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.

House, Go Home

I made the terrible mistake of watching House on television recently. I think that my brain is starting to turn to mush.

Apart from the fact that he and his staff are somehow capable of performing and administering any and every test and procedure in the hospital, feel that they have the right to invade and inspect patients' homes at will, and have no qualms at talking patients into experimental and dangerous therapies that have little likelihood of doing them any benefit - they seem incapable of taking an adequate history, performing a physical examination, or ordering investigations appropriately or safely.

The plot tries to account for this by placing him in a Department of Diagnostic Medicine that handles all the difficult cases - but many of his cases are far from difficult, or are completely contrived. He and his team are just incompetent.

I better stop watching before I become as incompetent as he is.