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IS IT just me? I’m constantly bumping into warning signs. I’ve never slipped on a wet floor, but I keep walking into those signs that say “Warning – wet floor”. Sometimes, the treatment is worse than the disease.
This is the way I sometimes think about current risk-management culture.
Much has been said recently about the stress on young doctors in training, including tragic suicides. While the discussion continues to focus on workload and working hours, and issues related to the trainee-supervisor relationship, we must look more deeply at what specific features in the workplace culture cause distress among our colleagues.
A workplace with a risk-averse, error-intolerant management culture may present a toxic environment for young trainees, already suffering from a surfeit of self-judgement. We select trainees for their diligence, attention to detail and drive to do well. We give them a job that includes unavoidable uncertainty and conditions that can make them error-prone. Then, we watch them like a hawk, swooping down when perceived imperfections are found in their work. It is ironic that some of the solutions proposed to mitigate risk and error stand a greater chance of causing error.
This brings me back to my problem with warning signs. No doubt, wet floors are seen as an occupational safety hazard. But what if the solution – the unpredictably-placed warning sign, sitting below gaze-level – causes more injuries than it prevents?
What if a significant proportion of errors are caused by an overcrowded task list, excessive interruptions and multiple conflicting demands? And what if the proposed solution is more checking and reporting – more checklists, more forms to complete and more frequent interruptions in order to complete the checks? Could it be that the solution worsens the problem?
We now have the perfect storm: a group of self-critical high-achievers, already terrified of making a mistake, already time-poor and task-burdened, being given more and more tasks as a way of “managing risk”, and more and more scrutiny, lest they trip.
Perhaps it’s time to get rid of the warning signs and just concentrate on the slippery floor. Is the floor being washed too often, with the wrong cleaning products? Could we change the floor material, change the cleaning times, or re-engineer the cleaning process in some other way? Do we need more cleaners, or cleaners with different skills?
While cleanliness is important in hospitals, a healthy and competent workforce is essential. Our community spends decades educating and training young people who will eventually become our doctors. We want them to be meticulous, motivated and caring. We can’t afford to destroy their confidence in a cloud of risk-aversion, or drown them in an unending avalanche of tasks. If we continue to do that, tragedies will continue to occur.
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. She is an executive member of Friends of Science in Medicine.
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The moment we adopted defensive medicine in place of clinical acumen and plain common sense, the health system was doomed.
Thanks Sue for drawing our attention to a huge challenge. Surely there is a sweet spot between diligence and hyper-vigilance. I have long observed that the latter is a key ingredient of occupation related anxiety and PTSD. The current wave of contemporary management appears ripe to evolve from its present practice of “perfection” and its coupled risk-averse driven negative mass transference, to the next iteration. This could be targeting “imperfect perfection”. That might bring us closer to that desired sweet spot. If that be the case, it represents an interesting marketing exercise to the general public and the politicians who rely on them.
Sue, thank-you for articulating so well the nature of a problem which is becoming overwhelming in public hospitals. This should be mandatory reading for all managers.
Not only are there issues in the workplace that can be addressed there is also the issue of depriving trainee doctors of their greatest psychological supports – their family and close friends. Trainees are often rotated to other towns away from those who know them well, who can detect early signs of significant stress, who can offer a normality to life / a release from the work pressures when on time off. I know many doctors in training living away from their partner, and at times their children, for 6 months at a time all in pursuit of their training.
Dr Ieraci has raised an issue that has been the elephant in the room for a generation; that is that documentation is dangerous!
The excessive paper work that must be completed in order to satisfy administrators and lawyers causes enormous cognitive distraction and significant mental fatigue.
It is Monty Pythonesque that we protest that health professionals are for patient safety, yet we suspend our disbelief at how unsafe it is to satisfy evermore paperwork. And it’s not just junior doctors. The nurses on a general ward, for example, could never be hoped to be able to give enough attention to their patients.
We need fresh minds to focus on the important clinical needs of the patient. There should be an absolute moratorium on any paper work that is not vital to the communication of the clinical state of the patient.
Until and unless administrators are held responsible for the safety cost of mental fatigue and cognitive distraction we will continue with the nihilistic belief that “well we just have to do it”.
The medical and nursing professions need to stand up for patient safety and liberate themselves. It’s amazing the enthusiasm of ward staff when you understand and legitimise their concern about the mountain of documentation they need to complete every shift.
Checklists can be a very powerful safety tool if done right, but some of the checklists that have been imposed for the sake of administrators covering their arse are an absolute joke.
Any bereaucratic solution will result in more bereaucracy.
As a survivor of the public hospital system I have terrifying memories of drowning in a mixture of hospital busywork and training checklists while being consistently hounded by administrative staff for work that would not help patient care, and then required to complete patient discharge summaries in unpaid overtime.
With a heavy workload, a draining exam burden and precious little training or input from seniors, junior doctors are set up to fail in most training centres.
At some point the training and practice of medicine has turned into ‘The System’ – a bloated administrative behemoth that exists for the purpose of itself, consumes all, and pushes all efficiency and responsibility to the coalface clinicians on the bottom who have, to their credit, adjusted and coped for decades and are now reaching breaking point.
Doctors could learn from their nursing co-workers on how to unionise for real improvements to work conditions
Sue, The extent of the risk dilemma you describe in your typically erudite manner is well illustrated at the end of your article- “If this article has raised issues for you, help is available at:……” Hospital administrators as well as journal editors clearly need huge support from all the Sues of this world if this problem is ever to be contained.
Our new graduates have received a university “experience”. Frank Furedi’s monograph “What’s Happened To The University? “A sociological exploration of its infantilisation.” is, in my view an essential if sobering read requiring a retreat to a “safe space” and remedial counselling after or during the experience.
This “ex-doctor” is grateful to be out of it.
I wish I could say that stress diminishes after completion of training in Emergency medicine.
But with the state of the public hospital system nowadays, it most certainly has not.