Medicine and politics: not the one and only

Medicine, in my experience, is not always a precise business. There are decisions we make, there are choices. We make mistakes and we have to own them. And we are better at it when a community of thoughtful, experienced and clever people put their collective minds to work.

IT’S the story that keeps on giving and Mr Scott Morrison’s self-appointment to additional ministries reminds me of some important lessons I’ve learnt as a clinician. No – not a political rant. Let me explain.

Adverse events offer a chance to learn and make changes for the better

As a middle level clinician, the most wonderful thing I learnt was that the hard decisions didn’t have to, and shouldn’t, be made alone. It was a relief to understand this. An ethical challenge: seek advice, have conversations. A moral dilemma: talk with others, listen to other stories, read the cases from others. A diagnostic puzzle: refer for an opinion, seek further reading and have ongoing conversations with those who may have similar experiences. Unusual diagnosis: look at published case studies, talk with those who have experience, through conversation or reading, face-to-face or online. In fact, each time I remember this, I feel relieved!

Facing the COVID-19 pandemic at the start of 2020, I (and all health care workers) read avidly everything I could, case reports initially, early data, small trials. Even now, in the third pandemic year, a day rarely passes without us reading, talking to others, or seeking information about COVID-19, its diagnosis, its treatment, its sequelae, its prevention, its consequences.

We look at the work of others in the hope that it will provide us with guidance. We look at other pandemics, at history, to seek patterns and understand how others dealt with what we face.

Though an apparently experienced and senior politician, it seems Mr Morrison did not look to history to understand collaborative decision making at times of crisis. According to journalist Ronni Salt, writing in The Shot, he apparently “thought the ‘greatest emergency in Australia since World War II’ necessitated him saving Australia’s federal cabinet from itself – single-handedly”.

He seemingly ignored the work of five Prime Ministers before him, who served during that war between 1939 and 1945: Arthur Fadden (National Party), Robert Menzies (United Australia Party), John Curtin (Australian Labor Party), Frank Forde (Australian Labor Party) and Ben Chifley (Australian Labor Party). On 27 September 1939, the first meeting of the War Cabinet was held and it was determined that “matters of major policy should be determined by the full Cabinet” (my emphasis). Later, Menzies as Prime Minister established the Advisory War Council in 1940. This included members of the War Cabinet. Importantly, membership was extended to the Leader and three members of the Opposition.

Of course, there are times when a clinician must make a quick, accurate and lonely decision. And we do. However, given a choice, the support of reading, of talking it over and seeking opinions, learning from our own and others’ experience is hugely helpful. The process of explaining it to someone else helps our own understanding, and the conversation helps us to think through to a conclusion. And, in general practice we have certainly learnt the lessons of the lonely autonomy of the solo GP: our work must be benchmarked with an awareness of what others do, how others have thought. And in hospitals, when someone has a cardiac arrest, we call for the arrest team.

It seems Mr Morrison also failed to see what most clinicians learn as a fundamental principle in their first year as an intern: none of us, absolutely none of us, is indispensable. We can all always be replaced by another.

As we rotated through those first 10-week terms, I learnt when the nurses applauded us, or the boss said “good job”, we would still move on and another would take our place. I would be forgotten within days. I thought the next doctor would not do as good a job as me – I was wrong, and they did. Not the same way, not in a way I thought best, but just fine. I liked to think some of my patients missed me, albeit briefly; we still moved on.

It also appears the Governor General failed to keep records, so there is no mention of the circumstances (let alone the conversations) surrounding his role in Morrison’s additional ministerial appointments. Health care workers have learnt the lessons of secrecy and poor record keeping. Late last century, Dr Stephen Nicholas Cluley Bolsin cast a light on the high mortality rate and the work of paediatric cardiac surgeons at Bristol. The routine examination of near-misses, adverse events and critical incidents through modern clinical governance processes resulted and has fundamentally changed our practice and our thinking. The bringing of light to both poor and good practice requires careful record keeping and data collection – essential to inform our striving to improve.

“Dr Bolsin collected data and took them to an increasing number of colleagues. No one ever said he was wrong to do this; rather, he was told to take care to verify his information and discuss it with colleagues, including those whose work gave rise to his concern.”

Now the Australian Government is seeking to shore up the “loophole” examining whether there should there be rules or laws to prevent a recurrence of a practice that the Solicitor General has advised “was inconsistent with the conventions and practices that form an essential part of the system of responsible government”. In clinical care, it is just not possible for us make rules for or have experience of every nuance and every possibility. “Never say never” is commonly repeated. We are guided by a commitment to the best solution for our patients, and we depend on others to provide understanding, insight, experience, thoughtful reflection and good sense. It’s our safety net and requires an openness and willingness to be scrutinised.

Medicine, in my experience, is not always a precise business. There are decisions we make, there are choices. We make mistakes and we have to own them. And we are better at it when a community of thoughtful, experienced and clever people put their collective minds to work.

I cannot abrogate my responsibility. However, to shoulder it I should seek all the advice and conversation to which I have timely access, to make the best possible decision for that moment, particularly in times of crisis or when faced with the greatest of emergencies.

Dr Lilon Bandler is a Sydney-based GP, medical educator, and Associate Professor with the Leaders in Indigenous Medical Education Network at the University of Melbourne. She is Medical Director of health services at the Wayside Chapel.

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

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