Reviewed: Dane Chalkley, Tessa Davis
Irony – when the literal meaning is the exact opposite of the intended meaning.
This blog is aimed at those of you that have recently started as a registrar. Your new role includes increasing clinical responsibilities and supervision, studying for college exams and working on a research project in your “free time” whilst trying to achieve that elusive work-life balance.
With such a key transition, it is critical that you affirm to your peers your new more senior role. It is also important that you acknowledge your increasing responsibilities and initiate some efforts to reduce your workload.
Bullying is undoubtedly bad. However, in this blog, I will let you in on some secrets to the dark art of bullying that will reduce your workload without a junior doctor ever noticing they were bullied.
The simplest introduction to the dark art of bullying is when you are asked for a consult. This immediately provides you with the upper hand as the doctor is requesting you to do something for them and their patient.
The phone consult is ideal for those of you wanting to dip your toe into the murky waters of bullying in medicine. Medical school and junior doctor training have effectively eroded your empathy, but some registrars will still find face-to-face bullying initially uncomfortable until their skills are honed.
Is the consult actually somebody else’s job? This is the first step. Irrespective of the consult, there will be always a chance that it could be someone else’s work. Depending on your hospital, it may require asking the doctor requesting the consult to go back to all the admissions over the past 20 years to see if they have been admitted under another consultant, to recheck the roster or to otherwise delay the consult until it becomes your colleagues’ job. This is time-consuming for the referring doctor, but even if it is only infrequently successful, it is an efficient use of their time to reduce your workload.
Frequent interrupting is the easiest technique to create a sense of unease in junior doctors. It is important that you don’t allow the junior doctor to get into a rhythm and this is achieved by asking lots of questions from the start. Interrupt the presenting complaint with a quick, ‘What’s the medical record number?’ This will throw them off very early while also signaling that you’ll be tapping on a computer without really listening. It is always important to ask a number of questions that the junior doctor will not know the answer to. This creates a sense of failure in the junior doctor and increases the gratitude that they will bestow upon you for seeing their patient.
Silent treatment. This is a more advanced technique. It involves not saying anything until the doctor requesting the consult thinks that you are either asleep or have hung up on them. This will instill in them a feeling that you are so unimpressed or bored with the consult and that they aren’t worth listening to. All without saying a word – efficient and effective.
The referral may sound completely reasonable, but a really good way to undermine the confidence of the junior doctor is to insist on a more senior review before you grant access to your prowess. “Have you discussed this with your senior?” is a solid opener but a, “perhaps your senior should see them first and call me back if you still want me to” is a real self-worth destroyer. Save this for 16.45 on a Friday and then pop off for your weekend without handing over. That’s where this strategy excels.
Feel free to not answer your pager – perhaps leave it unfathomably far away from you, wait for the third one, answer but state you’re in a meeting and can’t talk now. You know they’ll be champing at the bit when you finally return to them to impart wisdom. At this point techniques 1-4 can be maxed out with the preceding junior’s anticipation sealing the deal.
The beauty of the face-to-face interaction is that you are able to combine verbal and non-verbal communication cues.
Strategies that I have found effective include a shrug, a shake of the head, eye-rolling, turning your back on the person speaking to you or turning around and doing another job. Why make eye contact at all?
Choice of body position is worth considering; looming over the seated junior or slumping further into a chair for the standing opponent are excellent strategies. ‘You’re lower than me’ or ‘this is my territory’ are what you are showing here.
Whichever strategy, it is important that the person asking for help somehow feels ignored or worthless.
As with most of medicine, this written guide is only a start and is aimed at the novice practitioner. It will be with further experience and learning from your senior consultants that you will become an expert in the dark art of bullying. Once you are aware of some of the secrets, you will identify how many of them have been integrated into routine medical care. The sardonic smile, raised eyebrow or peering over your lowered spectacles are all examples of subtle signs that you may not even of been consciously aware of.
Rest assured that although some of the strategies may be difficult to implement initially, it becomes easier over time. By the time you are a consultant, you will be unaware that you are even doing so.
Hopefully, most of you noted the irony in the blog. This was my attempt to highlight a serious issue within medicine. I am not suggesting that asking questions when you receive a consult is not good medical practice. To the contrary, it assists you to prioritise your workload, clarifies the reason for the consult and ensures that the necessary information is available to address the question you are being asked.
But many of us have used the strategies described at some stage. I know I have. Typically, justified by the pressure of time or we fall into the trap of adopting these types of behaviours when we are hungry/angry/late/tired or feel uncomfortable or uncertain in our roles. Regrettable, sometimes it is because we are having a bad day and we want someone else to know about it.
Sadly, I see the impact on junior doctors every day. Following a request for a consult, senior review or referral for admission, junior doctors describe feeling stupid or worthless. They often don’t know why. It is unacceptable to make a junior feel shit for doing their job. Don’t underestimate the harm you may cause. The impact is cumulative and just as damaging as other forms of unacceptable behaviour in medicine that we more commonly associate with bullying.
The culture around requesting a consult is so endemic in medicine that junior doctors frequently blame themselves when they face such responses. Doctors feel they “deserve” to be treated this way if they don’t have all the information, they call at an inconvenient time or just because. Junior doctors don’t deserve this. Requesting a consult is a difficult skill and as a junior doctor they deserve appropriate and timely feedback provided in a supportive way.
We have developed an onthewards consult guide to assist junior doctors with the task of requesting a consult. But it is to the receiver of a consult or a referral that this blog is directed towards, as without you we can’t create a culture of communication between colleagues that is respectful and kind.
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Med reg
June 7, 2018 at 9:00 amIt’s interesting that you feel that ‘irony’ is an excuse for this article. In case you hadn’t noticed, Dr Edwards, medical registrars formed a large component of doctor suicides last year.
It’s interesting that you feel both asking questions and listening silently fall into ‘bullying’ in this category. Although this has been dressed up as a reminder for respectful communication, this article is actually a blatant attack on medical registrars.
Why do medical registrars ask for MRNs when taking consults? I’ve lost track of the times I’ve been referred a diabetic who hasn’t had a BSL checked, a rapid AF where the referrer can’t tell me a BP, a chest pain without a troponin and a stroke call without a CT angio despite 6 hours in ED. It’s never okay to be rude to a junior, but you have to acknowledge registrar pagers can go off every 5 minutes. It’s a basic courtesy to have answers to simple questions ready.
Most of all, I’m disgusted that a page run predominantly by RPA doctors feels that it is appropriate to publish this drivel whilst the hospital is simultaneously running a BPTOK program.
James Edwards
June 7, 2018 at 7:28 pmHi Med reg,
I am sorry that you felt the article was a blatant attack on medical registrars. That was not my intent. I deliberately didn’t mention a specialty or within which context the consult was requested to reduce the risk that a group would feel singled out.
I did consider carefully before publishing the article given the nature of content. I had a number of reviewers including medical registrars as I was concerned that is would be interpreted differently from my intent to highlight the problems associated with communication within consults.
My inclusion of “I am not suggesting that asking questions when you receive a consult is not good medical practice. To the contrary, it assists you prioritise your workload, clarifies the reason for the consult and ensures that the necessary information is available to address the question you are being asked†I thought reflected your reasons why we all ask appropriate questions when we are called.
The mental health of doctors is one of the reasons why the blog was written. In my experience with junior doctors, requesting a consult is one of the most challenging skills required of internship. They also describe the feeling of worthlessness on a regular basis after such calls. Many interns are in tears after such difficult conversations. This is not isolated to junior doctors and most registrars will have had similar experiences speaking to their consultants. The reason why registrars were chosen in the blog was that it fitted with them having to “learn the dark art of bullying”.
My attempt was to highlight that we as a medical community have a lot of work to do in how we speak to each other in a collegiate and supportive manner,
James
med reg
June 7, 2018 at 11:09 pmHi James,
I’m not sure how ‘not specifying a specialty” is meant to mitigate a concern of not singling out a group of people. The group you’ve mentioned is the new medical registrar. As a medical registrar outside of a tertiary hospital, there certainly aren’t any other specialties by which we’re distinguished. It’s all general medicine. We’re the group you’ve singled out.
I appreciate that you are trying to create a conversation about healthcare communication but agree with the comments from some of the ATs below. Although you may have not intended to cause offence, this is an attack on medical registrars dressed up as humour. What is most disappointing, however, is that you are an ED consultant. Your position and experience place you far higher in the hospital hierarchy than a new medical registrar – as per one reviewer, ‘from the top level’.
I question whether this sort of article about registrars and the attitudes displayed towards them is really appropriate from a consultant – particularly a consultant on the HETI prevocational committee and codirector of a department of a large training hospital, as per the biography published on this article. Your comment that some medical registrars have reviewed this article does not adequately address my concerns.
James Edwards
June 8, 2018 at 6:58 amHi Med Reg,
In my hospital, there isn’t such a thing as a medical consult. There is no general medicine and only subspecialties. The blog was referring to a consult directed at a doctor.
I acknowledge that the language created an impression that it was directed at a single group.
The views expressed are my own.
However, my intent is to create a better culture within medicine and having senior leadership is essential for that to happen. That is why I have taken on such roles and founded onthewards.
I think consultants taking about such issues with doctors in training is a positive step.
James
Kate
June 7, 2018 at 8:47 pmI am in full support of what Med Reg has posted. I find this article to be a thinly veiled attack on medical registrars who are some of the most overworked and psychologically stressed doctors in the medical system. Particularly at a time when many of them are trying to work full time and sit physician exams.
I am an advanced trainee and work in a busy tertiary hospital. I frequency don’t leave the hospital until 9pm, I’m constantly on call and it is not uncommon to work 12 days in a row. We are not work avoidant, we are not trying to dodge referrals or to shift responsibility. We are trying to do our best for patients and be as supportive as possible but we have our limitations. It is not the intention of registrars to belittle junior doctors or to make them feel inadequate. However, when I am woken up at 3am, I don’t think it is unreasonable for the person at the other end to have answers to basic relevant questions.
As an intern and junior doctor, part of the learning process is to learn to refer competently. If I couldn’t answer basic questions about a referral then the medical registrar would tell me to go back and take a history and call them back. That is not bullying it is professional competency. I would never call a consultant without knowing the key facts on a patient case and I think that the same respect should be accorded to medical registrars.
You should look at why medical registrars are exhibiting this behaviour and I suspect it is because they are exhausted, suffering high rates of burnout and work related stress. If you want to prevent this ‘culture’ amongst medical registrars then why don’t you backfill leave, provide better cover, don’t roster registrars to 14 hour shifts etc etc.
James Edwards
June 7, 2018 at 11:28 pmHi Kate,
Thank you for taking the time to make comments on the blog and advocate for your medical registrar colleagues.
As I have previously stated, the blog was not directed at medical registrars or any particular group.
However, the inclusion of the term medical consult was my oversight. It is directed at all clinicians that a junior doctor calls for an admission, advice or transfer to hospital. I used “we†throughout the article. This is my problem and I share it with the medical community.
In regards to the poor quality of consults, in my experience they can be divided into 2 groups.
1) the doctor who is “lazy†and hasn’t bothered to take an adequate history and physical exam
2) the doctor that doesn’t know what questions to ask, the unconsciously incompetent
For the latter, we have developed a number of consult guides to assist junior doctors through collaboration with medical registrars (https://onthewards.org/onthephone/) to improve the quality of consults generally. It will hopefully make that 3.00am phone call slightly more bearable.
I want to make it clear to our readers that asking questions of junior medical staff is good practice.
I agree with all your comments relatedly to the challenging work environment and the impact that it has on the wellbeing of doctors in training
I want to repeat that for any readers of this blog that have felt targeted I sincerely apologise.
The blog has created a discussion on a topic that I think is important and is all the better with a diversity of opinions. onthewards are always keen to publish different viewpoints and insights.
James
Another ed reg
June 8, 2018 at 8:27 pmHi team.
I’m an ed reg and i agree, the article stirs the pot, and in a way entrenches the “us vs them” mentality. I do think it’s funny though- it made me laugh and was nice to see a stressful part of my job packaged in a humorous way.
But what I disagree with is the notion that being busy is an excuse for being rude.
We’re all busy. We have different jobs with different cognitive challenges and rosters. The reality is we don’t know the ins and outs of each other’s jobs.
Common courtesy and a collaborative approach is possible at all times.
Getting taken for granted, talked down to, or even ridiculed by admitting teams is the worst part of my job. It is the fastest way to burn out a doctor, and put them at risk.
We’re on the same team after all! We should act like it.
Cameron Gofton
June 7, 2018 at 9:17 pmHonestly, I felt persecuted by this article as a medical registrar. Labelling it ironic doesn’t mitigate that this is an article that belittles those individuals who are under the most stress in a hospital, as evidenced by recent suicides. One of my BPTs read this article today and burst into tears because “no matter what they do, they never feel like they’re good enough”. These BPTs are doing the best that they can, being placed in untenable situations without the necessary training due to an unwieldy and unforgiving health system that does not care about them. They are working when sick and exhausted because there is absolutely no one to cover them and they don’t want to burden their fellow registrars who are also sick and exhausted. At times they are responsible for holding entire hospitals together with their bare hands with little recognition and minimal support, and they are doing an admirable job.
Whilst your aim to decrease bullying of interns may have been achieved, you’re essentially bullying fragile registrars who are spending every day trying to just keep patients alive. I’m very disappointed in the entire tone and content of this article. Instead of writing an article like this, we should look to address the redistribution of workload for registrars. Only then will this communication issue be able to be addressed.
James Edwards
June 7, 2018 at 10:50 pmHi Cameron,
Thank you for your comments.
The blog was not directed at medical registrars but at all clinicians that a junior doctor calls about an admission, advice or transfer to hospital.
There is no doubt that medical registrars are a susceptible population and it wasn’t my intent to persecute, belittle of cause anyone distress.
Cameron please pass on my apology to your BPT and make sure that they are OK.
I would have chosen a time post-BPT exam if I predicted that medical registrars felt singled out in the blog.
There is increasing recognition that the stresses faced by doctors in training are typically outside their control and that system changes are required.
Within my different roles, I advocate strongly for such changes on behalf of doctors in training.
The aim of the blog was to highlight behaviour that I think is endemic in medicine and to remember to empathise with the person calling you.
This was an attempt to start a conversation about creating a change in culture in the way we communicate with each other. This would improve the environment in which we all work.
It is becoming clear that a segment of readers of the blog have felt that it targeted them and I sincerely apologise to each of them.
Cameron, I would hope you would understand that I wouldn’t deliberately try to bully an individual or group.
James
ED doctor
June 8, 2018 at 12:42 pmMed Reg, I feel that you have taken this article very personally, and also made your response a very personal attack on Dr Edwards. I work in ED, and assumed that this article was aimed at : new ICU registrars, new anaesthetics registrars, Surgical registrars, psychiatry registrars, and even new ED registrars taking handover from junior doctors.
Also, as the article (with irony) states “It will be with further experience and learning from your senior consultants that you will become an expert in the dark art of bullying”, this problem is identified by Dr Edwards as endemic at all levels of practice. As someone who works in ED and whose job therefore frequently involves calling registrars for reviews and admissions, I have also observed this.
I think that it is natural to hope that the cultural revolution will occur with new generations of registrars, given that they are not yet indoctrinated in the Dark Arts as Dr Edwards describes. That is why Dr Edwards has addressed the article towards new registrars in my opinion, not because they are the only, or by any means the worst, offenders. But because they can be agents of change.
I also think that context is very important. Just as a junior doctor not having “answers to simple questions ready” may be a sign of unconscious incompetence and not a lack of courtesy, Dr Edwards has written this article with the very best intentions in changing a damaging culture of communication. This is evidenced by his stated intentions in the article, as well as by the fantastic website that he runs for junior doctors (in his “spare” time). I found the tone of your reply quite scathing, which does not really honour those good intentions of the author. Just as a scathing response to a junior doctor who is less than competent does not honour their good intentions in trying to become competent.
George L
June 7, 2018 at 10:30 amThis is a great article which I wish I read a few years back. I recall many times getting a drilling down the phone line or a rather abrupt response to a consult. Often you would feel physically uncomfortable post the event and then simply brush it off. I find it perplexing that we as doctors, who should have skills with respect to empathy for our patients, seem to lack empathy for our own colleagues. I came to medicine late and have worked in the academic and coproprate space – the level of bullying type behavior I observed on a daily basis in medicine would not have been tolerated in my previous roles but we seem to tolerate. Change can only occur when you put a name to it …acknowledge the problem… this article puts a name to it and most importantly places the responsibility back on those who display the behavior. Great article for all doctors alike PS sad thing for me is that I’ve on the odd occasion been the bully and ended up needing to call the person back to apologies for being a shit … probably doesn’t erase the feelings the other person experienced but sorry does help and striving to do better next time is proof you meant it.
Ahmad Alcheikh
June 7, 2018 at 4:17 pmOne of the ironies of medicine is that it is a profession about caring and yet where we sometime can treat each other in these ways. Sometimes the registrar is also perpetuating a culture they have been a victim of themselves. Great piece James, good to see this issue being raised from the top level.
James Edwards
June 7, 2018 at 7:16 pmHi George L,
Thanks for your comments. I hope this can create a conversation around changing our behaviour in medicine and recognising the impact that our actions have on doctors of all levels, but especially those early in their career.
Your comments that these behaviours would not be tolerated in other industries is unfortunately true.
Most of us would recognise that occasionally we may slip into this behaviour but having the insight to recognise that this has occurred and the respect to call the doctor back is to be commended.
In my experience, the power of that follow up phone call should not be under-estimated,
James
Dane Chalkley
June 7, 2018 at 10:48 pmWhen James showed this to me we suspected it would be controversial; not because we felt people would feel attacked, but because they might not understand the irony.
I think it’s very worthwhile that a debate has arisen because a group of registrars feel this was aimed at them; although it’s simply not true. I wonder if that reflects the pressure that registrars feel and the awful rise in depression and suicidality. It is because of that worrying trend that the blog was written. To ensure we all look after each other; not to point a finger.
We made a podcast about language used in EDs for the same reason. We don’t feel that anyone wants to be perceived as unkind, but a language and style of interaction has developed (in all specialties and at all levels) that can leave a more junior clinician feel terrible. James and I would never want anyone to feel attacked. Quite the contrary. I encourage you to read it again, reflect on behaviour you have witnessed, been in receipt of and used (James and I are included in that last group), and consider it as a call to look after each other; whoever we are.
ED doc
June 8, 2018 at 2:42 amAs an ED advanced trainee, this article shares my experience on a daily basis.
I’ve seen many junior doctors dissolve into tears after making a referral. Often, the inpatient speciality registrar is unaware that the doctor they’ve just belittled over the phone is sobbing in the office.
Having to argue until I’m blue in the face with an inpatient registrar is easily the worst part of my job. I’m not your intern/slave to be sent on paper trails that won’t change a patient’s emergent management/negate the need for admission, but I’m the one standing here in front of this patient trying to advocate for them. It’s absolute DRAINING, and at times soul-destroying. There are days when I think that I can’t go on anymore and keep doing my job, because it’s just grinding me into a pulp.
Inpatient speciality registrars: yes, you may feel victimised by this article. Yes, you have lots of pressures on you. We recognise that in ED. But that doesn’t erase the fact that intentionally or unintentionally, a lot of you employ these very tactics. There’s a difference between saying “look, I understand what you’re saying. But for xxx reason, I think for this patient it might be more beneficial to discuss with xxx speciality.” Or “for this reason I think they’re safe to go home, but I’d love to see them in the outpatient clinic. Can you organise that please?”, rather than resorting to bullying tactics like the above.
It’s a shame to hear a very valid viewpoint be drowned out by accusations of persecution. Please, place your own ego aside and try and look at this article for what it is. And try and do better. We ALL need to do better (ED included!).
Unfortunately, such behaviour becomes normalised. You learn it from your bosses, from the very first day that you start in hospital as an intern. Don’t let the cycle continue!
Anon Reg
June 8, 2018 at 7:26 amGreat article, James and Dane. I found it insightful and hilarious.
To the registrars commenting above, I think they are missing the point – it’s not about what we ask our juniors, it’s about how we ask. James isn’t advocating blindly accepting all consults without asking any questions. There’s just a kinder way that we can go about it. There’s a big difference between asking the junior basic details they might have missed through inexperience, vs belittling them for wasting your time. When I was a junior, I saw some of the most overworked registrars who still took a few moments to say a kind word. That goes a long way. Medical registrars, of all people, can recognise the importance of that.
Registrar
June 8, 2018 at 10:19 amThere are so many important points to this article. Let us not take this as a stab at any of our specialities. We work together as doctors, optimal patient outcomes are our priorities. Let us not continue this horrible culture that is bullying within medicine.
I have been a speciality registrar for a few years now. When I selected my speciality, I was well aware of the on-call requirements (being on-call all day, everyday, for days-weeks at a time). I remind myself that no one forced me into this. And therefore, no one else should pay for my work hours, demanding on calls, or lack of sleep.
Bad referrals are really the ones that need more attention and guidance. By saying ‘when I am considering this diagnosis, I am interested in ___________’, I am not only getting more information and triaging, but I do hope I am teaching someone something new, and that they’ll start learning how to make better referrals. I always leave my mobile number for this return call or text message – there’s nothing more annoying than making someone go through switchboard again, or getting another ‘No Caller ID’ call. Most of the time I still need to see these patients anyway – why make myself upset by getting annoyed at someone else?
I also remind myself that no one knows my speciality as much as I do. Something that is basic information to me, may not be basic information to another speciality, and hence I cannot expect a resident to provide me with the same relevant, concise information that I would then refer on to my consultant.
It took me a while to finally take this approach with my referrals. So I do hope these words help someone else. I am not perfect, but I always try keep myself in check.
As a more junior doctor, I have been bullied by registrars (surgical, medical, radiology, anaesthetics). I came to realise this – the ones who are more likely to be aggressive, are the ones who are inexperienced themselves, question their own skills and knowledge or have their own issues they’re dealing with (Exam stress, family stress etc). Unfortunately, some of us are just lazy.
While I do not support unreasonable working hours, the push for simultaneous work/study/research and unfair rostering – it is definitely not our interns, residents, other departments, or allied health members who should pay for this. Escalate these issues with your consultants – make an argument for more registrars within the department (basic trainees, unaccredited registrars). This won’t happen overnight, but it will help make the unit better for someone else. That someone else may someday be you.
Being overworked is no excuse for bad behaviour.
Stop bullying and excusing it!
June 8, 2018 at 12:18 pmCan not believe a medical registrar is justying this bullying by making it all about themselves. Newsflash, this article is not about you all doctors regardless of specialty and if you are employing the bullying tactics used in this article then you have to know you are making lots of doctors who consult or refer to you miserable and reducing them to tears. This is a beautiful article James and Dane thanks for sticking up for those who are often treated badly due to other people’s frustrations and their entitlement that just because they are overworked they have an excuse for this.
Anon doc
June 8, 2018 at 12:56 pmInteresting article, James and Dane. I think there is a lot of truth in the points you are making. I often wonder whether our counterparts in other professions go to work expecting to be belittled and humiliated on a regular basis.
It is interesting that it is medical registrars who feel personally victimised by this, and that they perceive themselves to be the most overworked and stressed out people in the hospital. I would argue that the surgical registrars or O and G registrars are put under more pressure, often have greater workloads and have less supportive bosses than medical registrars. For reference, I am not a member of any of these groups.
I suspect that BPTs in particular feel stressed out because they are actually very junior and feel a self-imposed weight of responsibility that other clinicians do not expect of a pgy3/4. Let’s be honest. It’s your boss’ opinion I want, not yours.
Lastly, I would advocate for us all to try and have more empathy for our colleagues. Everyone is working hard. Everyone has specific stresses and responsibilities in their working day. Your specific priority may not align with your colleague’s specific priority and, as such, they may not have all of the detail you might have collected. Maybe before snapping down the phone think of all the other pressures that doctor might have on them at this moment. Maybe then we might all get along a little better.
Bashir
June 8, 2018 at 3:12 pmDear Colleagues,
I am saddened that this article has stirred up such vitriol from some of the people it is trying to reach.
The culture of medicine is poor. We work hard in difficult conditions with the best of intentions. We devote ourselves to the service of other people in their time of need.
But we treat each other with contempt.
I do not believe that this article is an attack on the medical subspecialties, or on the medical registrars as a group. Rather, it is a commentary on the medical culture. I read it as a lesson to ALL new doctors rising through the ranks of any speciality – don’t be a prick (because it’s really easy to be one).
We are the new generation, we can be better, but we need to carry the positive changes upwards as we become more senior.
There is nothing wrong with a robust and professional conversation. We are literally dealing with issues that have life changing implications for others, but we all know when it gets out of hand and we all know when we are not being kind.
Each of us is working earnestly in a tough and under-resourced system. We have good intentions and we are doing our best. Let us recognise this and be at least as kind to each other as we are to our patients.
Emily
June 8, 2018 at 6:41 pmI really don’t think this article intended to single out medical registrars. I’ve encountered all of the above strategies as an intern and resident and it definitely wasn’t specific to medical referrals (in fact they often seemed to be amongst the more reasonable receivers). I’ve had trouble with all areas of medicine, with referral experiences that have ranged from slightly nerve-wracking to downright humiliating and awkward. I don’t think we can pretend that this behaviour doesn’t happen, it definitely does. So I interpreted this article as being about greater cultural and systemic issues in medicine (and the healthcare system), which I think do need to be named in order to be addressed. And surely the specialty registrars commenting above have had their own negative experiences when trying to make referrals as a junior doctor? And was it not embarrassing and stressful for you then too? I know our jobs are hard and some days can be frankly horrific, but given the power in that telephone call often lies with the receiver, I do think they have a responsibility to kind and patient especially with juniors on the other end of the phone. I also think if you can put the referring doctor somewhat at ease, they’re going to find it easier to get the information across to you in a sensical fashion (rather than bumbling along nervously at 100km/h which is what I often end up doing).
Jamie
June 8, 2018 at 8:39 pmFirstly, thank you for posting such a pertinent article. It seems the art of satire has been wasted on a few readers – the use of ironic humour to stir reflection and provoke thought on more serious issues.
It is short-sighted to take this piece of writing as an attack on one speciality from another, the message intended deserves more respect than that.
Whether you are an ED intern referring to a med reg, an ortho reg receiving a handover from a trauma SRMO, a gen med resident asking for an endocrine consult, a respiratory reg requesting transfer of care to the cardiology team, or an ED consultant requesting an MRI from a radiologist… all of us, no matter our speciality or seniority must perfect the skill of requesting and receiving consults. It should be regarded as a clinical skill like all the others.
We have to deal with enough unavoidably stressful interactions in our job; communicating with each other should not be the thing that leaves us feeling frustrated, belittled or inadequate.
Being sleep deprived, hungry, burnt out, over worked, or underpaid all seem like valid excuses for falling short on our communication over the phone; however we manage to perform other more sophisticated and complex tasks under such circumstances, so simply being tolerant and polite with each other should be a minimum requirement.
We all work hard to keep our knowledge and clinical skills sharp – perhaps effective and respectful telephone communication should be regarded more highly within our clinical responsibilities.
Taking ownership of improving this in ourselves will be key to changing this culture. I know after reading this article I will certainly reflect more on the effectiveness of my phone interactions – whether it be an O+G reg who has been oncall for 3 months or a terrified ED intern… have I added to their already stressful day and frayed their final straw of mental health? Or have I encouraged the collegiality that is necessary to keep all our heads above the water?
Yet another ED reg
June 8, 2018 at 10:48 pmI think that those above making it about themselves aren’t really grasping at the satire of the article. We’re all overworked, and admittedly, we’ve all probably been a bit obstructive at one point or another. Some specialties are worse than others, but I think that doctors as a whole are not innocent in this bullying culture, and to attempt to justify it or excuse it is shortsighted and dastardly. Some of the things that I’ve seen us do to each other would be an immediate HR complaint outside of the medical profession.
The author is clearly not trying to single out med regs. Yes, your life is difficult, but so is everyone else’s. We’re all overworked and under significant pressures in one way or another. As another comment posted, we chose this specialty… unfortunately we’re going to have to take the good and the bad. For example, I understand that choosing ED, that regrettably my need to use the facilities, avoid bladder stretch, drink my now cold coffee, dealing with verbal and physical abuse from upstairs and patients, or simply sit down for a second to regain my faculties, will often take a back step to managing my patients and my chaotic department flow. He has apologized for any perceived fault multiple times above, and attempted to clarify the satirical intent of this multiple times. Those who are still complaining that he hasn’t proven he’s “sorry enough” in his apologies… seriously? Most of us are burning out; all specialties have suicides in higher numbers than they probably should. The key thing, is to recognize that this is not a malicious attack against your personal specialty. It’s satire. It’s supposed to get us thinking about what has become normalized in our practice, and to realize that it needs to change.
It sucks for all of us, and yes the system needs to change, so we can reduce the amount of stress on us…
But therein lies the rub: the system needs to change. We as doctors can’t change how management screws us all over (seriously though, I think doctors as a whole need to start getting more involved with upper management and healthcare on a government level), so at least we can try to not hurt each other. We can do better for each other. Why argue and belittle the baby doc that’s asking you for help with their poor referral, when you can teach them how to do it properly? We’ve all been there at one point… and if we don’t all help our colleagues get better… then these garbage referrals and discussions will keep coming from them as they progress on. Don’t forget that these people will also be your equals at some point, and some of them will remember for better or worse what you did to/for them; it would be shortsighted to think that the abuse is acceptable because “I’m the registrar, and they’re the bad intern/RMO.”
We as a whole need to do better; it doesn’t cost us anything to be nice.
Surg Reg
June 9, 2018 at 5:50 pmI thought this was hilarious. I have probably used all 5 methods. But now that it’s spelt out I probably shouldn’t. Usually the guy who asked for the consult (rightly or wrongly) isn’t the one left to make the call.
AnaesReg
June 10, 2018 at 1:11 pmGreat topic James and Dane. Read the article with bit of a smirk, and can easily relate to previous [and ongoing] unpleasant calls. Reading the article did not make me think of medical registrars, but of my various experiences with all sorts of doctors on the phone. “Med Reg” clearly feels victimized and I don’t see this write-up as targeted at all.
“Thanks, good job” goes a long way – let’s support each other a bit more
Matt
June 21, 2018 at 10:49 amA gem of an article. This has been the gist of my experience as a junior doctor at a busy tertiary hospital. And that of most of my junior colleagues. Being belittled and condescended for simply being on the learning curve. It amazes me that these BPT were merely in the same role as merely 3 years ago.
Thank you so much Dr Edwards for speaking out
Registrar
June 26, 2018 at 1:41 pmI really enjoyed reading this article! I was a med reg not too long ago, and am now a subspecialty reg.
What I found very helpful during my time as a med reg was to actually get to know doctors from the other teams. When you know the ED doctors who are making referrals to you, or the subspecialty regs you are making referrals to, it helps you be friendlier (you also know which doctors are struggling with their jobs, so you can make a loud internal sigh, and get on with helping them instead).
I think to survive and thrive in medicine, one should not take things too seriously, let alone personally (I’m not talking about patient care – of course we have to be serious about patients). Interacting with different teams in a public hospital is a fine art. You learn when the appropriate time is to bring up a consultant’s name, when to mention certain key words or catch phrase, how to invoke your own seniority… I am never rude and have never blatantly bullied or demeaned someone, but I have certainly used various techniques to ease off my job burden, and I know those same techniques have also been used against me. At the end of a long day, I get together with friends, complain about everything and get things off my chest. You’ll burn out very soon if you take things too seriously. Working long hours whilst studying for exams, doing research projects, trying to get into subspecialty training, being apart from family and loved ones due to training requirements, planning for wedding (basically a million things at once!)… We’ve all been there and done that. I don’t think they can be blamed for doctors (including med regs) committing suicide. A lack of coping mechanism is what probably drove people over the edge. So if there is one thing junior doctor needs to be taught, it is how to have a laugh.
ANON
September 5, 2018 at 7:45 amAs important that this is in raising the issue of bullying in the medical profession, sadly this is a one sided view which doesn’t take into account the person receiving the referral. There have been instances of compromises in patient care when referers provide entirely wrong and unsafe information over the phone. There’s also an issue of efficiency and avoiding unnecessary admissions which the doctor in emergency could have achieved if they simply asked the patient a few key questions or did a basic physical examination. The role of inpatient teams is not to do this task for the ED doctor within the four hour rule after the triage nurse does the assessment. Too many times this has happened and is not reflective of all doctors but this perpetuates the culture of bad consults and bad habits. At the end of the day patient safety is key and asking questions to clarify is not “bullying†or being obstructive but rather coming from a place where inpatient teams rely on this information to make decisions over night or to create a proper plan in a time constrained situation.