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Surgeons apologise for extreme culture of bullying

The Royal Australasian College of Surgeons has apologised for discrimination, bullying and sexual harassment by surgeons.

The apology comes after a draft report and recommendations were released by an Expert Advisory Group (EAG), commissioned by RACS in response to reports of bullying behaviour in the surgical field.

The report found there is culture of bullying that is considered a ‘rite of passage’ within the College with the intent to prepare trainees for surgery.

Although the report admits that not all surgeons behave ‘badly’, there are individuals or groups who wield power and are repeat offenders. There is a lack of accountability structures in place which results in a major stumbling block for change.

“The EAG Report has identified that many of those affected have not felt they could trust the College to complain,” RACS President, Professor David Watters said in a video message.

“These behaviours have been too long tolerated and have compromised the personal and professional lives of many in the health workforce,” he said.

The report found that 49% of Fellows, Trainees and International Medical Graduates (IMGs) report being subjected to discrimination, bullying or sexual harassment. It also found that 71% of hospitals reported discrimination, bullying or sexual harassment in their hospital in the last five years, with bullying the most frequently reported issue.

EAG Chair, Hon. Rob Knowles AO said: “We have been shocked by what we have heard. The time for action has come.”

Woman told to ‘get tubes tied’

The report found that minority groups, particularly trainees and women, were the main targets of bullying.

Women were subjected to sexual harassment including demands for sexual intercourse and were not considered suitable for surgery by many of the bullies. Survey respondents reported discrimination for pregnancy and for asking surgeons for part time hours or time off to care for sick children.

The report noted comments from survey recipients such as:

“I was told I would only be considered for a job if I had my tubes tied.”

“I was expected to provide sexual favours in his consulting rooms in return for tutorship.”

“I felt sure I was marked down because I didn’t respond to my supervisor’s sexual advances.”

Racial discrimination was a recurrent theme, the EAG reports, with active measures to exclude surgeons from practice in Australia. Survey respondents reported incidents of abuse such as:“They want you out of the country or they want you dead.”

Related: Bullying and harassment: can we solve the problem?

“I still fear that he could ruin my reputation and destroy my life”

The report talked about the fear encountered by surgeons, even in participating in the survey itself. Most of the fear was about career loss, particularly how much time, effort and expense had gone into their career thus far. One respondent wrote: “Reputation is everything…public hospital appointments depend on reputation.”

Respondents felt that power and lack of accountability had led to the issues that exist today. They felt that there was a lack of accountability from top surgeons as well as a lack of accountability and action from hospital administrators.

“There is a hierarchical system which is often dictated by senior consultants behaving in a chauvinistic manner, which I believe has been handed down over time. The acceptance/tolerance of appalling behaviours in the past has no doubt enabled the tradition of bullying/narcissism to continue,” a survey respondent wrote.

Report recommendations

The report has five key recommendations, which include undertaking a review of process in relation to complaints, provide avenues of support including mentoring programs and contact officers.

They say the college should provide for greater measures of accountability, develop training and awareness programs to help lead and influence and continue to review their structures for more inclusive practice.

Professor David Watters says the college fully accepts the recommendations and will publish an Action Plan by the end of November that addresses the issues raised.

“All Fellows, Trainees and International Medical Graduates (IMGs) will need to champion and model the high standards of behaviour we expect of others,” he said. “There is no place for discrimination, bullying or sexual harassment in surgical practice, surgical training or the health sector more broadly,” Professor Watters said.

Read the full report on the RACS website.

The Draft Report is now open for comment about errors of fact or suggestions for action that will strengthen the EAG’s recommendations. Comment can be emailed to eag@surgeons.org by 18 September 2015, before the EAG finalises its recommendations to the College on 21 September 2015.

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Medibank saga remains unpreventable

The full page ads last week in some capital city papers may have heralded ‘peace in our time’ in the dispute between Medibank Private and Calvary Health, but the big insurer’s approach to safety and quality in our hospitals is still in question by hospitals, doctors, and patients.

While Medibank and Calvary may have finally signed a contract, the detail of the belated agreement remains top secret.

While the AMA agrees that any commercial details should remain private, it is in the public interest that any agreement over Medibank’s draconian list of 165 preventable events should be disclosed.

Calvary CEO, Mark Doran, told Adelaide radio that Medibank Private had agreed to engage with the Australian Commission on Safety and Quality in Health Care on what they believe are preventable events, and that they will act on the call for an independent clinical review process. But that’s about all we get to know at this stage.

Related: Medibank-Calvary contracts stand-off: what it means for doctors and patients

AMA Vice President Dr Stephen Parnis said that Medibank’s ‘trust us, we’ll do the right thing by you’ response is not good enough.

“I’m a doctor and I don’t say that sort of thing to patients anymore,” Dr Parnis said.

“I’ve got to give them the specifics. And I think Calvary and Medibank Private need to do the same here.

“We’d like to understand exactly what the arrangements are with regard to that long list of 165 complications, which Medibank was erroneously calling mistakes, to understand what is going on with those as a result of this new agreement.

“The concern, of course, is that if you’re insured it’s the detail that tells you what you’re covered for and what you’re not covered for.

“The treating doctors need to understand what their patients will be covered for so that they can treat them in the appropriate setting.

“Up to now it’s been hardball by Medibank.

“The AMA rarely intervenes in these sorts of disputes but, because it has such wide-reaching implications for the health system, both private and public, we have regarded this as essential that, one, it gets sorted out, and, two, that it is done in a transparent way.

“It is positive that the Commission for Safety and Quality in Health Care is now involved.

“The Commission does things the right way when these complications are being assessed to try and reduce risk, rather than what was happening with Medibank saying these are not complications, they’re mistakes, and if they occur we’re not funding them or we’re dramatically reducing our funding.

“So we need more detail here because it doesn’t just affect Calvary and it doesn’t just affect Medibank Private. Every other player in the health system is watching on here.

“If this sets a good precedent, wonderful. If it doesn’t, then it’s going to have repercussions for everyone.”

John Flannery

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I’m an alien, I’m a legal alien; I’m a French doctor in New South Wales!

Migrating is a daunting but fascinating experience

Joint winner

I was far from imagining how my life was about to change when I reluctantly came to Melbourne in 2008 for a medical conference. Who wants to spend 24 hours locked in a plane with his boss, spend 4 days at the far end of the world and come back to his work duty on Monday, with jet lag? At the conference, I met a beautiful Australian woman, and I was “Thunderstruck” (AC/DC was the only thing I knew about Australia at that time). When I am asked why I left the picturesque south of France and came to Australia, I respond that I had the misfortune to fall in love with an Australian lady — and my interlocutors usually wipe the disbelieving expression off their face and replace it with a cheeky grin (oh, you French men!).

Being an obstetrician and gynaecologist, my transplantation has involved a lot more than the acquisition of medical terms. It has been a journey in terra incognita, exploring the intimacy and most personal attitudes of my new fellow citizens.

For instance, the biblical notion that pain in childbearing should be severe — “with painful labour, you will give birth to children” — is a notion that has been opposed by French feminists since 1968 (part of the legacy of events in May 1968 in France). In my former French unit, we were very proud to announce an unusual 70% epidural block rate — 10% less than the national average. I was shaken when I realised that most public Australian units have a 30% rate. The accessibility of anaesthetists is certainly related to workforce and economic considerations beyond the scope of this essay, and I acknowledge that pain has multiple dimensions (individual, cultural, historical). Still, let me tell you that French women would rather go on a “Love strike” than give up on what they consider to be a major social acquisition!

In France, women’s health is addressed by office gynaecologists (a subspecialty that has existed, again, since 1968). Mothers take their teenage daughters to their own gynaecologist, at a relatively young age, and we belong to a familiar landscape in the collective unconscious. Here in Australia, I am always amused when I have a 24-year-old visiting a gynaecologist for the first time and looking with horror at my examination couch.

The culture of good food also presents a point of difference. Women presenting with amenorrhoea due to hypogonadism usually have a particular personality that manifests in a tendency to overexercise and a preference for a diet deficient in lipids. To screen the French patients, I usually asked how often they would use butter, crème fraiche and mayonnaise or eat croissants. Here, if I asked such questions my patients would gently laugh at me and reply that they do not live in the Good food magazine. I often explain to my patients undergoing in vitro fertilisation that in case of hyper-response, we will withhold the final trigger injection, and the risk of hyperstimulation will collapse as if we opened the door of the oven while baking a soufflé. That is something that every French kid is taught by his mum (“the guests wait for the soufflé not the other way round!”); I am not sure if this analogy is relevant for Australian patients.

I had to change not only my vocabulary, but also my expressions. When I ask a French woman if she suffers from stress urinary incontinence, I ask her if she leaks in winter when she coughs and sneezes. Here, it is irrelevant most of the time, but my patients taught me the “trampoline sign”: they leak when they jump with their children in the backyard. Such a sporty, outdoor way of life! Another example is the “key in the door sign”. I used to ask French women if they had a burst of bladder overactivity when returning home from work and inserting the key in the keyhole. In Australia, my patients often deny this symptom, but after a quick second thought, they reply that they have the “driveway sign” when they park their car in the driveway. Same behavioural patterns, longer distances and size of the continent, I suppose.

Five years have passed since I stepped off the plane. I was a bit apprehensive, I must confess, wondering if I would be able to translate all those years of French practice into a different linguistic and cultural context — all the precious skills that my masters had taught me in the art of medicine, like being able to decipher non-verbal communication, reading almost subconsciously the subtle changes of emotion in the voice of your patients, finding the right words to appease and reassure.

I consider myself lucky: the integration has been a smooth process rather than a bumpy road. Yes, there have been a few awkward moments, and it certainly shakes one’s confidence to become a beginner again; but believe it or not, it has been a wonderful journey — not only to translate, but also to relearn “La Médecine”.

Murder of a Prisoner of War, 1943

a twirling geisha fan
sends the blood splatter into a thresher
of the executioner’s calligraphy
samurai sword in signature
arranges a last viewing
those black hollyhocks
seduced from bamboo cages
of delirious patriotism
that could have written you
all the wanted promises
made and broken in the slow click
of a shoulder going back
in how your hair fell then
and a kiss floated like blossom

The pouch of Douglas

Early in 2014, journalist and media teacher Tracy Sorensen was diagnosed with Stage IIIc primary peritoneal carcinoma. She was treated with chemotherapy and radical debulking surgery, and is now in remission and writing about the experience. This is an extract from a longer work in progress. A version of this work was first published on her website, The Squawkin’ Galah (http://squawkingalah.com.au), on 23 October 2014.

The pouch of Douglas is a small area in the female human body between the uterus and the rectum. It has a name and a shape, but the essence of it, the point of it, is that it is a piece of nothing. The territory of the pouch of Douglas is infinitesimal; because when all is well, the surrounding organs slide against each other like two slugs in a mating dance. The pouch of Douglas, like the pouch of a mother kangaroo or a coin purse, can expand to accommodate growing or multiplying things.

The pouch takes its name from Dr James Douglas, an 18th century Scottish man-midwife who wrote anatomical treatises and held public dissections in his own house. In 1726, a woman by the name of Mary Toft, who lived in Surrey, England, announced that she had given birth to baby rabbits. Her local doctor was astonished and ran off to let everyone know. She had been in normal labour, he said, with regular contractions. And then appeared the baby rabbits. The woman enjoyed her celebrity. But Dr Douglas smelled a rat. He went to see her himself, to put an end to the nonsense. He examined her and declared her a fraud. William Hogarth later made an etching of Dr Douglas standing at Mary Toft’s bedside, gesticulating, with the rabbit children running off in all directions, unmasked and embarrassed.1

Rabbits came to Australia with the First Fleet. Like currency lads and lasses, they grew healthy on fresh air and good eating. They eloped into the bush and ate the crops that were planted for them and built burrows in the new estates that opened up as far as the eye could see. Australia’s emblem bore the kangaroo and emu, but the continent was in fact governed by rabbits. The anti-rabbit wars, when they came, were conventional and chemical; mass slaughter and hand-to-hand combat.

By the time I could walk and talk, I knew that rabbits had to be caught and killed. Even the family cat could do its bit. “Go and catch a rabby, Ginge”, my mother urged the big hard tomcat that went with the dairy farm my parents worked for a while. That was in the south of Western Australia, where it was green and lush and muddy. That’s where my sister and I had the job of herding calves. We always stopped to examine the hot pats of manure. We noted that some were sloppy, some firm. We wore plastic galoshes. Dad was always hosing out the stalls where the cows had been. Mum grew tomatoes at the back door of the weatherboard soldier’s settlement cottage that we rented from the farmer.

My partner Steve walks over land near Bathurst, in New South Wales, that was box gum, then eaten-out farmland, and is now a land care reserve. He stops at likely spots and takes coordinates with his pocket GPS. These are rabbit burrows. Rabbits eat the delicate native grasses being coaxed back onto the land. Someone else will come by, later, to gas the burrows. The rabbits will lie there, dead, under the ground. We go walking with our black Labrador, Bertie. Bertie is getting old and pretends not to see rabbits, because he can’t be bothered to give chase. Kangaroos stand stock-still as we approach. The full, hanging pouch with just the joey’s legs sticking out.

There’s something in my own pouch. Cells are multiplying, well fed and happy, burrowing down in new estates. They’re going wild, like rabbits.

Dr Douglas named his pouch of nothing. Nothing is like a magnet for something. Nothing is a big blank page with a pencil beside it. Nothing can be a blessed relief. There is nothing there. I slide on my conveyor belt into the big white donut machine. The warmth of radioactive fluid is strange at the back of the neck and around the bladder. “Breathe in and hold.” Pause. “You may now breathe normally.” At this point, I have never heard of Dr Douglas or Mary Toft or her baby rabbits. They belong to the new country on the other side of the donut.

My rabbits are multiplying. Rabbits need Lebensraum. Some must leave the pouch of Douglas for opportunities elsewhere. It’s dark and wet and they can’t see where they’re going. They’re like baby kangaroos, blind and pink-skinned, groping their way towards the teats inside the pouch. Only this journey is in reverse. They must burrow upwards, as if towards the light, but there is no light, only another soft place to grow. They slip between organs, like a finger. They make room for themselves.

Ginge moves stealthily through grass, his belly close to the ground. He gives his hindquarters a tiny shake, springs through the air, brings down his prey. He closes his jaw around the neck, drags his prize home.

Ginge stands at the back door, offering up his rabbit. “Good boy Ginge! Thank you very much. But you have it, Ginge.” Ginge drags it behind the woodpile. The flesh is soft and bloody.

Fresh for 24 hours

The Halloween design
made me choose it: cantaloupe pumpkins
pineapple haystacks, coconut ghosts —
an edible bouquet.
Guaranteed fresh for 24 hours, the ad boasted
just right for the afternoon shift
in the delivery room at the far end
of the hall, late night nurses
who whispered, knowing how quietly labor would end
the morning shift who cried.
No rush leaving.

Flowers wouldn’t do. Fruit
a perfect gift, so ripe
juice bursting with each bite
like a promise

Study of the small structure possessing great power (title of a David Smith sculpture)

The body knows how to mourn while the mind
keeps lists and answers mail and makes
a hair appointment. Asks the waiter what’s
inside the dim sum at the next table.
The body wants to sit on a low stool, speak
only when spoken to, and allow a seven-day
river of memories and tears to wash it clean
but the mind won’t allow this,
the mind thinks it can run forever
so here I am, without my father a month now,
on and off planes, speaking more than spoken to,
checking something else off the list
as the dam in my throat closes and my voice
disappears, the voice I depend on,
the body shutting down the blind machine.

Coming of age

“You are old when you’re born”, he* said.
So much living and dying
during those nine months:
clefts, gills and neural ridges
thrown up, filled in, torn down —
a time-lapse drama of evolution
played out on the foetal ocean floor.

Your cells by nine months
are wearied by wars
have forged truces with alien forces
built machines underwater
visited palaces drawn from fine tissue
played parts in evolutionary dramas
relaxed briefly on now sunken islands.

By birth your genes have had their day
your destiny set. I’ve heard
earnest clerics say we should
be born again. Terrible penance
surely to go through that once more.


*Stephen Simpson, academic director of the Charles Perkins Centre, University of Sydney