Sing Don’t Whistle
Without prior knowledge of what happens to whistleblowers, a person would blow the whistle with at least three expectations. First, that the truth (or falsity) of their assertions would be fully investigated. Secondly, that any inquiry into their assertions would follow due process, which would be independent and independently verifiable and to be based on principles of common law. Thirdly, that they would suffer no retribution, unless their assertions were false. That is the ideal world which whistleblowers often expect….K Sawyer.
In August 2003, after many long months … no, years of battling against bullying, and crying out for quality to be higher on the medical care agenda than mateship, I was sacked by the Royal Children’s Hospital, in Melbourne (the phrase used by the hospital was “contract not renewed”). The Hospital Board had concluded that there was no justification for the claims of bullying, and there was no evidence that care of patients could be better. Already, you can tell I was right!
How many of us (as patients) have been less than satisfied after an episode of medical care and felt there was nothing we could do about it? So, asserting that care could be better is always correct. Nothing is ever perfect!
While the concerns about care were the main driver, and the driver to families coming to see me for a second opinion. The response to the temerity of families making choices for themselves and of me daring to give an independent second opinion produced some amazing responses from colleagues. Statements such as … “If a patient comes to you for a second opinion, you should agree with the first surgeon”, and “if you don’t get along with me I am going to get you” (the bullying); and, with regard to research into new ways of fixing urology problems, it was said, “I don’t believe it because you thought of it” (the boys’ club). And, from a senior surgeon, who should share in the glory of the achievements of one of his staff, made the last of these outrageous said such a thing.
You might then think that I would want to write a book with the title “Trust me I am a Doctor”, just to get back at the boys’ club. Well yes, but only in as much as the current, and past, and probably future culture in health care has been an imbalance of power that undervalues the input of experts, making healthcare fail to progress, and be too expensive. The experts I refer to are the patients and their relatives who are not heard, which is why we have all heard people say, “the doctor just didn’t listen”.
I hoped, and now hope again, that daring to put a series of events for the public to review will result in the career of medicine being a happier one for doctors and other healthcare professionals; that medicine will be more of a caring profession, rather than one with a focus on treating, and that you will be more able to trust.
Imagine, you walk into the doctor’s room, you are nervous, worried about what the symptoms might mean, wondering if you are a hypochondriac, and the doctor caused you to feel you are an idiot. Or, you are a mother worried about your child, so you go to the hospital and are seen by the junior resident who seems to know less about unwell children than you do; you get put in your place by either words or body language that say “what would you know you are only a mother”; you leave the clinic or hospital, only to find that your baby starts fitting. Naturally, you say to people “the doctor just didn’t listen”. Wait a minute, are you sure you “just didn’t tell”! They are the experts; of course you doubt yourself.
I don’t make these assertions as part of the blame game, but as recognition of the healthcare system failure that is multifactorial, and includes the undervaluing of the participation of the unwell person, and their relatives in the information gathering and decision making. When we (patients) blame the medical carers we avoid our own responsibility in the failure of the two way communication. It is our (doctors) fault that we do not listen to both the words and the body language, but we work within a system that sets us (both patients and clinicians) up to fail. You as a patient and relative (and taxpayer, and politician) need to take some of the responsibility for poor quality care in medicine … poor quality care (not necessarily poor quality treatment). If you are a doctor, nurse or politician and you disagree, read on.
Until we fearlessly face the fact that we currently are in the dark ages of medicine compared to the development of space science we will continue to run around the same medical rat-cage wheel. The COVID19 media hype about the vaccine development highlights that competition rather than collaboration dominates “progress”. Yes, we have developed new techniques and technologies, but we are moving further away from caring, and further toward treatment and management. Noting that, occasional, good treatment can be bad care!
If you want the best treatment, you will have to assist your doctor. Your doctor is human. Doctors have illness, work and home pressure, work-mates who treat them unfairly, with bullying in the medical world being rampant, add to which there is often anger and aggression from people who are sick. In a world of ever-expanding knowledge, there is a limit to how informed any one doctor can be, even a specialist within their own specialty. Therefore, you need to go to the doctor armed with all the knowledge of your illness you can muster, and you need to collect the thoughts from relatives, magazines, television and the internet, and be reading and wanting to be further educated. After that, if you are unsure about the advice you have received, do yourself and the doctor a favour, seek further discussion, or even a second opinion. It is not only your right to be well informed, it is your obligation; and rather than having to “keep the bastard honest”, be sure that you become part of a team aimed at getting a good outcome for your wellbeing.
I hope these chapters help you understand your role in your own health outcome, the human side of your treating physician, the faults in the system that set doctors up to fail, and the importance of patient autonomy, open communication and second opinions as factors influencing better health outcomes.
Writing this book stemmed from experiencing listening to many families both before and after I was dismissed from the Royal Children’s Hospital in Melbourne. Part of the disconnect from the Children’s Hospital came from parents seeking someone who would listen to their concerns; part of the disconnect came from a failure of others to read the body language of a distressed family, or even to listen to the words, in some cases. Comments like “if someone comes to you for a second opinion, you should agree with the original surgeon” were part of the “club” mentality that resulted in my dismissal, and against which the public, and all doctors, should speak against. Interactions with multiple organisations such as the College of Surgeons, the Medical Board, the National Medical Ombudsman and the Health Services Commission and a number of parliamentary investigations have shaped my views.
Medical students in the 1970’s were not taught how to communicate. We didn’t need to, we just had to take the history, do the examination, order the tests and start the treatment. Making a decision for the patient was our job; they wouldn’t know any better than don’t know anything about medicine. However, improved care will come from improved understanding of more than just the superficial story that a patient brings to the doctor, followed by working through the options with the patient, as if they are an equally respected experts, who has come along to discuss a problem of mutual concern.
Let me put the later chapters into context, by exploring the background to my entry into medical school and thought on a desired philosophy of medicine.
To be a doctor is the dream of many a child, and often times the aspiration of parents of high-achieving offspring of the middle-class, particularly when those parents were struggling small-business people who started there working life as a bell-boy and maid in a Melbourne Hotel. And, even more-so, when the widowed mother lives in a small country town where the success of a son going off to medical school can be worn as a badge of honour. The reality of medicine as a career was not understood, and the reality of life as a doctor was glorified, perhaps even considered mythical.
Career guidance in the 70’s, for someone at the top of a country school class, was little more than, “you are good at school, you should consider doing medicine”. The long hours, high stress, dealing with sick, dying and stressed people was never part of the discussion, and training to deal with these issues was not a prominent part of the subsequent training. The role models in the surgical world were certainly less than ideal. Also, business management, how to manage stressed staff and how to deal with aggression and bullying were certainly not part of the medical school curriculum, and not what was expected. Being rich, and being able to care for people were often mentioned in discussion at medical school, but it was not entertained that, as a person (as a human being), you would constantly have to face conflict over your welfare versus others, and income versus patient benefit. Money certainly interferes with quality when it comes to the provision of medical treatment, mainly because of competition and greed.
Doctors are not trained to care, they are taught to treat and manage: letting go means losing control, even to the point of letting death occur when the ending of life allows for the greater good, but with the challenge of a loss of control by the medical team.
One truth that friends have taught me in recent times is that we, as doctors and nurses, have failed to appreciate the important role the patient has in their own healing. If they don’t take the tablets, if they don’t stop smoking, it is obvious that the person is not only not helping themselves, but are causing harm. If the patient feels unable to tell the story to an abrasive clinician, then the doctor makes his or her decisions on inadequate information, thus the care of the patient is compromised. This form of compromise to patient care is little understood. We, the “caring” professionals, end up making the wrong decision because we have not listened to the other “expert” in the room, ie, the patient. The patient knows their body, and in order to be able to decide the best option, we need to get all the information from that “expert”. The history of the symptoms and signs will only be fully understood if we respect the informant, and the examination is never adequate when the patient is uncooperative. Also, the appropriateness of the therapeutic options cannot be determined without the views, beliefs and commitment to the treatment program. Failure to take into account the patient expertise, particularly the right to have a view as to the best option for the individual effectively removes their autonomy. The result of the removal of autonomy from our clients, and by only superficially listening to their story, is that the customer leaves the clinic or the hospital, goes home and says to their family and friends “the doctor just didn’t listen”. We are more likely to have missed the diagnosis, or we apply a solution that doesn’t satisfy the patient’s need; they are not well treated, and/or the doctor is faced with a law suite.
The belittlement and put-down that is part of a dysfunctional interaction between the doctor and patient, is symptomatic of a culture in health-care that produces a process of competition between doctors, both between specialities and within specialties. After-all we make money by attracting patients because we are considered “better” than our colleagues. Decision making about where to send the patient for treatment or investigation, or how to investigate a patient is too often influenced by keeping control of the patient, or the financial implications of the decision. The policy of “better, quicker, cheaper”, and “quality over politics” should be applied more widely; it influences daily decision far less that would be in the interests of all.
This book is an attempt to highlight some of the features of the stress and strains in the medical world, and how they produce a culture within health-care that does not allow for the primary focus to be “Caring” with a capital C. Much of the problem of poor outcomes, and unhappiness and bullying in the work-place would be overcome by quality and caring being the primary agenda items. An important part of improving the quality of care will be to better empower the consumer to be a partner in the health-care decision, but not in the committee room, rather in every patient to doctor (any healthcare professional) interaction.
The people responsible for the content are inspirational people like Patch Adams, caring clinicians I have worked with through the years, but most importantly parents and children in Australia, New Zealand and England who helped allow me to understand the need to listen. One powerful lesson, taught to me in developing countries, is that the ultimate expression of caring for a dying person is to be able to let go.
One way for a doctor to learn is to be on the receiving end of “the” behaviour, as reflected in the following poem about childbirth:
THE OTHER SIDE OF THE WALL
Pain swells and ebbs:
Pain bloody pain.
Struggle, squeeze and flow,
But still no second stage;
The first’s platform
Has been crowded with
Indifference to the singular self.
Percentages and norms –
Ugly bastards who
Glare at you with
Smug, unhelpful grins.
“Go away. Come again.
Pleased to have you here!”
“Nuisance – come back
When we think you are
Was heard, from the corridor,
In whispered indignation.
“How dare they have educated input
Into a child’s destiny”.
Pain relief will only
Come from an injection
Of twentieth century.
Cool comfort, but welcome,
Is a smile shaded by a saluting hand.
Careful, here comes the commandant:
The temperature falls.
And pain relief will only
Come from an injection
Of twentieth century.
(published with permission of Papyrus Publishing)