Ask – and you will receive

Doctors work in a fairly hierarchical profession.  There are grades, lots of letters before and after names – all of which mean things to those in the know (even Mr means something special to those in healthcare in the UK)

Your rank in the NHS means a lot – and means that you get treated differenty from your colleagues, especially when asking a favour, or making a request or referral.

A couple of instances recently have made me think about how I use my seniority in the medical hierarchy, and how this can lead to adverse unintended consequences.

The first thing which made me stop and think was a conversation I caught a snippet of in the mess.  It was between two new house officers (most junior grade of doctors – just out of  Med School)

“I didn’t know why I needed the scan, so he said no, I couldn’t have it urgently, and I had to go back – and my registrar shouted at me, and told me just to go and get the scan – today!  Next time I think I’ll just make something up to get it done.”

I have also noticed that in meetings about discharge dates and plans, if the chair of the meeting is really keen for answers, and won’t move on until a discharge date is set – the junior staff start to offer anything as an answer – just to get the focus off them.

These examples show how the pressure felt by junior staff to be seen to be up to the job – able to get the scan, or able to predict discharge dates – can lead to misinformation, and where the care or safety of a patient depends on the answers given, can lead to harm.

The basic problem, as far as I can see, is twofold.  On the one hand – the questioner wishes to have a quick, accurate answer.  The other is that it is assumed that the most junior and least experienced members of a team are going to be aware of, and hold all of the information which more senior, experienced colleagues think is important, and be able to convey that in high-intensity interactions, which hold great significance for them – for if they fail to come up with the goods, they perceive that their reputation will be tarnished.

Sadly, and predictably the way out of this is to make stuff up – ask someone something enough times, or place such importance on simply having any answer – then you will ultimately get an answer, even if it is nonesense.

There are some good things about hierarchies in the training of doctors, and I am sure that no-one would disagree with the idea of a progression of responsibility as one climbs the slippery ladder of medical training, but if they are so steep sided as to make it easier to blag one’s way through day to day life, rather than do the job properly – something has gone wrong.

As I continue to move along the path to a consultant job (if such a thing exists when I get there) I hope that I will be able to achieve a balance between maintaining high standards in my own, and my teams practice, without stepping into the territory where my team will simply mislead me to ensure a smooth ride.

If I ever get to hear that people have simply lied to me to avoid saying ‘I don’t know” then I will have failed.

If that has already happened – please get in touch (ideally privately) – I need to know when and how I let that happen – only through hearing about our failings will we ever be able to address them. ( see The Johari Window for more on this)



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