Power and persuasion…

During the course of most shifts, it is possible to find a clinical situation that requires input from other teams, from individuals with greater specialist expertise than yourself, or who have special skills which you would like to access.  This is a feature of modern medicine, and working in distributed teams is an essential skill to acquire.

Recently I have come to notice though, that the facts of a case are often not enough to achieve the results that  are needed.

For example, a patient really needs the input of a specialist team.  The facts of the case are clear – and available to anyone with access to the notes, the results on the computer system, and the PACS system. BUT, when a house officer, or and SHO calls the registrar of the specialist team, the referral is refused / batted / turfed / delayed.  For some reason there is something within the history which is so significant that the specialist feels other differentials are more likely, or the case is not as severe as presented, or not as urgent as implied by the junior.

However, if the same information is conveyed by a registrar, very often the case is taken by the receiving specialist team, but even then there can be a significant proportion refused or delayed.

When a consultant makes the same referral, often less information is conveyed, but the action requested initially is often carried out, without question, and without quibble.

So, if the facts of the case remain the same, what is it about the delivery of each above which changes the outcome?

Clearly presentation of the relevant information  – there is a whole industry going on in hospital to get patients accepted by teams – the old “buff and turf” of the House of God – but also in reality – see here

But is that all it is, a more skilled salesperson?

Clearly not – hierarchies are involved here – especially hierarchies of power.  Consultants have almost ultimate power owing to their stature within the hierarchy – they are perceived to have a high level of  coercive, legitimate, expert and  referent power.

Registrar grade doctors probably hold a degree of expert power, and referent power, whereas the SHO and FY1 have little power of any kind, unless, by happy chance they previously worked with the person receiving the referral, conferring some referent power.  (French and Raven proposed this taxonomy of power)

Is this right, and correct as system of referral and obtaining specialist input?  I have a mixed view on this – it is helpful when receiving referrals to have the story explained by someone with enough expertise as to make the argument for my involvement compelling, and the most frustrating referral is simply a stream of information with no focus, and no request – just an expectation of input, but I try to take each case on its merits – and try to be blinded to the grade of the referrer. So yes, I pay attention to expertise – and clearly it is advisable to ensure that those who control your working conditions don’t get too hacked off with you!

I’m not sure how well this serves me, as I am probably seen as a bit of a ‘soft touch’ – but I do believe that if a team needs specialist help – it benefits the patient more to have a swift, easy answer, rather than a frustrated team looking after them who are probably beyond their level of comfort and expertise, and are therefore more likely to make poor decisions, or misguided interventions.

So when you are next called by a house officer or nurse – don’t just use the power differential to rubbish what they are saying, but take the facts on their merit – the messenger might misrepresent the facts of the case, but the facts will remain – and on the end of them will be a patient that is likely to benefit from a specialist opinion, even if it is a clear and justified rationale for why specialist procedures, treatments or interventions are not required.

And if you take the time to educate, you may not save yourself some time, but you will be raising the floor of the knowledge of the health service – and that can be just as important as getting off the phone to do whatever it was you were engrossed in.


2 thoughts on “Power and persuasion…

  1. I find your reflection on what can become very routine parts of the job, but are essentially fascinating complex sociological interactions, very refreshing.

    I think the issue with seniority is partly to do with appropriately presenting the patient – when I was a Med Reg I used to get an unholy amount of Vascular referrals, usually from a house officer who didn’t have any idea why they were referring. Eventually after enough refusals (always explaining to the house officer that I understood that they weren’t being given the necessary information and please ask their SpR to call me), the SpR would finally make the referral, explain the actual clinical question and then we could proceed. I now experience the same thing with referrals to the MDT from other oncology teams. The problem is that if the correct information is not conveyed, the specialist may not answer the correct question and the problem continues. As with all things in medicine, ultimately, it becomes a question of communication.I do have some sympathy with the idea that if people are asking for help and are unable to even express what help they need or summarize the issues in any way, then their patient probably needs a lot of help as they clearly don’t know what they’re doing.

    Having said all that, I do sometimes find as a Consultant, merely saying “I am the Consultant” has a lot of traction with imaging departments, bed managers, surgical SpRs etc etc

  2. Toby, hope you and the family are well.

    I live by and try to teach the following principle.

    There are ONLY two types of referral.

    One, from a someone who knows what they are talking about (98%) and you therefore need to go and see the patient.

    Two, from someone who has no idea that they are talking about (2%), in which case someone who does know what there talking about needs to see the patient. And if you class yourself as someone who knows what they are talking about, then you need to go and see the patient.

    There are always ridiculous exceptions that prove the rule but living by this principle of inevitability has done wonders for my blood pressure and has meant that in the last 5 years, I can count on one hand the number of patients I have refused to see.

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