Dealing with Bureaucracy, Bullying and Politics in Medicine

As a follow up post to Bullying in Medicine, where I covered how doctors may bully other doctors, I thought I’ll cover how medical bureaucracy can victimise individual doctors. I’ll be posting the various comments and arguments that bureaucrats have made in relation to individual cases, all of which are publicly available. The purpose of this post is to provide an insight into the spectrum of strategies employed by bureaucrats and doctors in power in dealing with individual doctors. Consider them to be buzz words and phrases. As a disclaimer, I state that at the time of publication, I do not have any personal connection with any of the following cases.

  1. http://www.adelaidenow.com.au/news/south-australia/surgeon-sues-state-government-for-12m-in-bullying-claim/news-story/f18818ddb85b0e06e74438eb1eeb4d11
    • “In its defence, the State Government, through the public-owned health agencies involved, says Dr Morley’s lack of supervision and employment issues arose through his incompetence rather than bullying or harassment.”
    • “It says Dr Morley did not accept the proper supervision provided to him, breached the implied terms of compliance with supervision by failing to accede to the direction of his supervisors and engaged in illegal activity by recording a patient conversation without consent.”
    • “The Government claims appropriate feedback to support and improve Dr Morley had been wrongly constructed as bullying and harassment.”
  2. https://independentaustralia.net/life/life-display/bullying-just-the-tip-of-the-iceberg-in-medical-administration-dysfunction,7811
    • Sham peer review and wrongful use of mandatory notification to the Australian Health Professionals Regulation Authority (AHPRA) are used to attack senior health professionals. Too often, the system is manipulated not in the public interest but in the interests of the notifiers. The reasons appear to be personal and commercial.”
    • “Internal reviews are open to criticism for lack of independence, lack of transparency, whitewashing and cover up.”
  3. https://independentaustralia.net/life/life-display/bullying-and-collateral-damage-the-case-of-dr-emery,9119
    • “Dr Emery was then targeted by a group of  “colleagues” in Townsville and Cairns. They lodged notifications to the Australian Health Professional Regulation Agency (AHPRA) in the guise of mandatory notifications. They did not discuss this action with Dr Emery before doing so. AHPRA then placed restrictions on his registration without adequately investigating the truth of the allegations. This group was eventually responsible for Dr Emery having to withdraw from the Townsville Mater Hospital and Cairns Private Hospital.”
    • “The director of medical services at the Townsville Mater Hospital suffered collateral damage from his efforts to protect the interests of Dr Emery and the North Queensland community. He was targeted and notified to AHPRA because of his support for Dr Emery, cleared by AHPRA but no action was taken against the perpetrator of the unfounded complaint”
  4. http://www.smh.com.au/national/australian-surgeons-accused-of-cartel-behaviour-to-control-fees-20160922-grm5rh.html
    • “during the recording, two leading surgeons discuss the candidate’s migrant background, talk about the local doctors’ views of him, and decide to measure him against how others perform on the day. This last decision leads the examiners to lower his score so he fails. At the time, one of the examiners worked in the same city as the overseas-trained candidate who failed the high stakes exam.”
    • “The college says an investigation of the video and recording found no bias against the candidate, and only “minor breaches” of protocols which did not play a role in whether the person passed or failed.”
    • “While the college does not record exams itself, it said its investigation found the published video did not accurately reflect what took place in the exam. No disciplinary action has been taken against the examiners. They were counselled instead.”
    • Here’s a published video of how examiners determine a candidate’s fate BEFORE the exam itself, based on their background: https://vid.me/0UfK
    • “Under college policy, an examiner who discovers they have an “actual or perceived” conflict of interest when they meet a candidate must raise it with a senior examiner on the day and take a secondary role. The professor did not do that. Dr P failed. He continued working under supervision on the understanding he would sit the exam again in future. But his new supervisor allegedly told a colleague in late 2014 that he had “many friends” who would ensure Dr P never got fellowship.  “
    • “Over the next four years, Mr Tansley faced multiple complaints to the Australian Medical Board about his competence, none of which have been substantiated. There have also been allegations that one of his supervisors, Sugitha Seneviratne​, had an undisclosed, close personal relationship with him. Dr Seneviratne says she has never been in a romantic relationship with Mr Tansley and that this “smear” has been one of several designed to disturb his efforts to get fellowship.”
  5. http://thenewdaily.com.au/news/national/2015/09/10/toxic-culture-fear-surgery-departments/
    • “In some instances the people handling the complaints were the perpetrators, while other concerns were for the reputation it may bring with it.“They report making a complaint as ‘career suicide’ and fear being ‘black-balled’ in areas such as selection, references, job recommendations, appointment processes, and career path,” the report said.“Nothing is anonymous in medicine … even filling in this questionnaire is extremely uncomfortable,” one comment read.”

More to come..

Bullying in Medicine (Bullying Amongst Doctors)

Here’s another subject I thought I’d touch on which the outside world would seldom have an insight into.

Bullying is rampant in the medical field, right from medical school, through to junior doctor hospital work, to specialty training to being a consultant. Why?

That’s what we’re here to explore.

Firstly, here are the phases of medical training in Australia:

Medical student –> Intern –> Resident Medical Officer (RMO) –> Registrar –> Fellow –> Consultant.

Let us now focus on some of the authorities who have an influence over virtually every doctor’s practice:

  • Employer (e.g. medical practice, hospital, local health district etc, private company etc.)
  • AHPRA (Australian Health Practitioner Regulation Agency)
  • Medical Boards
  • Specialty training colleges
  • Department of Health (State and Federal)
  • Medicare
  • HCCC (Health Care Complaints Commission)
  • Medical Indemnity/ Defence Organisations
  • Professional associations

Each of the above entities has an organisation structure (or food chain) and separate complaint handling processes, policies and procedures.

Who can bully doctors?

  • Other doctors (often those who are more senior or have been established longer)
  • Other staff (e.g nurses, senior hospital administration, practice managers)
  • Specialty training providers
  • Regulatory bodies
  • Patients and the public
  • Media
  • Lawyers

Below, we’re going to focus on bullying by other doctors:

Some  bullying strategies I’ve witnessed or experienced:

  • From seniors:
    • “Raise an issue, and I’ll make sure YOU are flagged as the issue”.  The senior will immediately flag the junior to all senior staff, and possibly to governing or regulatory bodies. Management takes the side of those who are higher up the food chain (who act as a buffer for issues, and have a greater influence on their job stability)
    • “I might break the rules, but still, do as I say and hush up..or else, I’ll make sure my examiner friends fail you, and/or will make sure you won’t be employable by telling my kangaroo club about you”
    • “I don’t like you, so i’m going to”:
      • Raise concerns about your performance and show how you lack competence or are a danger to the public. Subsequently, “monitor” you closely under the microscope, micromanage you, and put you on a performance review plan.
      • Destroy your reputation amongst other staff e.g. if you’re taking over the shift, say something down the lines of “oooo, I’m not sure how things are going to go with him/her on…I’ll have to come back in the morning and make sure everyone’s safe”
      • Overload you with work and responsibility to the point you know you can’t cope and will either voluntarily leave, or, will give management a reason to comment on your poor performance. Potentially report you to regulatory bodies, and recommend imposing restrictions and conditions on your registration.
      • Humiliate you during meetings or in front of others by asking you questions you don’t know the answer to, or reminding you of cases that went bad under your care.
      • Use feedback forms with a vengeance. I will be vindictive by providing negative feedback about you, knowing that these feedback forms will be visited in the future throughout your training, and can be used as evidence against you. This may impact on your career progression.
      • Give a bad reference about you.
      • Question you on every decision,  and ask you to justify every action, regardless of how insignificant it appears.
    • “I don’t know you but I’ll reverberate the negative comments others made about you because I don’t want to stand out”.
  • Equals :
    • Will make vexatious complaints about you to management to tarnish your reputation and get ahead
    • Will badmouth you to other equals, so as to ensure you receive minimal support and cooperation.
  • Juniors:
    • Complain about something that will attract media attention e.g. sexual harassment (no disrespect to genuine cases, but many are vexatious, aimed at destroying your career)
    • Encourage patients to complain to management.

If senior bullies make a complaint about you, management often choose to conduct an urgent ambush meeting – this is poor form where they often give you last minute notice, do not reveal the meeting agenda, do not allow you to have a support person, and they make it clear once you’re in the room that it’s serious, that there is another person  who will be taking the minutes of meeting. They do not give you an opportunity to prepare, but afford themselves the chance to brush up on everything they need to know about you, to direct the meeting towards their pre-set agenda. They will go through your entire career history, sifting through all your feedback, complaints, term assessments, and will bring to light anything negative. They will not provide you specifics, but would rather, just remind you that a number of “concerns” have been raised about you, and encourage you to ask yourself if you are the problem, or if you feel you should take responsibility. They are not often prepared for you to question them, which will often cause them to become aggravated and wishing to brush your concerns aside, so they wrap up the meeting – which usually goes back to their underlying agenda for the meeting – often to punish you in some way, whether it is recommending you take leave, seeking counselling, going on a performance management plan or a multi-source feedback survey, or withdrawing from the program or employment.  Behind your back, they will notify other senior staff or organisations and flag you with them. They will never support you over their buffer zone, so don’t bother explaining your concerns about them. Whatever they put in writing about you will be there forever, regardless of how reasonable or untrue it is. They will use this information in future meetings or reviews to form a case or evidence against you, with no regards to your perspective on the individual negative feedback from the past.

As the victim, you may feel extremely isolated. You know very well that telling anyone about your problems may do more harm than good:

  • There is no such thing as confidentiality amongst medical staff or in the medical field. Once you have opened your mouth, your words are no longer a secret, and may be used against you.
  • Telling colleagues may mean that you are damaging your own reputation. Your colleagues may fear retribution merely by associating with you. People talk! Can you imagine…if, as a male doctor, you told a colleague that a nurse made a false allegation that you sexually harassed her..what sort of impression is that going to leave about you? You are guilty until proven innocent. If word reaches the wrong people, and you have more such frivolous accusations against you, guess who’s career will be ending?
  • You may be encouraged to speak to your boss or training coordinators of your difficulties. Now just stop and think for a while. At the end of the day, as part of the complaint handling procedure, they’re really just there to tick the boxes and cover themselves. They are going to conduct a mediation process – hear both sides of the story, ask the parties involved to shake hands, then document it and file it away. Tick. Notify all relevant parties (e.g. training organisation, junior medical staff unit, medical board, AHPRA etc.). Tick. Recommend you get counselling. Tick. Now..as for loyalty aspect – are they going to take your side, or the side of someone who has been there longer or will be there longer? Or is more useful? e.g. nurses looking after your ward full of patients may be considered more important to have better long standing relations with than a transient intern or registrar in training. Your training’s Director will need the support of their subordinates to act as a buffer and to support their position of power. They will need the support of training facilities in order to be a viable training institute. What I am trying to say is, as a trainee, you are at the bottom of the food chain. If you are the domestic cat complaining about the leopard to the lion, the lion and the leopard will gang up and the two of them will destroy you. As opposed to just the leopard alone trying to destroy you and running out of steam. If you raise an issue, they will make sure that you become the issue.
  • If you lose faith and decide to report your case externally (e.g. to the Department of Health, the media etc.), you will be marked as the whistleblower. You will be seen as the troublemaker who can’t accept responsibility for their own actions and puts the blame on others. People who respond by boycotting you. The longer you remain unemployed, the tougher the questions will get for you and the more difficult it becomes for other health staff or the public to have faith in you. There goes your career.

Sure the above possibilities may paint a very pessimistic view for the victim. But that’s my job. I’m not here to highlight the few cases where issues are successfully handled, everyone shakes hands, gives each other flashing feedback and they all live happily ever after. I’m here to raise an awareness of the unspoken reality that doctors suffer.

Complaints should be handled with the hope of reaching an understanding for all parties, and not be used as vindictive weapons. Feedback should be constructive, so that a doctor can appreciate their strengths and weaknesses. Feedback should not used to inflict punitive damages on doctors down the track. Doctors should not be inhibited from speaking out about their pain and suffering for fer of retribution or a lack of confidence in complaint handling by management.

There is no need for the field to foster such rampant bullying. Doctors have one of the highest suicide rates. Bullying is not only a risk to doctors, but their patients too. Enough is enough!

The death of general practice – The Experts | Switzer

Source: The death of general practice – The Experts | Switzer

The following is a direct share.

 

By Ross Walker

An article in the Sydney Morning Herald on 1 May 2017 has raised significant concerns around the fate of general practice in Australia.

A new report from the University of Melbourne has seen a reduction in job satisfaction, problems with work/life balance and an increase in corporate ownership of medical practices.

These factors, combined with a significant reduction in income because of bulk billing, the number of people in Australia on some form of welfare, very long hours worked, the pressure to push patients through quickly, and not to mention the constant threat of litigation, has seen doctors leaving general practice in droves and many younger doctors opting for speciality training, where the rewards are greater and the work is often more interesting.

It is a bizarre notion in our society where the public will pay tradesmen a significant fee (and I’m not saying tradesmen aren’t skilled and do not do a good job), which is typically much more than a general practitioner receives who has had years of training with ongoing demands for continuing medical education and I would suggest, a much more stressful, demanding job.

If the general practitioner dares not to bulk bill and actually charge what I would suggest they are worth or heaven forbid, the Government suggests a seven dollar co-payment, there is this ridiculous outcry from the public and the usual nonsense from the socialist left.

I’m a specialist and I’m not complaining about my lot but I’m defending my pathetically remunerated, very dedicated, hard-working colleagues in general practice.

We have already witnessed over the last few decades the death of the general physician, leaving most patients with multiple, complex medical issues and having at times up to five specialists managing their (so-called) health, but better stated, diseases. But, if we lose high-quality general practitioners because of all of the above issues, I can promise you the health of our nation will drastically suffer.

Until general practitioners are adequately rewarded for providing high-quality care, which includes better pay for longer consultations, more focus on preventative health strategies and more autonomy in the management of their own practice by cutting the ridiculous bureaucratic red tape, we will continue to see the current exodus from what was once (and still is in certain practices) a vital service.

Published: Thursday, May 11, 2017

The General Practice (GP) profession in government funded models

Australia’s “universal medical insurance scheme”, Medicare, offering healthcare to Australians, is based on the British NHS model. For too long, a critical shortage in investment into general practice in UK has lead to unsustainable pressures that are beyond the coping threshold.

On average, a general practice receives £136 per registered patient for an entire year of unlimited medical service. This is less than the cost of an annual cable TV subscription. Not surprisingly, patients are lining up for this free-for-all, leading to waiting lists of up to 3-4 weeks.  Under the contractual agreements between general practices and the NHS, practices are prohibited from offering a private service to their registered patients, due to a conflict of interest. Here are some of the consequences that UK is experiencing with this model:

  • Growing resentment amongst GPs, leading to an ever increasing number of GPs quitting full time work, or prematurely retiring from the profession all together, and not being replaced by younger trainees due to a lack of incentive, enthusiasm and practically unrealistic service targets.
  • Surgeries are facing a recruitment crisis.
  • Increased demand and poor funding from the rather stagnant Federal budgets means that the demand simply cannot be met. Safe, effective, efficient and high quality comprehensive medical care would become a distant dream.

As such, general practice is on the brink of collapse under UK’s current model. It’s a real shame that Australian politicians and the Grattan Institute are looking up to this model, without learning from the UK’s lessons. The only way general practice will be sustainable is if there is increased investment into the industry, whether it is from the government or from patients directly, or both. Under-investment is simply not feasible. Bulk billing is not feasible unless the Medicare rebate is in line with the AMA recommended fees, which at present is around $80 for a standard consult. $37.05 is the current Medicare rebate, which is a far cry from the minimum funding required to deliver healthcare.

It’s a shame that the Australian government is already planning to trial this “annual subscription” aspect of the UK model with its Australian title, “health care homes” :

http://www.health.gov.au/internet/main/publishing.nsf/content/health-care-homes

Unrealistic Expectations when visiting your GP

Here are some common scenarios that I encounter frequently:

Patient books a standard consultation (10-15 minutes depending on the practice), but..

The patient then comes up with a shopping list of problems that they want solved then and there itself. The doctor then offers to discuss these issues during another consultation. Many patients will be reasonable about this, especially after the doctor explains that in order to offer quality care, the ideal consultation involves a number of steps for each issue, including taking a relevant history, performing a relevant examination, explaining the possible differential diagnoses, and offering a variety of treatment options. However, there are also many patients who choose to respond with aggression, often using one of the following arguments:

  • “I have never met a doctor who refused to address more than one issue at a time” <– I’m sure you haven’t. They must have solved your life story in 10 minutes.
  • “but this is the main reason I came in today” <–which is why you mentioned it at the end of the consultation
  • “how rude” <–offering an explanation is considered reasonable and polite.

The moment the doctor informs them that it will cost them more, they tend to opt to book another appointment, or disappear all together. Win win situation.

“It should all be on the record. I’ve been through this with others before”

Yes, I do understand it can be frustrating to have to explain a problem more than once. However, there are many reasons why a doctor you’re seeing for the first time should take a proper history from you:

  • It may not all be on the record. This could be because not all notes have been transferred from another clinic, or not all the information you discussed with another doctor in the same clinic may have been documented.
  • If there is a library of notes about you, it’s really not prudent to review in detail every note and correspondence prior to your arrival. This can not only be time consuming, but your presenting problem may have nothing to do with what’s on record. If you go to the library looking for a specific book, you can enquire about it with the librarian, and she can look up the relevant section and point you in the right direction. The librarian will not go through every book on the shelf prior to a patron making an enquiry. The GP setting is no different. Just as a librarian has to know what sections are stocked where in the library, it’s good practice for a GP to familiarise themselves with a summary of your relevant medical conditions prior to a patient visiting them. Once the patient opens up about a specific problem, the GP can then focus on evaluating that particular problem in the overall context, and retrieve the relevant available correspondence.

At the end of the day, transparent two way communication and cooperation from both parties translate to improved healthcare outcomes.

More to come on expectations..