-urgent abdominal x-ray to assess for constipation in a young adult, something I had been taught to avoid, particularly in the young. Before I even had time to explain that the radiation exposure for an abdominal x-ray was equivalent to taking seven chest x-rays and to suggest an alternate plan that I felt would be safer for the patient, the consultant yelled at me in the busy nurses’ station: “I’m the psychiatrist, when I tell you to order an x-ray, you order an x-ray”. No one else said a word, and I have no idea what the nearby medical student made of this role-modelling. Somewhat to my shame, I ordered the x-ray, fearing repercussions. Most doctors-in-training I know are employed on only 12-month contracts, and the near doubling of medical school graduates since 2002 means training positions are in short supply.
When a patient’s death in hospital is sudden and unexplained, as in Mrs Bromiley’s case, there are both hospital and coronial processes to investigate its causes and to make recommendations on how to prevent a similar event in the future.
As has been widely reported in the Australian media, three doctors-in-training died by suicide in New South Wales between September 2016 and January 2017. On 4 April, 2017, three colleagues and I wrote to NSW Minister for Health Brad Hazzard about their deaths. We briefly offered other doctors and medical students the chance to support our letter, and were inundated with over 150 co-signatures.
By our figuring, three young doctors taking their own lives within just 4 months was the final straw in a decades-old, multifactorial mental health problem in our profession. We believe it warrants a special commission of inquiry into the training and workplace factors that affect doctors’ wellbeing, and articulated for the Minister how such an inquiry ought to proceed. Our request was sent with a cover letter of support from the NSW branches of the Australian Medical Association and the Australian Salaried Medical Officers’ Federation; however, when a response arrived over a month later, our suggestion was politely declined.
In his response, the Minister referred to the Junior Medical Officer Wellbeing and Support Forum that he had directed the Ministry of Health to convene on 6 June 2017. I attended this forum and was impressed by the Minister’s comments, and that he stayed for the entire afternoon. In his closing address, he all but committed to introducing a Western Australia-style exemption in the NSW mandatory reporting law, something that the NSW Medical Council also supports. As has been argued for years, this would be an excellent change – but it is not enough.
In addition to changing mandatory reporting, it would help if doctors-in-training weren’t so scared and unsupported in claiming all of the overtime they work, so it could be clear how much the system demands, so doctors felt their time and efforts were valued, and so that department “business cases” could justify employing more doctors by saving on overtime.
It would help if we borrowed from the airline industry, and not only introduced safer rostering practices, but addressed extreme power differentials and negative aspects of medical culture by, for example, always introducing ourselves and using only first names instead of distancing junior team members from their senior colleagues with the selective use of the “Doctor” title.
It would help if the specialist medical colleges had to justify low pass rates for their assessments despite having such intelligent candidates, abolished all-or-nothing exams that are hugely expensive and run only once a year, and were required to regularly justify or else lose their monopolies.
And, I still believe, it would help if at least one jurisdiction funded an inquiry that properly investigated these and other factors affecting trainee wellbeing (such as lack of autonomy, poor leave accessibility, worsening training pipeline bottlenecks, and bullying), with a commitment from the outset to developing and implementing reforms, similar to the Garling inquiry from the early 2000s.
In the meantime, it helps that families of doctors such as Chloe Abbott and Andrew Bryant have spoken openly about their loved one’s suicide, so that this enormous and urgent problem can no longer be ignored as an abstract statistic, and instead becomes as human for all of us as it has been for so many bereaved families for all these years.
Benjamin Veness is a psychiatry registrar with a Master of Public Health and a background in corporate strategy. He is a Churchill Fellow and a past president of the Australian Medical Students’ Association. Twitter @venessb.
Dr Veness was supported to attend the Junior Medical Officer Wellbeing and Support Forum by MDA National and the Department of Psychiatry at Alfred Health.
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Thanks for this discussion, and especially to Ian Hargreaves (comment 9) for his thoughtful comments. To the anonymous person who posted comment 20, I don’t think labelling those who post more nuanced views as self serving bullies or narcissists is helpful. Ben’s article is interesting and thought-provoking but it is clear our hierarchical system is not the whole problem. In my opinion, it is a bit problematic to imply that the suicide of a worker is entirely a work-related problem, regardless of how demanding the profession is.
As a specialist registrar I had ongoing health issues throughout the exam process and severe bullying at multiple sites. However, the specialist college was worse than any of the direct bullying I received at work. I came to the end of my training with 9/10 exams completed and told there could be no more attempts. They would not reconsider or review my results and would not consider the context of health issues (2 surgeries required during exam process). The colleges are laws unto themselves and the AMA tends to be completely unhelpful in this scenario. There is no recourse. No government ombudsperson or organisation to turn to for help. AHRPA doesn’t seem to want to get involved with such issues even though they relate to training and licensing. I find myself with the option of starting the long process of retraining in a completely new specialty or writing the exams to qualify in another country. Both are a form of exile. This is not an uncommon story. I know of several similar from the same specialty and many more from others.
There should be a national inquiry into the colleges and their practices. If so many doctors are failing, it reflects poor training or something even worse which is profiteering off training doctors. Recently, as many as 50% failed the GP exam. These people have their marriages and lives completely disrupted and bullying / mental health concerns are often just treated with lip service. Counselling is only a minor help to doctors stuck in a hostile work environment and dealing with colleges that have no outside control or oversight. I am not surprised by the number of doctor suicides. I am surprised it is not higher.
I think the problem stems from insecurity of some consultants. I worked in the psych ward in Australia, but also overseas in other countries and noticed that clinical skills of Australian psychiatrists are generally not on pair with their overseas colleagues. There is a lot of negative selections and they have a hard time telling apart boderline from bipolar or psychosis, let alone work up constipation.
This is really common scenario of constipated young patient. You need to look at history (has there been a previous procedure in abdominal cavity i.e. risk for adhesions, diet, opioid drugs, etc.). Is there nausea, vomiting, has the patient been passing gases? What is the abdominal examination: guarding, rebound tenderness, can you palpate (faecal) masses, have you auscultated the abdomen for (hyper)peristalsis? Swallowing air is a common occurrence among psych patient and junk food diet is also very common. Then you need to be able to observe the patient over the period of time, before ordering imaging as you can do more harm than good.
I have seen psychiatrists in Australia ordering all kinds of expensive studies from MRI to gene sequencing for what is considered a clinical diagnosis in other countries. Yes, senior people usually know better but hey, we’re in Australia!
Powerful article Ben, I applaud your efforts in raising awareness of medical officer mental health and trying to address the reasons for this. I don’t think this is an “Either/OR” scenario and there are no wrong answers in reflecting on our own medical practice. I’m sure the scenario you wrote of has helped to shape the doctor you are and who you want to be.
We know as Medicos that narrative often overpowers evidence, and you asked that a jurisdiction investigate the factors affecting trainee wellbeing. So, what currently is the evidence that harassment and bullying from senior doctors is leading to medical officer work related stress and suicide?
The 2013 Beyond Blue National Mental Health Survey of Doctors and Medical officers found that both were reported causes of work related stress. 9.5% (8% for men and 11.7% for women) of doctors and students reported difficult relations with senior colleagues. Whilst 4.5% (4% for men and 5.3% for women) reported Being Bullied as a contributing factor. Interestingly these rank as 17th and 21st on the list of top 24 factors contributing to work related stress.
Whist having no place in modern medical training it would seem that bullying and difficult relations with senior doctors is not what is currently causing the major work-related stress issues for medical officers.
So, what is?
The same report highlights some interesting factors that could lead toward greater gains in improving the mental health of trainees. It found that women are suffering disproportionately higher rates of stress across 23 out of the 24 major factors. The Top 6 for both men and women include; Conflict between study/career and family/personal responsibilities (37.4% vs 19.8%); Too much to do at work (31.5% vs 20.7%); Responsibility at work (28.5% vs 15.8%); Making the right decision (28.6% vs 11%); and Fear of making mistakes (28.3% vs 12.4%).
In discussing these findings with a female CEO of a Health Network, she felt these last two (fear of making mistakes and Making the right decision) were major contributing factors. She raised Lean In the book written by Sheryl Sandberg the COO of Facebook that raises the internal barriers that women feel. Self-doubt, Uncertainty, fixation on perfection, and hesitancy are all much more prevalent within women are leading to higher levels of stress and cessation of career progression.
Sadly, the report found that women are feeling higher Emotional exhaustion/Burnout (38% vs 27.4%) and attempting suicide more often (3.3% vs 1.6%).
So, whilst making all efforts to remove bullying and unfair treatment from seniors is a no brainer. Perhaps a greater impact could be made by acknowledging the disproportionate impact these stressors have on our female colleagues and changing the system to reduce them for the sake of us all.
This has generated a great discussion if nothing else.
In reply to comment 23, I agree there are arseholes everywhere, in every profession and certainly not limited to medicine. Ever worked in a kitchen? Chefs are ruthless… These people are also quite driven and unfortunately this drive is rewarded. We all know a smarmy little two faced jerk (Not gender specific) that succeeds despite their outward demeanour to their underlings… Yes, there are also amazing Consultants and Registrars that make learning medicine a Privilege. Perhaps a solution in a similar vein to JMO accreditation is the anonymous feedback from JMO’s on their registrars and consultants to be reviewed at consultant meeting with department heads, the poor ones are cut and the good ones rewarded.
In follow up to Comment 19, and response 20. I don’t think that I fill the shoes of a “self-justifying bully” or a ” Narcissist”. I’m a trainee not a senior and I’m simply saying that I don’t think this applies to all Junior Doctors. I have had a different experience that is all. I’m in agreement that the bullying is shite and needs to stop. I personally have never experienced it in training (once as a med student in Victoria but that guy seriously wasn’t wired right). Is that because I trained at an awesome hospital? Partly. Is it because I’m a Tall(ish) Muslcular(ish) Male(ish)? Probably, I experienced one surgeon who would simply grunt (I don’t think grunting counts as bullying) at me while my female colleague and friend (whom I know to be very competent and knowledgeable) on the same rotation after me was given regular dressing downs both in theatre and on the wards bringing her to tears. It was disgusting but it was the statistical outlier. Have I received feedback in front of my peers, definitely and its embarrassing as hell but it wasn’t toxic hierarchy or a consultant acting “Egregious”. It was a consultant who didn’t have the time to sit me down later on and wanted to address a problem then and there. Dynamic Feedback. Thankyou for supporting HPARA though, I’ve recently discovered them and its an amazing initiative.
In response to comment 16, mandated working hours such as found in ICU and ED are amazing. I’m convinced that this is the way forward for all specialties. Mandating reduced working hours whilst training and studying for college examinations makes sense from an individual mental health point. Imagine working 30 hours a week and being able to focus on study for the rest of the week leading up to examinations. Or like in ICU work the long(ish) hours and have an entire week off to recover, study and actually enjoy life or see your family. It would financially also reduce overtime and on-call costs from the hospital point of view.
Yes there are the most awful bully senior doctors. Yes there are the most helpful supportive senior doctors. The issue is how to tell. the same horrible prick consultants were the bullies at school, the proud traditional private school boys with a sense of inevitable superiority, and the ghastly pretentious registrars. The difficulty is in keeping the hierarchical pretentious doctors from destroying the keen young doctors with clear enthusiastic brains. Some of them too will become bullies. If a more senior doctor is on call the junior doctor has to be able to call them, and if they are rude or disrespectful they can go. The hours of junior doctors must be approved by an independent, outside of the system judges
Stop the bad and encourage the good. The best consultants are a wonder to learn from, and the worst are sad, pathetic, socially inept bullies. Look after our juniors with humor, concern and support, and ditch the old hierarchy system. Surgeons used to be called Mr. I guess some twits still want to be called that.
The matter of possible bowel obstruction and X-rays – and of clinical authority – is a case in point. Does one order ‘a non-urgent abdominal x-ray to assess for constipation in a young adult’? Or was it ‘bowel obstruction’? Obviously the problem was abdominal discomfort, possibly ‘tenderness’. In the clinical circumstance bowel obstruction will be an uncommon but serious cause of the symptoms and signs. How does one exclude it? There are three underlying determinants to that process: what is the clinical picture? who will assess the clinical picture? and what are the clinical skills of that person? Is a psychiatrist the best person to assess an acute abdomen? Does a specialist always over-rule a ‘non-specialist’ whatever the clinical expertise of each?
In Australia in the late 60’s and early 70’s I observed the specialists kicking the GPs out of hospital practice. There was to be no role for a GP in a hospital. If the patient’s condition involved more than one ‘system’, the consulting specialist would call in the relevant other specialities. GPs were a lesser breed. In Canada, between 1974 and 1980 I worked in a different milieu. Half the doctors on the clinical staff of the Royal Columbian Hospital, then the Kelowna District Hospital, were ‘family physicians’. We admitted all patients, then internally referred to specialists, as we did externally in the community. We dictated a ‘history and physical examination’ that was typed and placed directly under the typed specialists initial ‘clinical assessment’. We did ‘rounds’ on our patients in hospital, Monday to Friday, before the start of our community clinic work. We held the retractor for all operations performed on our patients, having conjointly decided on the surgical procedure, and followed the patient’s post-operative recovery. We dictated the discharge summary, as we discharged the patient from the hospital to our own community care. It was what the specialists wanted. We would button-hole a consultant in the hospital corridor, give them a 30 second run-down on a patient we were going to refer to them in the community. They would suggest further preparation (lab work, imaging) and ‘triage’ the patient on the spot.
We kept the specialists’ ‘socks pulled up’. They kept our ‘socks pulled up’. The specialists knew more than what we did about their own speciality. We knew more than they did about every other speciality. It was an egalitarian medical community.
I cannot imagine ‘resident medical officer suicides’ occurring in that environment.
I think the contemporary Australian circumstance that has led to young doctor suicides is utterly heartless. The complete antithesis of the ethos of ethical clinical care. Inevitably the senior doctors in such a circumstance will verbalize a ‘rationale’. Is it “…they simply could not ‘hack it’. They were never ‘cut out’ to be a doctor?”
Can we apply the ‘medical paradigm’ to the circumstance? Characterise the problem, identify the causes, formulate preventive and operational responses – and implement them?
A coronial inquest will be very embarrassing to the profession. We should do something – effective – before the family of a deceased young doctor demands one.
It has been over a decade since a member of my family took his life in the hospital in which he worked.
When a patient dies under our collective care, an incident report is filed. A coroner’s report is done. Nation-wide changes are implemented.
When a colleague dies, somehow we just pause for a moment and continue on with the ward round. It might be compared to that man that killed his brother and then boarded a public bus across the state like nothing happened.
I agree that the job needs to be done and that patients do rely on us to provide care. But isn’t it time that we pause to look after each other? The culture has to change. We need to make the doctor ‘well-being’ and ‘work-life balance’ a priority and put some action behind those words that training colleges promote in their member newsletters.
Ben, fantastic article. Thank you!
In reply to 18 & 19….
These comments are typical of the self-justifying bullies who perpetuate the myth that “if I had to go through hell then, you must too!”.
They move blame to the bullied junior doctors by saying that they need to be more “resilient”.
What a joke.
In true narcissistic form, the senior doctors, by not admitting there is a problem, (or by shifting blame to the junior doctors) allows them to continue their egregious behaviour.
In reply to 11. I am a member of HPARA and can strongly recommend membership.
This piece is certainly passionate and will strike a cord with many I’m sure. But it’s hardly balanced. What of the trainees that not just succeed but thrive under the current model. That become better consultants with higher levels of resilience. Do we potentially lose these doctors and lessen their accumen because of a minority that cannot succeed under the current system. You mention an inundation of support received for the letter, I don’t think 150 people constitutes a majority within the vast numbers of medical officers in training in NSW(certainly the letter was born out of care and nobel intentions)
We have one of the best (32/191)healthcare services in the world according to the WHO. I wonder how much of that is due to the medical training the consultants have had and are now overseeing. Perhaps instead of blaming others and as juniors we should look into ourselves and have better judgement of what we are cut out to be.
I loved paediatric surgery, it was amazingly fulfilling in a way that I’ve found in only one other specialty. But it involved moving every 6 months with ridiculous hours for the seven years of training followed by the rigors of consultant surgical life. When I discussed it with my fiance (also a dr) and we looked at what we wanted in life; family, hobbies, travel, smiling… It was the other specialty that won out. Everything has an opportunity cost, so have the maturity to realise that and if you cant cope then change specialties after all there’s 50 odd of them.
I for one love my job, I love my training and I have appreciated every criticism that I have received. If I have done the wrong thing i expect to be told so that I can improve my performance and better the patient care. I am better for the current model of training and as a result so are my patients
Be careful what we wish for. One of the greatest strengths we have as a profession is the ability to self-regulate (to a certain point). It is rare when the members of parliament are called to investigate and legislate on an issue with the ensuing outcomes being more beneficial or tolerable than the previous ones. Asking a group of career managers to deliberate over the working conditions of our profession, one that they know not one intricacy of, is fraught with danger. I fear we would shed the role and responsibility of self-governance with little if any gains.
Are the recent deaths a tragedy, of course, but in no more or lesser amount than any other death. Emotion clouds judgement, this is true. I would hate the good intentions shown here to pave the road to a proverbial or proletarian hell.
In response to comment 15, the pass rates of the new Psychiatry training program have fallen since the new program was implemented 5 years ago. In particular the written essay exam. Whilst the causal factors are complex, this does not represent a sudden lack of competency in every cohort taking the exam in the past 5 years. It does represent a training program that needs review. It leaves trainees out if pocket up to $5000 for sitting the exam multiple times, not to mention the mental distress.
Hi Ben,
Great article.
I believe we need to be very careful about our hour restrictions however. Not because ‘you must do x many million hours in order to be competent at y’ which has been throughly debunked, but because some current roster arrangements, for example ICU roster arrangements that have 12/13 hrs on 7 days a week (ie 81 or 94 hrs a week) or ED rotations that have 10 hr shifts as opposed to 8 hr shifts are, in many cases preferable to having to the alternative:
The ICU rotation allows 7 days off following, and the ED rotation allows for 8 shifts in 14 days as opposed to 10 shifts in 14 days.
I am not sure that I agree about postgraduate examination pass rates, certainly in psychiatry, I am surprised at how lacking trainees are in both knowledge and clinical skill. Part of this resides with the poor quality training. In 2 states that I have worked in, I have been advised that there are is no specific training in history taking and mental state examination, which is akin to cardiologists going through training, without being supervised and educated in using a stethoscope.
Great article Ben, and so great to see and feel us all coming together to stand for us as people, and as a profession. If we cannot take care of ourselves, how on earth can we truly care for others? We have to be the instigators of true change. HPARA is a great platform for us all and the recent conference was inspiring. It is well worth taking the time to look at their website and watch the videos of the presentations…particularly those of Maxine Szramka and Caroline Raphael.
The proper comparison of the practice of medicine is not with the aviation industry but with the military, and that doctors and nurses are the accepted collateral damage of the system. I am merely being realistic here rather than making any value judgment on what the system should be rather than what the system ought to be. To this end, it behoves the profession to properly inform prospective students of the dangers of studying & practicing medicine (including the suicide statistics). It is clear that if a person volunteers to join the military, that they know that the chance of dying/injury greatly increases…..the same must be clear to prospective doctors that the chance of suicide increases by 200-300percent.
As an aside, refresh your mind of the Jack Nicholson speech in “A few good men” and with the judicious alteration of a few words within the speech can be applied to medicine https://genius.com/Aaron-sorkin-a-few-good-men-you-cant-handle-the-truth-annotated.
In all respects , an excellent piece by Ben ( we went to med school together)
Suicide of a Psych junior doctor in Queensland 2016. Appalled at the lack of compassion shown by my senior colleagues/CD. Raised concerns. Brushed under the carpet. Its about time we as mental health professionals treat our colleagues who are suffering with the same compassion we do our clients. Would love to be part of this group/ movement. We need to save doctors lives not break them
Benjamin Vaness has rightly identified a serious problem that has been increasing since AHPRA was formed in 2007. It has been recognised and reported repeatedly since then. Suicides, depression, loss of confidence, burn out, resignation, family breakdown, vexatious reports, increasing legal actions and personal damage have all been identified as increasing increasingly suffered by Health Professionals. Damage to the Health Professions from Nursing to Medicine and all the other Health Professions regulated by AHPRA have endured these same increasing issues that are exposed in this article. It is now time for urgent reform to address the problems.
Health Professionals Australia Reform Association (HPARA) was formed some 3 years ago to fight for reform of our regulation system. Our membership is steadily growing. Since then HPARA has organised two successful National Meetings. Our membership is made up of many Health Professionals from all the professions regulated by AHPRA. International and local experts and speakers from professional bodies, experts in psychology, in the study of bullying, medical administration, safety practices, vexatious reporting, peer review and the legal professions have been at these meetings and in their presentations have well documented and identified the deficiencies of our current regulatory system.
The first meeting in 2016 in Sydney was very well attended and presented to the public and health professionals many of these problems with the regulation and registration of Health Professionals in Australia. There were experts from many fields to identify the problems of sham peer review, bullying, vexatious reporting, misuse of process and the damage done to health professionals in the fields of medicine, nursing, psychology, and the other health professionals regulated by AHPRA. Two recent Senate Enquiries have also been presented with the failings of Health Professional regulation in Australia, and those Senate enquiries have identified these issues and called for the reform that is urgently needed.
HealthProfessionals in Australia are not protected by the rules of natural justice, the right to a fair hearing, the right to due process or to protection from from vexatious reports. Our last meeting in Melbourne was even more successful and well attended. The Chair of AHPRA was presented with the evidence.
Our membership of HPARA is growing, an d it represents all disciplines regulated by AHPRA, and we have continued to call out the failure and mistakes of our regulation authority and also pointed out repeatedly to our Colleges, Associations and the General Public that action for reform is needed now . Health Professionals in Australia are suffering from an unjust and unfair system that denies the right of the assumption of innocence and leaves health professionals with less legal rights than afforded to other citizens who have been accused of criminals acts.
As the the current Chairperson of HPARA I ask each of you to support our organisation in its call for an enquiry, such as a Royal Commission, and the needed reform of our Health Regulation Authority that we so urgently need. Our Colleges, Associations and State Health Departments seem unwilling to demand and are not yet supportive of any call for transparency and accountability of our regulation authority. The College of Surgeons pays lip service but real change is not forthcoming.
If you do not believe what I have said above look at the website we have set up. Do a Google search of HPARA and watch the presentations that have been recorded at our annual meetings and see the evidence of the wrongs done to health professionals yourself. This will explain to you the real mental and personal harm done by our defective regulatory system.
John Stokes
Chairperson Elect
Health Professional Australia Reform Association
I am afraid that excessive hierarchy is only part of the problem. Hospitals, in particular, but also other areas of medicine, are administered by too many people who do not understand (or don’t care) about the working conditions of doctors; especially junior doctors. It’s very easy to draw up a roster with 80 consecutive hours without really understanding (or caring) what that actually means to work those hours.
I am a latecomer to medicine and I am agitating for change. It’s up to us to advocate for ourselves and create the changes we desire for our practice and that of future doctors. No one is going to hand it to us on a platter. It’s relieving, albeit overdue, that this is on the national conversation and I intend to keep it there. You have to call out bullying or unreasonable behaviour, speak up about your working conditions, don’t settle for less.
Medicine is never going to be a cakewalk but it doesn’t have to be the death of you either.
As a result of crashes like Korean 801, when your plane lands at Sydney airport it is not the pilot landing it, but the copilot. This is not to break the hierarchy, but to harness it – the senior pilot error-checks the junior. This sounds appealing in a medical setting, to have a more senior GP supervising each consultation, or a more senior surgeon supervising each operation, with a more senior anaesthetist supervising the airway management of the primary anaesthetist. However, when you work out that this instantly doubles the cost of medical care, you see why nobody (other than our politicians) gets their flying bulk billed. Remember that a simple flight from Sydney to Melbourne carries about 180 passengers at a cheap fare of $100 each, i.e. over $18,000 per hour. How much would you pay for a safer medical consultation?
The big aeroplanes, such as the one mentioned in the first paragraph, actually have at least 3 fully trained pilots. If you think there is no hierarchy, you may be amused to find that the pilot in the third seat is known as the ‘sexual advisor’, from the typical captain’s response “if I want your f**king advice I will ask for it”. And ironically, the airlines know that when the goose hits the fan, the juniors have to instantly obey the precise instructions of the captain, without his having to explain himself: “I am the captain, when I tell you to land in the river, you land in the river”. Even when the captain chooses to land in the Hudson River. Because, as well dramatised in the movie ‘Sully’, there are times for mulling and collaborative consultation, and there are times for individual decisive action.
In medical care, larger numbers of people may not help, as in Dr Veness’ second paragraph where “multiple senior doctors” failed to do what was apparently evident to the nurses, who also failed to do what they thought should be done. And as the reviewer in the independent inquiry noted, there was an ENT surgeon there who had experience in tracheostomy – was his inaction due to his lack of ‘excessive hierarchy’ and failure to assert himself as the best person in the room to take over?
20 years before Mrs Bromiley died, I watched a near-identical event, as a team of highly-regarded anaesthetists failed to ventilate a patient with angiooedema. My boss was a cardiothoracic surgeon who even then was called a bully, who had inspired a strike by nurses, and had many junior doctors quit on his term (I got the job after my colleague quit in fear). He entered the room like Clint Eastwood, strode past the struggling anaesthetists with a simple growl of “Let’s cut his throat”, and within 10 seconds, he had the trachy tube in. Patient saved. He was an old-school hierarchic tyrant, yet whenever the caring, collaborative surgeons got into real trouble, they called for his help. He could make decisions, and implement them.
Mrs Bromiley died because her surgeon didn’t stride forward and say “I am the best person to save her”, perhaps not wanting to look like a bully, or appear critical of his anaesthetic colleagues. A lack of a clear hierarchy lets all express their sincere opinions, but leaves no-one in charge to make a decision.
Hear Hear Ben. I agree it would be great to have an inquiry to investigate this matter fully. Only when we truly understand the nitty gritty details of what is going on can we truly solve an issue. If we don’t completely understand it in its breadth and gravity we end up providing well intended short term solutions. What you are calling for here is an evolution of our medical culture. Every life matters, including those in the medical profession.
A very interesting and important article. In his fascinating book The Checklist Manifesto: how to get things right (2011), Atul Gawande sheds light on the issue of providing an environment, in surgery at least, where junior staff are able to speak out about things which are going wrong. He also draws on the experiences of other industries such as the airline and building industries in preventing disastrous mistakes.
X-ray the abdomens of non-symptomatic patients in ANY psychiatric hospital and you will find a TYPICAL “pseudo-obstruction” pattern in a large number, especially those that are severely psychotic. Operating on these people is NOT indicated, as any psych hospital registrar, of some standing, will tell you. As a radiologist, commencing practice as a registrar at RPAH in 1967, I have seen this very often. It is hard to convince the clinicians NOT to operate, but to closely observe the clinical situation, in these cases. These psych patients are often major aerophagers (air swallowers} and it is this that some presume to be the cause this situation. Surely the senior bloke knew all about this clinical phenomenon?
Anecdotes always get in the way of evidence related practise and behaviour. After 20 years in private practice I took on some sessional work in a Melbourne teaching hospital. I was treated like a middle grade registrar. I’d had enough after six months and quit. I’ve also been criticised by a judge for not “giving enough weight” to an opinion expressed by a junior. Damned if you do and damned if you don’t.
Just think how beneficial it would have been for Ben (and the observing medical student) if the consultant (who I readily agree usually does know better than the junior) had taken the time to explain this like the above commenter did rather than belittling him and behaving like a prat.
The psychiatrist ordered the abdominal xray because of the small chance of missing a bowel obstruction.
I recently saw a patient diagnosed with constipation without an xray – bowel obstruction diagnosed 3 days later – required resection.
The consultant usually knows better than the junior.
Take it from an ex-airline employee that moved into medicine – the culture of medical hierarchy is SOOOOOO deeply ingrained that there will only be limited changes to the interaction between senior docs and their underlings (of all types) within my working lifetime (the next 25 years). I can assure you that questioning a medical opinion (as we were trained to do in aviation) leads to ridicule, or worse (and yes, threats to fail rotations). No wonder nurses just won’t question things – why put your head up when it will be at least kicked?
Sadly, the lessons I learnt, and practices I observed in aviation are nowhere near ready for implementation in medicine. Even at most basic levels, hospitals are staffed on weekends and nights (and most evenings) by the most junior staff. Even in the middle of the night, there is an experienced Captain, and at least one experienced Flight Attendant – try finding a Consultant of ANY type after hours, even in a tertiary centre. (They will claim to be ‘on-call’ but how aften are they NOT called due to fear? How often will they ‘only’ provide telephone advice?). ANd no-one wants to pay for Consultant presence anyway……what a way to run a health system….
This is a simply excellent article. As a senior specialist surgeon I have spent my whole career vacillating between doing something that I love within an environment that I hate thanks to the attitude of my surgical colleagues. Cronyism, boorishness and paternalism are still rife within my specialty, despite the ludicrous hand-wringing exercise that RACS has just put us all through. Absolutely nothing will change until surgeons (and other doctors) deal with their biggest demons – greed and fear. Greed speaks for itself. Fear of course is directly related to ego. I could go on but I’ll leave it there.