Bully for You, Bully for Me

Since the 4 Corners "At Their Mercy" episode this week, there has been some discussion about bullying over at PagingDr Forums, a great source of medical chat for those who are interested. Occasionally I go on a bit of a rant there, and obviously this issue has riled me up somewhat. Interestingly the 4 Corners episode was preceded by a very powerful and relevant episode of Australian Story on Retired Lieutenant-General David Morrison.

My last post was a rather personal piece, with relevant identifying features altered. It was about my experiences as a bully, but I have similarly experienced it differently as a victim. I have received some feedback that it does not help the cause of eliminating harassment and bullying from the workplace. I respectfully disagree, since I think that identifying and rehabilitating the bully is just as important as identifying and helping the victim. I also believe that there is a complex personal interplay in these situations which deserve more than a simple "I'm right. You're wrong" approach. That is a recipe for sudden, knee-jerk changes that can cause far more damage to a system than the benefits it may bring.

I can imagine the objections now, that medical bullies are heinous individuals that deserve to be stripped of their qualifications, their right to care for patients and to teach, and that they should be publicly named and shamed, or even executed. If you found out today that the surgeon who saved your life was a bully is that seriously what you would want to happen to them?

Also the other argument that is made is that the destruction of any career or the loss of life from suicide is tragic and that even if that happens once it is once too many, let alone four times in the space of a few months. Well that is absolutely true, and I agree completely, but we also accept that there is a road toll for the benefit of being able to zoom at speed around the country. We accept that there is a terrorist risk for all of the freedoms that we enjoy. Callous as it may sound, why do we now not accept that some people will not make it through training and might even be harmed in order for the general public to enjoy quality healthcare from highly-trained experts?

The question is how do we go about preventing those preventable incidents? What cost are we willing to bear in the pursuit of preventing them? These are hard questions, and they are questions that we as a society fail to answer, in the same way that we all want the best healthcare using the most expensive drugs and technology, but we also don't want to to pay greater taxes to cover the cost (currently ~9% of GDP).

This question was posed by an aspiring medical student over at PagingDr Forums:

I'd be interested to know how much infrastructure there is to teach doctor's working through the ranks leadership, mentorship and people managements skills... or even teaching skills? (Beyond observing those around them?). I realise doctor's are time poor but I wonder if formal development of these skill would go some way to improve things.

The Royal Australasian College of Surgeons runs training courses in professional and non-technical skills which encompass these areas of leadership, team communication and teaching.

• Non-Technical Skills for Surgeons
• Safer Australian Surgical Teamwork
• Supervisor Training Courses (SAT-SET)
• Keeping Trainees on Track (KTOT - to help struggling trainees)
• Training in Professional Skills (TIPS)

Some might argue that these should be taught earlier. Several other Colleges run similar programs.

Another comment was from a doctor:

An issue that came up was question/answer method of teaching, and that this was bullying. I must admit I do this all the time and never felt like I was bullying anyone. Are medical students saying that ANY questioning is making them upset or is it just contextual, ie. Don't ask me in front of patients/other people?

Speaking for surgery, the Q&A type teaching mirrors the format of the final surgical exit examinations. You are in a closed room with two examiners who basically ask you questions until either they run out of time or you give up (for more information see here). Even if you answer all their questions they think of more until the bell rings. It is not practical to simulate that scenario in private on a regular basis during a working job, so the scenario is simulated at the bedside, at the operating table, or in unit/department meetings. The questioning is not intended to be malicious or threatening, but they are intended to be challenging, to tease out lines of logical thought or consideration, to highlight areas of deficiency and to promote motivation to self-study.

Unfortunately generations of doctors have been brought up with this myth (perpetuated in the media along with lots of other bad work practices because, heck, it's entertaining) that the questioning (or "pimping" which I think is a terrible term) should be used as a chance to mock trainees on their errors, to get them to "harden the F(*#@ up" and that it is most effective if they are pushed to the brink. It is also easy to forget that it is a public forum in front of other co-workers and not a private one like the exams. Lastly if there is a power imbalance then the questioning/teaching process is an opportunity to reinforce that, which sadly some seniors find irresistible. This practice has become so much a part of medical folklore that it is seen as a bit of a joke.

Thankfully the vast majority of surgical teachers realise these limitations and are very sensible in how they employ this teaching strategy. A small number do not and need to read this article.

As for modern education theory that recommends that confronting trainees with their errors is wrong, and should be done in a safe, private, comfortable teaching environment after you have assembled a mountain of data about their errors and prepared a comprehensive performance management plan... well you can imagine the challenges of implementing that in a busy, service-oriented workplace.

The sexual component of the 4 Corners episode is what really kicked everything off, with Gay McMullin's rather inappropriate and deplorable comment that "What I tell my trainees is that, if you are approached for sex, probably the safest thing to do in terms of your career is to comply with the request". RACS has proactively worked to address bullying and harassment for many years, but the public seems to care more when it is sexual harassment, not just regular run-of-the-mill workplace bullying. This is very unfortunate because workplace bullying and harassment is a form of disruptive interpersonal conflict that is made possible by a power imbalance, and exacerbated by chronic and short-term stressors that develop amongst both the harasser and the harassee.

Remember that most definitions of bullying or harassment (and most certainly sexual harassment) is one that is based primarily on whether the harassee has taken offense or feels threatened. The intent of the harasser may not be relevant and harassment can be unintentional (see this Parliamentary document Section 1.55 "Intentional versus Unintentional Bullying"). Therefore factors that increase the harasser's aggressiveness and factors that increase the harassee's sensitivity will logically play into its manifestation. (I am trying to be polite here).

Sexual harassment is however seen as something that arises because of an innate "evil" within the harasser or workplace which is part of their nature and cannot be remediated. This is not a constructive way to view things. It is effectively shaming hard-working supervisors and teachers who have made a terrible mistake without offering them any form of salvation.

I think what is more relevant is the concept that there is occasional harassment that occurs in settings of heightened workplace stress (whether contrived or not) and there is harassment that occurs as a deliberate and repeated pattern of sociopathic behaviour. Regardless of whether there is a sexual component these are two very different scenarios which require two very different approaches. The former is a combined human factors and systems issue ("culture change" or changing the structure and methods of hospitals/teaching - realising of course that this could be very expensive both in terms of financial cost and time cost to surgical training and patient care systems) and the second requires identifying and rehabilitating the individuals involved (this may also involve punishment and/or compensation).

Ultimately the cases described in 4 Corners were tragic, but hopefully they represent a tiny number of the daily surgeon-trainee interactions throughout Australia and New Zealand. For those that are proven, they should not have happened. For those that are just allegations, they deserve to have their investigations completed without intererence. For the rest of us, it is a salient lesson in what not to do. More importantly it highlights what we should speak out about because as Ret Chief of Army Lt-Gen David Morrison said "The standard you walk past, is the standard you accept."

I am a Bully (Yes, you read that correctly)

Not long after I gained my RACS Fellowship and became a fully-fledged consultant surgeon, I found myself operating at 3am on a bleeding patient. This young girl’s life was literally slipping through my fingers. I had tried everything: pressure on the bleeding veins, applying clamps and pushing with swabs on sticks, suturing the holes that were getting progressively bigger and bigger, pledgeted sutures, packing the abdomen, clamping the aorta to stem the venous haemorrhage.

Everything I did seemed to make things worse, and I felt this rising tide of frustration beginning to well up inside me. Even worse everything seemed to be happening in slow motion. The retractors I needed weren’t available. The scrub nurse couldn’t find the instruments I asked for. The needle holders didn’t grip. The scissors didn’t cut. The lights weren’t right. The psMonitor was going flat.

I had never experienced this as a trainee. There was always a senior surgeon to turn to, who had the responsibility. Up until then I had not truly faced the prospect that a patient would imminently die because I wasn't up the the task - and then my assistant stuck the back of my hand with a needle.

“What the F!@)(k did you just do?” I exclaimed. The moment after I had said it I had realised what had happened. I had just abused my hard working registrar, who was just as tired as I was, even more nervous than I was, and completely undeserving of my foul-mouthed critique of his left-handedness. The look on his eyes told it all. His face went pale, and he looked like he was about to pass out. But it was too late. I had become a bully.

Anyone who has read my blog before will know how much I love to boast about myself (completely justified, of course). I am, after all, the perfect model of the considerate, caring surgeon. I spend an inordinately long time with my patients in clinic, and they all love me even though they have to wait two hours beyond their appointment slot.  I put up with the incompetence of the constantly rotating stream of junior nurses all the time because I love to teach, and it takes an extraordinary level of medical student ignorance to irk me.

But it has taken a long time for me to become this tolerant. I have had to hone this skill over many years, gradually learning how to refrain from my natural instinct to yell, throw sharp objects, scrunch my face and stamp my feet. This has turned me into the wonderful teacher, leader and all-round nice-guy that I am today (except for Othman who thinks I am a "nasty consultant").

Occasionally, however, something makes me snap. I liken it to a generalised epileptiform seizure. If I am tired, stressed, ill, overworked, underpaid, and forced to work in an underfunded, under-resourced healthcare system, or god forbid going through a divorce, then my likelihood of losing my cool increases. I can keep it in check, but given the right stimuli my inner bully emerges and a torrent of abuse will inflict itself upon whomever is the nearest appropriate target. Sometimes the odd phenytoin-laced movie voucher from hospital administration for unpaid overtime will stabilise my condition but otherwise I am like a coiled viper ready to strike at the next inappropriately metaphorical simile.

Last night, however, I watched the Four Corners episode on Bullying in Surgery and realised that I am not alone. Indeed, there are many latent bullies out there just like me. We are a horde of ugly monsters hiding in a world of reasonableness, tranquility and sincerity, like those damn vampires in Twilight. We do not belong here. We cannot change or adapt to this modern world. We must either destroy humanity and reclaim our place at the Iron Throne of Westeros or fade away gently into the night due to our irrelevance.

Indeed, I expressed this to Mrs Sheepish and she suggested that perhaps I should retire and then we could go all Greece-like and default on the massive debt I used to finance my medical education, specialist training and private practice. It took me a while to realise that she was joking and then she very sensibly pointed out that everybody has the capacity to be a bully in the wrong circumstances and that does not mean that I am a “bad person” who is beyond redemption.

Therefore tomorrow I will ring my ex-registrar who is now a respected and successful neurosurgeon working at an ivory tower and I will apologise for almost destroying his career. And I'll have a quiet laugh at him because he still holds the forceps funny.

PS For those of you with no sense of humour then you have my pity.

That Which Does Not Kill Us Makes Us Stronger

“The report of my death was an exaggeration” - Mark Twain, New York Journal, 2 June 1897. 

Firstly an apology to my long time readers – there has been some upheaval in the ranks of the Paper household and so other issues have taken priority over blogging and social commentary. Therefore this blog may have appeared to be dead or semi-comatose, but instead it has just been in hibernation. It comes back to life for worthy issues, and there have been at least three very worthy issues that deserve some attention. The first is something that should hit close to home for every doctor and health professional, being that of personal security.

Like many other surgeons around the country I was shocked at the senseless, violent attack on a fellow surgeon in Melbourne last week. I do not purport to know the details of what happened, but from newspaper reports and the surgical rumour mill, it appears to have been a targeted attack by a somewhat unhinged patient or relative. It was vicious and unrelenting and the victim has been lucky to survive, probably saved by the fact that it happened at the start of a weekday in a fully staffed major hospital.

I have chosen not to link to news reports of this attack as I suspect this colleague would prefer that his online profile and the rest of his life is not defined by this event any more than necessary.

Security in hospitals has been a hot topic. It has been championed by the AMA particularly in the Emergency Department setting.  Ambulance officers, ED and Psychiatry nurses often bear the brunt of violent behaviour from patients, along with staff in aged care facilities caring for confused and demented patients, as well as the perfectly intact but lecherous ones. GPs take personal security so seriously (especially after the tragic death of GP Dr Khulod Maarouf-Hassan in Melbourne some years ago - link included since I see little harm in doing so) that they now design consulting rooms around quick escapes and duress alarms. The last case I recall of an Australian surgeon being violently attacked was that of Victor Chang who was killed by some thugs with a rather daft plan to make money. There may well have been others that I am not aware of.

Some suggest that the problem of frequent violent assaults on health care staff is due to soaring nationwide crime and the standard knee-jerk response to these assaults is to beef up security, such as arming security guards with guns, putting up plexiglass screens, handing out duress alarms to all staff, and even setting up metal detectors at hospital entrances akin to some US schools after the Columbine Massacre. Obviously this risks escalation of violence and creation of a divide between staff and patient.

Others say that it represents inadequate mental health funding, or the natural outcome of community-based mental health care.

If you ask me, this represents a slow and gradual shift in the degree of respect that the community holds for health care workers in general. The nurse, the paramedic and the doctor are no longer perceived as someone who has dedicated their lives to the wellbeing of patients and the community in general. They become a valid target of outrage and violence.

Modern medical TV dramas (see ER, Chicago Hope, Grey's Anatomy) portray us as “real people” who have “real problems”. We are invincible and then we are fallible. We make a few mistakes and then we clock off and go home without a care for the bloke in Bed 22 with the fractured NOF and urinary retention that the overnight cover will sort out (unless it suits the dramatic love-interest plot twist for us to hang around in the on-call lounge).

Industrial bargaining portrays us as replaceable commodities, or heartless negotiators risking our patient’s lives for a 4% pay rise. (See Link 1, Link 2) Admittedly, certain health unions will play the same card back at the Government of the day seeking a similar productivity gain (how on earth do you measure productivity on a ward?).

Health care is no longer seen to be full of altruistic souls in a profession that holds a high moral ground. It is no longer a desirable profession to work in. It pays poorly compared to many careers in commerce or IT. It involves menial and what some might consider degrading tasks on a daily basis that cannot be delegated to some unpaid intern (much as we might try). On an hourly basis my plumber makes more than me and we both have to wade around in wee and poo. Who would want to be a doctor, and why do they deserve our respect?

The reason, I think, should be simple. When you are at your lowest, when your body is flaccid and your soul is shaken, when every skerrick of hope seems to be gone, we are the people to will tend to you, look out for you, and make decisions in your best interest until you recover and can make them for yourself. We have to act for your benefit above any personal benefit to us. And if you don’t respect us, it makes it mighty hard for us to respect you.

All Gloved Up and Nowhere To Go

My experience is that about one in 20 examination gloves (not to be confused with surgical gloves) have a fault of some sort - breaking while being put on, unexpected size discrepancy, holes present already in the glove, deformed glove or adherent to another glove.

I must admit, however, that I am not a big glove wearer. Cringe if you will, but I do not wear gloves to examine groins, scrota, or feet. I only go to the trouble of donning them if there is an ulcer, wound, pus, or (potential) intertrigo (commonly known as skin-fold porridge). I am, however, an avid hand washer and user of alcoholic hand rubs.

I also do not wear gloves when putting in IVs or taking blood. A poorly fitting examination glove is completely useless to me as protection against a needlestick injury. If non-sterile surgical gloves were cheaply available I'd consider wearing them - but poor quality examination gloves only make my job more difficult and dangerous.

From The Australian - Examination gloves fail lab testing

(Click to Expand)

Examination gloves fail lab testing
Adam Cresswell, Health editor | September 22, 2007

MEDICAL examination gloves fail Australian standards in up to three-quarters of cases, either by having holes or by breaking, when stretched, more easily than they should.

Australia's medical standards regulator is investigating after a survey of 24 brands of medical examination gloves -- loose-fitting, ambidextrous gloves commonly donned by health workers where blood or other fluids are present, to protect themselves and their patients from cross-infection -- has found 75 per cent fail required standards.

Of the 24 products, six failed on leaks, 14 broke too easily when stretched, and two were too thin. One brand of gloves was found to have holes in 34 out of the 40 individual gloves tested.

The testing was done by Enersol, an Australian medical device testing company that does a lot of work for international clients such as the UN.

The company this week described the findings as "extremely disappointing", as they suggested that health workers and patients alike were not getting appropriate protection from infection.

Enersol managing director John Gerofi said the results also raised a question-mark over the effectiveness of the regulatory processes used by the Therapeutic Goods Administration.

A spokeswoman for the TGA said the results were not dissimilar to its own findings.

"Doctor Gerofi from Enersol advised the TGA on 18 September that several companies' gloves failed to meet the 'elongation at break' requirements and the water leakage requirements of the Australian and ISO standards," she said. "The TGA is investigating these allegations."

Gerofi told Weekend Health he "became concerned about the rate of holes in gloves as a result of some tests we did for inter-laboratory comparison purposes".

"As a result, we decided to conduct a more formal survey of the Australian market to see whether the available products were complying with accepted standards.

"The results show clearly that many of the examination glove brands on the Australian market do not meet the TGA requirements or the Australian or ISO standards.

"Health professionals using these products, and their clients, rightly expect that the products will meet accepted standards. Regrettably, many suppliers in the industry are not meeting these expectations and the Government's regulatory processes are apparently not detecting the faulty products."

Gerofi said that many of the holes would not be noticeable on a casual inspection, and even occasional breakages would be "shrugged off".

"It is only if there is a whole series of breakages that anyone will lodge a complaint," he said. For the test, which assessed the brands against the relevant Australian standard AS/NZS 4011, gloves were filled with water and holes detected by any leaks.

For the tensile test, a sample of glove was cut out and measurements were taken for both how far it could be stretched before breaking, and the force required to break it.

While gloves with such holes were better for the purposes of infection control than no glove at all, the presence of even small holes meant infectious agents -- bacteria or even superbugs such as MRSA, or viruses such as HIV -- could pass through.

A spokeswoman for the TGA said the agency's regulatory processes comprised a combination of pre-market assessment, post-market monitoring and post-market vigilance programs.

"As part of its post-market monitoring program, the TGA routinely tests examination gloves for compliance with the relevant Australian and International (ISO) standards," she said.

"Over the past 20 months, 34 different samples (drawn from different batches of gloves and a range of manufacturers) have been routinely tested.

"Of those samples tested, 12 samples passed, two samples have results pending and 20 samples failed."

Of these 20, nine were from one manufacturer in Asia but supplied by different suppliers in Australia.

Some of the sample failures were due to labelling and other minor issues, rather than being safety related. When glove samples fail, the manufacturer is required to correct the problem or recall the product depending on the type of problem.

The spokeswoman said gloves found to contain holes were "always recalled".

Tips for Medical Students: Scrubbing in Theatre

Milk & Two Sugars from Tea at Ten recently made a post about being uncomfortable when scrubbed in theatre. I gave her some suggestions in the comments, and she suggested that I post my tips to my own blog, so here goes.

Ten Things to Make Scrubbing Up Easier

1. Make sure you have a piss before you start. Or get a pair of those NASA astronaut undies.
   
   
2. Do calf pumps and change your stance regularly, or else you will get venous stasis and pass out more easily.
   
   
3. Whenever you can, rest your hands and or forearms on the operating table. Preferably not the patient, as they can get pressure areas from you leaning on them for too long. Don't wave your hands around (especially over the wound) unless you want to get stuck with a needle. And remember to maintain sterility.
   
   
4. Always let the surgeon know when you are uncomfortable. They will understand. Better a moment to change position than a medical student unconscious on the floor (or in the wound).
   
   
5. Try to engage in banter (where appropriate). You are not the only person who is bored and can't see much - the primary surgeon is the only one who is actually doing something interesting. Mind you, as soon as you have something to do, like a wound to sew up - you will wake up immediately. Also don't feel that you have to talk medicine all the time. It may be hard to believe, but even surgeons have outside interests, and sometimes we are actually interested in you as a person, not just a student.
   
   
6. Tie your mask a little loosely, and tape the top edge to your nose. That way it won't ride up and you can breathe air in from around the edges of the mask when necessary. Make sure you have eye protection - find some goggles if you don't like the full-face masks. Often hospitals will stock very cheap disposable ones, or buy one between several of you.
   
   
7. Don't stick your head in the light. The surgeon loses their lightsource, and you get very, very hot. And then your head explodes, which makes a big mess.
   
   
8. Don't inhale diathermy fumes on a full stomach and don't wave the laparoscope around (both in the patient or outside). The smell of vomit tends to hang around the scrub sink for a few hours, and there is nothing like a laparoscope shining in your eye to make you go blind for a few minutes.
   
   
9. Check out what step sizes are available beforehand - it is more important that you are at a comfortable height than whether you have the best view. You don't want a sore neck, back or shoulders for the rest of your life.
   
   
10. If you are not too keen on getting your hands inside the patient, then sometimes the best vantage point comes from not being scrubbed. Crossing the blood-brain barrier can sometimes give an excellent view. As long as you can see, there is no need to scrub - you can just join in at the end when there is a wound to suture.

Barcode This

I hate bad reporting. Even worse, I hate the way that news.com.au uses bullet points that have little or no basis in the full article. Where does it say that patients are to be stamped with barcodes? The closest is this line:

"In the US veterans' health system, basically every patient has a barcode on the normal hospital wristband as well as their name and date of birth," he said.

For your information, Dr Wakefield, this is common practice throughout many hospitals in Australia and New Zealand. Perhaps Queensland is lagging behind? Mind you, the barcode is quite useless unless you have an army of staff wielding barcode scanners prowling the hospital. It's generally much easier just to check the name, hospital number and date of birth against the operating list, x-ray request slip, drug chart etc. It also doesn't stop people putting the wrong label on the wrong patient (and no, two wrongs do not make a right).

Wrong side, wrong site, wrong procedure or wrong patient surgery is a serious issue, and is not helped by sensationalist reporting. It is also not prevented by single step "solutions" like patient barcodes (which actually make identification more difficult rather than easier). Just like in aviation safety, errors are avoided by multiple layers of protection (The Swiss Cheese Model), and acceptance that responsibility for safety lies amongst all hospital staff, as well as patients themselves. Air crash investigators do not point fingers at individuals, and neither should health safety committees.

Barcodes for patients to stop medical bungles
By Janelle Miles
September 12, 2007 07:37am

• Patients to be stamped with barcodes
  
• 31 wrong operations performed last year
  
• Patient misidentification main problem

HOSPITAL patients in Queensland are to be stamped with barcodes in a move to prevent operations being performed on the wrong body parts.

Last financial year 31 mistaken procedures were performed, including three cases of the wrong tooth extracted and two operations on the incorrect part of patients' spines.

In another instance, a person's left tonsil was removed in error and a separate patient had botox injected into the wrong body part.

Queensland Health's Patient Safety Centre senior director John Wakefield presented the figures to a Royal Australasian College of Surgeons state meeting near Cairns.

They represented a huge increase on 2005-06 numbers, when six such cases were recorded, but Dr Wakefield said the centre had been actively encouraging public hospital staff to report incidents.

"You might think: 'Oh gosh, how do these things happen?' " he said.

"But as medicine has become more complex and we get people through the system quicker, there's more opportunities for mistakes to be made.

"It usually happens in very busy hospitals. A major Brisbane hospital when I was working there three years ago had 22 operating theatres. That's a surgical factory."

Dr Wakefield said although the mistakes were rare, with more than 800,000 patients admitted to Queensland public hospitals in 2006-07, they were all preventable.

"For the vast majority, there was very little harm but we regard all these errors potentially as leading to serious harm," Dr Wakefield said outside the meeting.

"We're unearthing a problem, a risk in our system, which we've got to fix."

An analysis of the cases found patient misidentification was a significant cause of the problem.

Dr Wakefield said Queensland Health planned pilot projects to eliminate the problem, including a study into the benefits of barcoding patients.

"In the US veterans' health system, basically every patient has a barcode on the normal hospital wristband as well as their name and date of birth," he said.

"It's a big technical investment but we'd like to explore that.

"It doesn't just protect against patient misidentification, it protects against the wrong drug being administered as well."

Stick me baby one more time

Unfortunately I have sustained my second needlestick injury in 12 months. This time, I was jabbed by one of my registrars. She managed to impale our scrub nurse as well in the same operation.

I cannot blame her for the event. We are new to each other, and still getting used to operating together. She is left-handed, and I am not. There is a clash on the operating table where we both like to put our hands. Goggles and visors reduce visibility but protect us from splashes. Double gloving reduces infection risk but reduces sensitivity in operating. Guarding the needle requires handling it an extra time with one's fingers.

Every protective manouevre we undertake compromises our ability to operate. If we are going to work with body fluids and sharp objects there will be a risk of exposure. We have to accept that fact of life, and draw an arbitrary line in the sand between our safety and our patients' wellbeing.

Those two blokes who got stuck in the mineshaft in Tasmania knew that they were at risk. What made that risk acceptable to them?

In any case, what irks me is not that it happened. Rather, it was the Infection Control Nurse^* who came over with her forms and wanted to debrief us on all factors contributing to the needlestick injury. "What could we have done to avoid this event?" I could have said any number of things, like:

• not done the operation and let the patient suffer
  
• use blunt needles that would have botched the whole operation
  
• not worn visors, improved visibility and risk a splash injury
  
• refuse to work with left-handed female registrars

It was clear that none of these were acceptable, or would get me out of her vice-like grip so that I could go and finish the rest of my operating list. So what did I say? "I could have put my hand somewhere else." It was lame, but it filled in the space on the form so I could get away.

Even better was her parting comment. "Why should we risk our lives for our patients?" The fact is, every health worker risks their lives every day for all of their patients. I negotiate insane drivers to get to work every day. I risk being mugged walking from the car park to the hospital. I run the risk of being strangled by a delirious post-op patient every day. And I risk contracting an infectious disease every time I operate. I would love some way to eliminate all of these risks without inconveniencing me or my patients. Unfortunately, the only way this will happen is if I quit and stay home all day. I'm still considering that one.

^*The Infection Control Nurse is a highly trained nurse practitioner / specialist clinical nurse consultant who has a plethora of duties, such as chastising people for needlestick injuries, chastising people for not washing their hands or using alcohol rubs, chastising people for standing in a room with a patient with "black colonies" (i.e. might have a remote chance of possibly having highly non-pathogenic VRE), and handing out jelly babies after torturing you with your annual influenza vaccination.