DISCLAIMER : This post is about how medics interact within the various tribes. It is NOT about primary care vs teaching hospital, ED vs medics, surgeons vs anaesthetists. I’ve had some people comment on twitter that this is ‘about being a GP undermined by colleagues’. It’s not. It’s about clinicians, of whatever ilk, either undermining each other OR failing to work effectively within a team as too busy showing off how good they are. It’s a piece inspired by astronaut Chris Hadfield’s book and the concept of new team members being either a’plus one’, a ‘zero’ or a ‘minus one’. Now read on…
Medicine attracts bright people. I am constantly amazed at the smartness of some of my colleagues…and the ongoing exposure to brilliance via the FOAMed community. Not that you have to be smart to be a medic. Before medicine I trained as a research scientist, with undergraduate, Masters and PhD in an arcane area of immunology. But a life at the bench wasn’t for me – I enjoy interacting with people too much – hence the drift into medicine as a mature-age graduate. At medical school it struck me that medics were NOT particularly smart – the ability to absorb, memorise and regurgitate several phone books worth of information seemed to be the prerequisite, rather than original thinking. But insistence on high grades and academic excellence are just a cut-off to limit intake into the over-subscribed medical schools…and this encourages competition at a very early stage.
“Doctors are ingrained to compete – there is competition to get into medical school, competition for intern posts, competition for residency programmes, competition in Fellowship exams, competition for the desired consultant post…plus the inevitable competition between specialties”
Don’t get me wrong. I am all in favour of clinicians who are high-achievers and keen to move themselves to the right of the Gaussian distribution curve (mindful of the fact that 50% of all doctors are, by definition, below average). FOAMed helps us achieve that goal and strive to be better. For guys like myself in rural practice, than means to aim to bring “quality care, out there”.
But there is an ugly side to this competition. We all have tales of colleagues who have fallen by the wayside – whether through alcohol or drug addiction, failure of relationships, mental illness (including suicide). I am pretty sure that most of us have engaged in badmouthing colleagues, whether in the same discipline or in other specialties. Some of this is good-natured banter (think anaesthetists vs surgeons)…but it can become ugly, particularly when detracts from patient care or is a result of stressors perceived as being outside our control (bed pressure, busy workload etc). Both Dr Gerry Considine and myself have blogged about this from the perspective of rural practitioners – but it works both ways – primary care vs tertiary & vice versa as well as between in-hospital disciplines.
It never ceases to amaze me that medical training fails to expose junior doctors to primary care, given that this is where most patient encounters occur. And of course the bullshit perception of ‘just a GP’ continues to be promulgated within the tertiary centres leading to the comment ‘just a GP, not a specialist‘. Dr Penny Wilson blogs nicely on this. From my perspective, the more savvy tertiary colleagues turn pale when I suggest they sit in my shoes – they understand the skills needed to spot illness in undifferentiated primary care patients and would rather the security of preselected narrow-focus work.
“before you criticize a man, walk a mile in his shoes…then you will be a mile away from them & have their shoes”
I have certainly been guilty of critiquing colleagues without understanding their work. Before making the move to rural medicine I was a dual-trainee in EM & ICU. It was VERY easy to sit back and criticise the perceived failings of other doctors, especially as EM & ICU generally see a narrow selection of cases that have not been caught in primary care – blissfully ignorant of the wonderful “saves” out there. Add to this a complete lack of awareness of what different specialties actually do, and the system creates perfect conditions for disharmony. One of my shorthands as an ED reg over 10 years ago was ‘GPFI’ – GP is a ****ing idiot. My how we laughed. Now I am older and wiser.
A recent article in the NY Times captures this problem well, describing a paper in the Journal of Internal Medicine “Physicians Criticising Physicians to Patients” which has been re-tweeted by myself and others. The NY Times article on doctors badmouthing other doctors is worth a read.
“doctors will throw each other under the bus”
As a more grownup clinician in rural practice, a salutary experience for me was managing a patient presenting with acute-on-chronic back pain. I admitted him for analgesia..then 24 hrs later his BP dropped suddenly and the underlying sepsis from his epidural abscess declared itself – the source from an infection picked up a week or so prior whilst gardening. His retrieval & intensive care stay was prolonged and complicated, with devastating sequelae.
A single comment from an ICU nurse “you should sue your doctor for missing this” drove a three-year wedge between myself, the patient and family – very difficult in a small rural community, but eventually healed once the time course and decision-making had been explained. Systems failings (no ‘early warning’ notification, failure to appreciate significance of raised respiratory rate and falling urinary output so deterioration not communicated to doctor) all had their part to play, as did cognitive bias ‘just a flare of usual back pain’. But that chance comment from an ICU nurse undermined the therapeutic relationship.
That’s one example. I am sure you will all have similar stories. The ‘barndoor’ appendicitis referred to the medics as gastro by an ‘idiot ED reg’. The flail chest mismanaged as an infective exacerbation of COPD on the Care of the Elderly ward after a patient has fallen against bed rails. Mistakes happen, diagnoses are revised. But we are often quick to hang our colleagues out to dry with the benefit of the retrospectoscope.
The more medicine I do, the less certain I am. As a senior doctor I have more appreciation of the myriad presentations of disease, the understanding that patients don’t always ‘follow the textbook’. Contrast this to the cocksure certainty of a relatively junior doctor. The old adage rings true – “How do I avoid making mistakes? By getting experience! How to get that experience? By making mistakes!”
FOAMed helps broaden that experience, sharing experiences and clinical discussions with colleagues worldwide. “Doing the simple things, well” is the essence of not just critical care, but all branches of medicine – particulalry in resource-limited rural Australia. Meticulous attention to obs (especially RR), use of bedside testing such as point-of-care lactate, having a heightened sense of “what if?” all contribute to better outcomes.
All of which brings us full circle and (finally) to the purpose of this post. As ultra-competitive clinicians, trained to be better than our colleagues in order to progress in a system that seeks to limit entry at every waypoint, it is all to easy to fall into the trap of self-aggrandisement and for want of a better word “pissing on perceived competitors”. But does this REALLY help anyone? Of course not. we are all players in the healthcare team, yet it is almost de rigeur to criticise the perceived failings in other specialties without any understanding of what they do.
How then does a team function well when all the members are highly competitive? I’ve just finished reading Chris Hadfield’s book “An Astronaut’s Guide to Life on Earth“. It’s not a bad read, although I suspect is a springboard for former International Space Station Commander Hadfield’s retirement from the space programme into motivational speaking.
Hadfield talks about initial assessment of team members as ‘plus ones’, ‘zeroes’ and ‘minus ones’
Astronauts are all ‘plus ones’ – highly competitive, incredibly skilled across disciplines (he describes a typical day as performing ocular & cardiac ultrasound on fellow astronauts, fixing a malfunctioning toilet, playing Bowie’s ‘Space Oddity’ on guitar and Commanding the ISS). ‘Plus ones’ add value to the situation – they are leaders. Everyone wants to be the ‘plus one’ in a situation, in order to demonstrate their value to the team. That’s only natural when you are used to competing.
It should go without saying that there is no room in space (or in healthcare teams) for ‘minus ones’ – people who detract from the team plan. They cause problems, whether through laziness, inefficiency or lack of awareness.
But Hadfield outlines the BEST astronauts as the ‘zeroes’ – people whose input is neutral and doesn’t tip the balance one way or the other. Typically they quietly get on with the business of ‘making things happen’ – helping colleagues not for personal gain but because it helps the team overall. Reflective before acting. Competent information sponges.
In medicine we all strive to be ‘plus ones’, often by being the first to answer in a small group session, the first to critique patient management until the patient came under your brilliant care, or to blame ‘the GP’ or ‘those clowns in ED’ for dumping a patient on the already busy acute medical take. But declaring yourself as a ‘plus one’ in a situation almost guarantees that you will be perceived as a ‘minus one’ regardless of the skills you have. we see this when selecting instructors for EMST – we don’t want the flashy know-it-all, we are looking for the quiet, reflective achiever (the ‘zero’) who helps others become ‘plus ones’.
The take home message? I paraphrase from Commander Hadfield’s book :
“When you have some skills but don’t fully understand your environment, there is no way you can be a ‘plus one’. At best, your can be a ‘zero’. But being a ‘zero’ is not a bad thing to be. You are competent enough not to create problems or make more work for everyone else. And you have to be competent, and prove to others that you are….
…even later, when you do understand the environment and can make an outstanding contribution, there’s considerable wisdom in practicing humility. If you really are a ‘plus one’, people will notice – and they’re more likely to give credit when you’re not trying to rub their noses in your greatness“
Our environment as clinicians is the entire health care system. We occupy different ecological niches (with some amazing psychopathology between us) – primary care – emergency – surgery – medicine etc. yet we often have little understanding of what happens in other disciplines and are quick to critique. Even more so when all we see is other people’s mistakes (ED, ICU).
But unless you understand the nuances of another discipline, be slow to critique and quick to praise.
Be a ‘zero’ not a ‘hero’. Wise clinicians know this.
COMMENTS FROM TWITTER – keep ’em coming or (better still) add a comment below :
Brilliant article from @ about badmouthing colleagues: Be a ZERO, Not a HERO
Such an excellent post Tim!!! Ironically a ‘plus one’ précis about some pervasive concepts 🙂 @
Simon Carley @