IT never seems to stop – story after story of junior doctor distress, bullying and burnout, even suicide. How many of us sigh and wonder when things will ever change?

In recent months, we have heard of hospital teaching departments losing accreditation status, young doctors leaving training schemes, and tragic loss of life (here, here and here).

Over many years, the quest for a solution has particularly focused on working hours and competition for training positions. It is sometimes suggested that the pool of supervisors includes vindictive narcissists who think that today’s trainees should have to endure what they went through to somehow “toughen up”. Again and again there are calls to refine medical student selection processes – though it is 40 years since the University of Newcastle, for example, began selecting students through interviews and aptitude tests.

When we talk about “culture change” in hospital workplaces, though, what do we mean? Do we mean responding to the stress of toxic work environments by offering yoga lessons and sessions with the employee counsellor? Do we mean that we should all develop more resilience to survive a toxic workplace? Is resilience just “hardening up” by a new name? Is the incidence of bullying changing, or is reporting more prevalent?

Much has been written over the years, from various perspectives (here and here). We’ve had College reviews, a Senate inquiry, pages of press reports, interviews and panel discussions.

In an attempt to come to terms with this apparently intractable issue, many of us look back over our own careers. What has changed? Here is my take.

First, while there is no doubt that junior doctors still work long and sometimes unsustainable hours, objectively, working hours have improved over the decades. There are more women in senior positions than ever before. Medical schools take a mix of under- and post-graduates. Training involves more hands-on and problem solving than ever before. There are many senior role models with families, and part-time work is more available and accepted than ever before. And yet morale seems lower than ever. What’s different?

In my view, workplace dysfunction is characterised by not one but two F-words: fear and frustration.

In the mid-1990s, the Quality in Australian Health Care Study rocked the nation by publicising the harm from medical error. What followed was an enormous shift towards focusing on quality and safety by collecting data, analysing them and putting in place a huge body of guidelines, restraints and surveillance processes. We learned that standardisation improves outcomes, that working under surveillance improves compliance and that, if highly trained and skilled doctors would just swallow their arrogance and do as they were told, things would be better. But what did we think would get better? Patient care? Workplace safety? Teamwork?

Let’s look at where that got us. In reality, health care is much safer. At least, it is if you only count certain types of errors. We have reduced many errors that were avoidable by better process design – medication errors, wrong-site surgery. We have better processes for handover. We have a myriad of new processes for falls prevention, risk documentation, early identification of possible sepsis, procedural credentialling. We have a large number of policies and guidelines. But we have traded the risks of “missing something” with the risks of overtesting and overtreatment.

And, more than ever, we have disseminated the two Fs: fear and frustration. Fear of missing something, of being blamed, of being called out by peers as being below standard, of being considered responsible for patient harm. And frustration at seeing a quality management system that cannot keep up with the sophisticated, complex system it governs. A risk management system that focuses too much on error analysis and ways of restraining staff and nowhere near enough on trust and value of staff. A system that is more about fixing than fostering.

It’s possible that bad behaviour – including bullying, blaming and belittling others – is triggered by underlying fear and frustration. Though trained to rationally calculate and hold risk, we may be driven to push it between each other rather than hold and manage it between ourselves and our patients. We may be induced to act more out of fear of blame than fear for patient welfare. Ironically, the patient may be completely left out of this dialogue of blame-shifting. And when we feel ignored and powerless to do our best work – even sabotaged by the system – we might take our frustration out on others.

I want to call for a different F word: moving risk management forward.

Health care is a highly complex endeavour staffed with highly educated, skilled and motivated professionals. Risk management should be equally nuanced and skilled, aimed at maximising performance of staff, not just limiting error. The focus should be on building trust and motivation, encouraging clinicians to do their best possible job because they are motivated to work well, not just because they are afraid of blame. Institutions should employ managers who are at least as skilled in this area as the clinicians they advise, and who see clinical staff as an asset, not a liability.

A healthy workplace culture calls for doing safety differently. This approach sees safety as intrinsic to good work, not as a separate bureaucratic process. It sees staff as talent to be developed, not as sources of risk to be managed. Just like good clinical work, good management requires courage. The courage to trust clinical colleagues to want to do their best. The courage to call people out when their motivation is poor but also to recognise when it is good. And the courage to share risk explicitly with patients, knowing that error is inevitable, but that mutual acknowledgement is what most patients hope for.

Junior doctors are as well selected, smart, well trained and well motivated as ever. Let’s create a system that helps them flourish and doesn’t drive them to frustration and fear.

Dr Sue Ieraci is a specialist emergency physician. After 35 years in the public hospital system, she now works in telemedicine and health system consulting. 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.

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

8 thoughts on “Doing safety differently: creating fertile soil

  1. Dr Craig Wilson, psychiatrist says:

    Dear Dr Ieraci,
    Thanks for your well considered piece about the discontent in medicine, and especially junior medicine.
    When I speak with junior colleagues, I hear (often whispered) that a strong contributor is another ‘F’ – financial.
    Young doctors have serious financial obligations, and face the same pressures of living in expensive cities as the rest of us. If they are post grad, they likely have higher bills and costs. If they are part time for work life balance, they earn much less. Maybe there was never a time when medicine was a lucrative profession proportional to the effort, responsibility etcetera, but it seems poorly paid now. Babysitters easily demand $30 cash in hand, while traffic controllers – with close to zero training start on a base rate of $42.45 per hour. Their penalties are far better than medicine. Interns start at $34.27 per hour. That all makes it hard to live, and suggests that the value of the job is similar to many untrained roles. Those traffic controllers often get to $180 000.00 with no significant training, no medicolegal insurance, and minimal fear of a law suit or complaint if they make an error. This is but one dimension, but it’s a genuine element that no one seems comfortable mentioning.

  2. Andrew Watkins says:

    Good comment, I agree with much of what you say and absolutely agree about the importance of the background administrative and regulatory culture.

    Does the analysis need to be more stratified by seniority, as I see the issues as being rather different for those of us further up the tree than for those just beginning to climb the tree ( or the greasy pole !)

    While hours are objectively shorter than what we endured this has not come from a global recognition by senior clinicians of the problem of overwork by juniors – there is still background kvetching about “not getting the experience” and “not committed like we were” from powerful quarters. This is part of the water in which our juniors swim and they pick up the vibe, along with all of the other “hidden curriculum” stuff, getting the feeling that they will be judged harshly for not doing the extra shift or the unpaid overtime not recorded on the timesheet.

    The more diverse medical workforce, an excellent change, means that the intersection between work and life is also more complex, our juniors having rather more dimensions to their lives than I had when I was 24 ( e.g kids, partners with job problems of their own etc ). Making the rest of life and family work sharpens up these clashes at the margins and significantly increases wear and tear.

    All of this is played out against the competitive pressure of exams and selection for restricted places on training programmes. While it felt intense when I was going through it many years ago, it is more intense and difficult now. In this environment the powerful bullies or the destructive teacher using the ‘ritual humiliation’ teaching method have a disproportionate impact. It is still too early to discount these effects.

    At the more senior level you are right on the money about the admin culture. The prevailing culture for some time has been of micromanagement by risk averse administrators who do not have the clinical knowledge or training to make a sane assessment of risk, beyond the risk to their own careers should something happen on their watch. Financial drivers dominate and we clinicians are left with little faith that our efforts make any real difference to the direction of our organisations, a potent source of dissatisfaction and burnout.

    It is interesting to note the response of administrators when I tell them that I routinely advise families of the absolute inevitability of error during a prolonged hospital admission, discuss this openly with them and work out pathways to manage the risks and the communication and conflicts associated. The response is generally of horror or blank incomprehension. The idea of treating patients / families as mature adults, with whom we have a partnership in managing clinical risks and to whom we must cede some control is utterly foreign to most.

    This is perhaps unsurprising, given that most are incapable of trusting and respecting clinicians and allowing much autonomy.

  3. Graeme banks says:

    The legal profession, suffocating swollen bureaucracy who absorb most of the health dollar, and the impertinence of laissez faire university trained nurses, should all get a mention as should the lack of support from relevant medical associations, colleges and so called peak bodies.Graeme Banks

  4. Jenny Bradford says:

    Is the experience of junior doctors really any different from junior accountants, junior lawyers, junior engineers, etc? There are bad people and bad cultures in every industry. What about the expectations of these young graduates?

    There are many schools who espouse a philosophy of “every kiddie wins a prize”, and lots of helicopter parents who are still “helping” their adult children through university. This means that a young graduate may never have experienced the real world until they get their first job. This is not to say that we should not try to change bad work cultures, and root out “bad” people, but surely it must be admitted that young graduates may have unrealistic expectations of what paid work will be like.

  5. Dr Antony Sara says:

    Sue
    thank you for your thoughts.
    Is it possible that another factor is that with the huge numbers of medical graduates, but the same number of training posts, that today’s JMOs are not as prepared to suck it up? In earlier times, many/possibly most would get onto a training scheme of their choice, so “we” just put up with it, knowing that it would be over in a few (short) years…???
    and another possible factor is that more mature age graduates, some with families (as happened to me), that similarly they are not as prepared to just put up with the behaviors, the hours, etc.
    Interested in your views
    Tony

  6. Ian Hargreaves says:

    Much has changed, Sue.

    The customers are more demanding. I used to tell people they would be in traction for 3-4 months, or a long-leg cast for up to 6 months, and they’d accept that. Now if I tell someone not to drive for two weeks while in a plaster slab they are disgruntled.

    The ‘patient safety initiatives’ you mention are oppressive. Like working in the USSR while the KGB man sat impassively watching you, the culture of safety/anti-bullying/error-prevention becomes a sword of Damocles, not a comfortable seatbelt or a discreet airbag. This oppression reached its nadir in the UK GMC’s treatment of Dr Bawa-Garba, thrown under the bus for a system failure and a clinically reasonable but wrong initial working diagnosis. Highly respected orthopaedic surgeons Angus Gray and Michael Solomon (both my former registrars) are currently being censured by the NSW health dept for having the temerity to whistleblow on the deleterious effect of cuts to cardiac surgery at their children’s hospital.

    ‘Procedural Fairness’ has trumped fidelity in industrial relations. As a JMO, I understood the tacit deal was: “You work your arse off, don’t screw up too publicly, and you will get a senior job”. Not tenure in a legal sense, but a symbiotic agreement. Now each position is advertised and a set of publicly available, specific objective criteria are applied. When my son was a 2nd-yr anaesthetic registrar, he had to apply for the next year’s job knowing that only 6 of over 40 applicants would succeed. Incumbency was not a guarantee of success. We have moved from ’till death do us part’ to ‘you will remain my spouse subject to your successfully tendering in an open application process each July, at which the leading candidate will be selected for the ensuing year (see website for documentation requirements)’. Good for your mental health.

    And in the background of training issues, when I went to medical school the specific, stated aim of universities was to equip us to function as GPs after completion of internship. VR did not exist (except on VicRail seats and the occasional old letterbox) and the default position was that if you quit or didn’t advance in physician/surgeon/O&G training, you could fall back on being a GP with an interest in internal medicine/minor surgery/delivering babies.

    Now the universities have weasel words like ‘equipping postgraduate medical students for lifelong learning’ rather than objectively assessable, specific competencies like cannulating/intubating/delivering/resuscitating.

    The safety net of general practice has been removed – yes, the RACGP did own the net, but they quietly removed it without input from the colleges of trapeze artists and acrobats. Nearly fully trained in Cardiology/Orthopaedics/O&G but didn’t get that final year job/2nd part exam? As Adam Kay will tell you, ‘This is Going to Hurt’. There is no alternative career path, we bravely go on like Alois Hinterstoisser, there is no going back.

    The ultimate casualty is collegiality. As a medical student, with no doctors in the family, I was made to feel like part of a greater team. Sure, it was something like the Wallabies where you had to keep your mouth shut and accept losing often, or maybe Bravo Two Zero where you were inadequately equipped for a mission of life and death, but you were in there with people who were on your side. I remember fondly the doctors’ dining rooms at the Royal Alexandra Hospital for Children or the Mater Public, where the hungry students got to have a free feed, and more importantly to sit beside our senior colleagues, we happy few, united against a common foe of injury and disease.

    Now the worst example is how our Colleges milk our trainees as cash cows, requiring them to cough up ever increasing sums of money for compulsory courses. Early Management of Severe Trauma? You’d think that was the universities’ job to cover such a vital field. No, but it’s cheap at $2,990 – leaves you a bus fare home from a $3,000 note. Oh, and the Refresher course every 4-6 yrs for a measly $2,225. Like the trailing commissions on financial products. Unless you’re an evil IMG, in which case you are up for about $20,000 per annum for ‘supervision’ by your unpaid surgical supervisors. Local graduate and want to be a surgeon? You’ll want to pay the Selection registration fee of $570, and the Selection processing fee of $880. They are the equivalent of a booking fee for surgery, entering you into the computer etc.

    When you finish training, you’ll want to sit the 2nd part exam (a bargain at $8,495) and if you are one of the lucky 60+% who pass, shell out for the Fellowship entrance fee of $5,550 (akin to a real estate agent’s key money) and of course a year’s Annual Subscription for a meagre $3,155. Obtaining a hour’s worth of face-to-face surgeons’ time for a paltry $17,200, more than any ‘egregious fee gouging’ for an operation. Hippocrates’ oath “to teach them this art, if they want to learn it, without fee” is long forgotten.

    Watching the recent documentaries on the Apollo 11 mission was a reminder of the olden days. Enthusiastic and idealistic young men, working together in a common cause even while competing for spots on the key missions. The most telling was when asked about the risks, the astronauts pointed out that they were all military/test pilots: a 30% chance of dying was acceptable. The concept of zero-fault manufacturing came from the Apollo programme, but the idea of zero-risk medical care is a pure fantasy.

  7. Sue Ieraci says:

    Hi, Tony. There IS an element of less tolerance for poor behaviour throughout society – this is a good thing, in my view. I agree that recent graduates are more likely to have greater family obligations and diverse lives, but I see this malaise in my own generation – those of us who cut our teeth in previous decades still feeling frustrated because our complicance is sometimes valued more than our judgement and skill.

  8. David B. Skegg says:

    There is more to “safety differently” than is written here. Erik Hollnagel’s work, on which this idea of “Safety II” is taken, really says that success and failure is the result of normal variability in function, and we should look more to understanding why things go right most of the time, than the exhaustive analysis of when something goes wrong. After all, if you failure rate is 1:1,000, it went right 999 times(!). Maybe medical administrators should take notice, do a resilience assessment grid analysis of resilience potentials, and gain a better understanding of how the world really works…. Just a thought

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