Perfectly placed to raise concerns

Being a doctor is a vocation but the reality of practice for some is not without its challenges. Guest blogger Victoria Bradley writes about her experience as a doctor in training.

When you type “being a doctor is…” into google, three of the top five answers predicted are “hard”, “overrated” and “stressful”. I think that’s a pretty good representation of life in the modern NHS. Healthcare environments can be abrasive places to work, and we can be cruel to each other. Morale is low, there are online ‘dropout clubs’ for doctors who can’t bear it any longer and, through it all, the media headlines demonize us.

Being a doctor in training has the benefits of supposedly protected time for education and structured supervision, but actually often brings a difficult balancing act between training and service. A recent JRPCTB (Joint Royal Colleges of Physicians Training Board) survey showed 91% of CMTs (Core Medical Training) reported spending 80-100% of their time ‘on service’1.

In the midst of all this squeezing it’s easy to lose sight of our patients.

Unsafe working environment

Earlier this year I was in a core training post and I alerted my trust to an unsafe working environment on the ward where I was working. I had every factor in my favour to help me report my concerns – I was in the last week or two of my job, so had no concerns about what might happen to me after, I’d passed my ARCP (Annual Review of Competence Progression), and I felt well supported by my peers and seniors. I was lucky that the trust where I worked took me seriously and made me feel supported and secure in what I had done.

But having gone through that process I came to a horrifying realisation. That I have seen countless examples of poor working environments over my career and never before have I done anything about them.

I defy any doctor to not recognise these scenarios. The night shift of trying to cover too much because the locum didn’t show up. Being asked to do a procedure solo you’re not confident at because there isn’t anyone more senior to supervise you. That member of staff everyone thinks is “a bit rubbish” and tries to avoid giving clinical responsibility to. The rushed decision making because of bed pressures.

All of those situations place patient care at risk but how often are they raised as issues? I would argue a tiny proportion ever see the inside of a board room, unless an SUI (Serious Untoward Incident) results. Most are grumbled about over a pint in the local – but that’s as good as it gets when it comes to debriefing our concerns.

And that’s because the prospect of putting your head over the parapet is deeply intimidating as a trainee. We are frightened to be labelled as trouble makers, to have our working life made miserable by the people we report. The survival instinct within us gets in the way. And everything we read about whistle-blowers in the press only reinforces that.

Working together

“Those in training are perfectly positioned to recognise and raise patient safety issues”

The ‘happy doctor’ paradigm

For me, the way doctors are treated in the NHS is at the core of this problem. To achieve the work we do with the resources we don’t have there has to be an assumption of saintly vocational dedication, and an absolute subjugation of a doctor’s needs. When we feel that we just want to get through the day and out the other side intact there is no scope for us emotionally or intellectually to be a good advocate for our patients. The corporate world has long known that happy workers means greater productivity and improvement across the board in key business demographics2but this message does not seem to have filtered through to the NHS.

If we could achieve those happy doctors – those in training are perfectly positioned to recognise and raise patient safety issues. They move around often enough to see the problems that long term members of staff have come to accept as normal, and they work across all clinical areas.

The proposed changes to the GMC national trainee survey  [Editorial note – this refers to some new questions being piloted in next year’s survey looking at how the training environment can support doctors in training to raise concerns] begin to ask trainees about the supportiveness of their workplace in general and perhaps take the first step to identifying those trusts furthest from the “happy doctor” paradigm.

In the meantime while our utopia is achieved the survey provides a safety net for doctors to report their concerns; as a last resort it offers to enable those who cannot otherwise make that leap.

Victoria BradleyVictoria Bradley is a Medical Education Fellow at Kings College Hospital NHS Foundation Trust in South London.

Footnotes

1. Tasker F et al. Survey of core medical trainees in the United Kingdom 2013 – inconsistencies in training experience and competing with service demands. Clinical Medicine 2014 Vol 14, No 2: 149–56
2. Harter J et al. Causal Impact of Employee Work Perceptions on the Bottom Line of Organizations. Perspectives on Psychological Science July 2010 vol. 5 no. 4 378-389

16 responses to “Perfectly placed to raise concerns

  1. The bullied doctors get reported to the GMC and the GMC procedures destroy them and scar them forever. There has been so many studies done by the GMC but no action is taken. Data without action is not productive but waste of time.

  2. Very valid comments but it all seems a bit “staged” to me. I would like to have some real world comments (which are unlikely to have actors in photographs) because then we would hear where the real problems are. So what was the “real” problem? All we have here is a series of “what ifs ?” I bet you’re seen before. What we needs are real events with the root cause and the outcome. In other words data, not asking people to put their heads above the parapet: life is tough out there.

  3. Spot on unfortunately. We got by mainly on gallows humour and way too many unpaid extra hours. You can only do that for so long when the slack that used to be in the system is inexorably removed. Can’t stay a happy doctor forever when that happens, however much you love the NHS. I am now a happy doctor in New Zealand. Higher staff:patient ratio (in my department anyway), more time to think, more time to enjoy the job and a chance to care more about my patients. Would love to fix the NHS but I only get the one life…

  4. Thanks for raising this very important issue as I have felt that it’s more common against foreign doctors and some of the consultants think that they can undermine and even molest doctors who are from other countries as they are not vey familiar with the system in Uk!
    The worst case senerio from my own personal experience is that I have raised concerned with GMC of not only bullying, harassment but of Racial discrimination by senior members of staff and GMC failed to take any action when I thought its more serious then bullying so I feel helpless.
    It made me think that a person like me who has worked in NHS for 9 years can not get GMC to acknowledge these issues how can more junior doctors can raise and face these issues!

  5. It seems to me as a doctor long retired from the hurley – burley of NHS practice that the drive to reduce service committments in favour of education may be throwing out the educational baby with the bathwater. A doctor is someone who is trained to think outside the box- to make decisions in stressful situations with which he or she is unfamiliar – using first principles and having the confidence to act on them. Decision making can only be learned by being left to make decisions. Clinical service committment is an essential element of medical education and patients are worse off for having doctors who are afraid to get involved in decisions which they would rather avoid and will simply pass on to someone else.

  6. Thank you all for your comments on the piece. Those of you that have made reference to issues with the GMC itself on this topic please know that I’ve asked the GMC to reply directly to you on this as I think it’s vital your concerns are addressed.

    Sean thank you for your support. How tragic is it, but at the same time how recognisable, that doctors in the UK see emigration as the way to be a happy doctor? As a profession we can no longer accept our junior members having to chose life OR job.

    Schofield I appreciate that clinical service commitments are a key part of clinical education, but I feel that the introduction of EWTD has fundamentally changed the nature of how much experience junior doctors can now obtain without more formalised training.

    The discussion of data Gordon asks about can start with that published by the GMC from the NTS this year on patient safety issues reported by concerned trainees. However I agree that data without action is not only unproductive, but ethically dubious.

    The article was written as a call to action for doctors. I work locally on projects to address the issues discussed here, that are outside the scope of this comment box – but gratefully welcome the chance to share best practice and ideas from all.

  7. Professional jealousy, abuse & racial discrimination are the main sources of bullying against doctors at the work place.

  8. Bullying is alive and well as much now in the medical profession as ever before. The GMC regularly colludes with this bullying by always investigating complaints of senior against junior staff, regardless of seriousness, but never investigating complaints of bullying made by juniors against senior colleagues. When will this culture within the GMC ever change?

  9. Thank God at least there are some people who speak out about this very serious issue. I believe as a junior doctor I had no support at all from anyone. I used to be treated worse then an animal by different members of staff and patients. I am a GP now and now I am treated like a slave by many patients. I have to be humble and soft to every patient even if a patient is swearing at me as I know if patient complains to the GMC then its always patient who is right. I have just accepted to work like a slave and have no dignity.

  10. Thirty years ago I was being bullied and excluded in a training post. I approached a well-known doctors’ trade union organization but the lady on the phone asked if I was “black” or female and when I said I wasn’t she said there was nothing for me. I moved on but was told later that a referee from that period was putting down adverse comments. I asked to see the references but was refused as they were confidential. I told all to the GMC – no good to me but a couple of years later we got the Calman reforms and structured training and of course references are no longer hidden. Still work in progress it seems. And, like the social workers tell us, those who have experienced bullying often repeat the behaviour when they achieve positions of power so there may well be some time bombs out there.

  11. I have been bullied recurrently throughout my 30 year medical career starting with medical school which was the worst offender and culminating in being bullied by some very senior people in the NHS. It’s the main reason I have not encouraged my own children to enter the profession and has left me with regrets about choosing medicine in the first place.

  12. Racial discrimination, bullying, intimidation are all daily occurrences in the NHS. The work culture needs to change. And yes, doctors do need to speak out. Too many accept this as a norm.

  13. I am now a GP, but as a FY1 in 2006/7 I was horrifically bullied – something which I can now barely believe I allowed to happen at the time.
    Worst of all I was threatened not to make waves as I wouldnt get ‘signed off’.
    Other senior colleagues were aware of the situation in that rotation and even privately acknowledged that it had been a problem for years, whilst my so-called peers were so grateful it wasn’t them under daily/hourly attack – they allowed me to be fed to the lions.
    Meanwhile, others in authority as mentors, blindly believed the out and ouright lies, and were dumbly complacent when faced with evidence to the contrary.
    For my (non-medical) husband it was all he could do not to march into the hospital and demand to know who was making his wife cry every day.
    I am happily, so far removed from hospital medicine as I can get.
    I am endlessly supportive of all of my peers, and teach teach teach with patience and support, I suppose I am trying to provide what I think all medical students, trainees & colleagues deserve – a non-threatening, non-anxiety producing environment where actual real learning and taking shape as a doctor can take place.

  14. Why is the national training survey unavailable to those on sick leave? What if their training programme has significantly contributed to their sick leave?

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