The higher you go, the less you know

There’s a hierarchy that exists within the hospital. Us medical students are at the bottom of it, but there is a whole food chain that we must slowly climb with each year that passes. From an intern, to a resident, to a registrar and finally a consultant, the journey is a long and tedious one. And as you become more and more senior, it seems that there is a risk the positive attributes and qualities that were once deeply ingrained in us will be slowly stripped away.

As you all know, I’m back at the hospital training to become an intern during the final 6 months of my degree. We are each attached to a particular unit and the idea is to integrate ourselves within the team and learn to become competent interns by the time January 2021 rolls around. I’ve already said that my team is very nice and it is clear the junior doctors are much more skilled than I could ever be. The registrars whilst overworked are incredibly friendly and willing to teach in the few moments they have space to breathe. The only people in the team I have virtually never seen or interacted with are the consultants. And fair enough, you don’t spend at least a decade climbing the ladder to end up doing menial tasks on the wards. You expect to be sitting in a nice, comfortable office and to have control in what you do. And no one will say anything because you’ve worked hard to earn that privilege. To be fair, every consultant is different and some are more hands-on than others. It just so happens that for the past 2 weeks, the consultant who is supposedly on ward service for our unit only ever liaises with the registrar and we’ve never seen them on the wards with us. Which I think is a little unique, because I see most other teams traipsing around the hospital with their consultants. However, my team is functioning extremely well regardless, so you could say we don’t even them.

But that’s not the issue I want to talk about. Let me first describe the incident in question. I’ll preface by saying I heard all of this information secondhand, therefore cannot vouch for its complete accuracy and certainly there’s always 2 sides to a story. But I will retell what I know and this is not about attacking anyone, but to utilise it as an example to make a point. Essentially a very senior and powerful consultant of the unit went to see a patient on the ward by themselves. Not sure why they chose that particular patient, they may have had a previous relationship or found the case academically interesting. They told the family some things and as they were leaving they waved to the nurse, giving a passing comment that “the ward team may want to consider some scans.” And that was that. No documentation of the encounter and no direct communication with the rest of the team so that everyone was on the same page. A member of the team then visited afterwards and explained what they thought was the plan, with no knowledge of the consultant’s prior involvement. The patient’s family became upset at the inconsistent information provided and as a result, there was a scramble to figure everything out so that there could be a coordinated, organised response. It made the team look bad and what’s worse was it was an easily preventable altercation.

When this was brought up with the senior doctor, they blamed the rest of the team for having “poor communication.” You could perhaps understand why this ruffled a few feathers. Effective teamwork requires a foundation of direct, closed-loop communication and transparency between members. This is regardless of whether or not you are a leader and what level of power you have. Telling a nurse (who is not formally part of the medical team) on your way out what your own team ‘might want to consider’ is insufficient. By the time it reaches the responsible individual it would be secondhand, perhaps even thirdhand information. How difficult could it be to find your team members and to tell them directly? Or even a brief phone call?

Additionally, it is drilled into us the importance of documenting everything and writing coherent notes. It should happen following every single encounter and should justify and explain every medical decision. It is the only way of proving something happened and to avoid medico-legal issues. The importance of note writing does not diminish with seniority and certainly should not be delegated to people who were not present at the time of the decision making. We cannot protect ourselves otherwise and if the patient had suffered complications or an adverse event as a result of what the consultant wanted, do you know who’d cop it? The junior doctor who felt obligated to order whatever their supervisor asked without understanding why or seeing it written anywhere. Thankfully, that didn’t happen and it was very admirable to see people standing their ground and escalating the issue. But the last I heard, there was no satisfying response. There was a begrudging “I am sorry you feel this way,” but no genuine apology or admittance of an oversight.

It really makes one think. Whilst there are plenty of fantastic clinicians out there, it doesn’t seem to be an uncommon occurrence that as doctors rise in the ranks, they forget how to be a good team member. And what it’s like to be the junior member at the bottom of the ecosystem. There is a fine line that exists between confidence and arrogance, and from what I’ve observed it’s fairly easy to tip into the lesser admirable side. I do think some become complacent in their position of comfort and power, and lose touch with the basics of providing medical care in a busy hospital. It might be why they appear aloof and disinterested, or seem to focus on other trivial things, such as ordering investigations for patients that are not clinically indicated but for academic purposes (I’ve seen it happen).

Whilst I understand consultant tasks to be more managerial and less hands-on, I think there are some basic attributes and qualities that should never change. Even if you are out of practise with the lowly administrative tasks, communication, empathy and admittance of mistakes should be qualities we all embody regardless of what line of work you do. It is a cliche, but with great power comes great responsibility. It should not mean you can waltz in and out of the team, assuming your staff will read your mind and do your bidding without questions asked. If anything, you should feel an obligation to protect them and to ensure the workplace is a fair and safe environment for all. Change needs to reverberate all the way to the top in order to truly make things happen. We cannot make the healthcare industry a better place without the efforts of all involved.

Having said all of that, it’s a little strange and sad to think that this may be the path we will unknowingly take in the future. Why do I think that? Because I don’t believe for a moment that any of our consultants started their careers having decided they would become detached and oblivious to others, especially since they would have worked their way up from the bottom. But just like traversing any other hierarchy, something can happen along the journey, something unconscious that causes people to lose a small piece of their humility and empathy. And they’ll never realise it either, or think that they’ve done anything wrong. It is also just too easy to follow the status quo and accept things as a “rite of passage,” instead of advocating for change. Oh, we’ve all been unfairly berated by someone before, it’s just something you have to accept. I’ll be the first to say that is wrong. But also the first to admit how hard it’d be as a junior doctor to speak up. It’s something I thankfully haven’t experienced yet, which also means I haven’t developed a clear approach to dealing with it. But don’t worry, I’ll definitely write about it whenever it happens so we all have that to look forward to!

Anyways, I think overall there is a changing culture in most hospitals. A lot of our current registrars and younger consultants appear to be very vocal in supporting a healthier workplace, and I hope that incidents like what I’ve described above are just outliers. I also hope that when I look back on my career in 50 years time, I don’t realise I’ve become a hypocrite and fallen into the same pitfalls I once condemned. I don’t want to become the type of person I disapprove of and do things that hurt and belittle others. I hope that being aware of it now will help prevent it in the future, even when I’m sitting in my nice little office as the consultant of a bustling team. Fingers crossed I never become the centre of a disgruntled medical student’s blog post and have my actions picked apart and criticised. I want to be better. than that!