Our Regular Colonist: thoughts on hierarchy

Thinking over last week’s incident, I realise that I missed the chance to react differently to the norm. I should have said to the watching medical students: this has been a demonstration of the importance of believing your own powers of observation over what you are told, irrespective of position in the hierarchy. No one ever had the nerve to say this to me – now I understand. The hierarchy – however much you think you are above such things, its effect is insidious; you feel at risk from inquiring minds stuffed full of facts ten years more up-to-date than yours – defensive is the natural position to take.

The cult of the new directly conflicts with the cult of the senior in medicine.

Like when the consultant came down, so condescendingly, to find us in casualty in our toiling inexperience with a huge backlog of patients. Perhaps, too, a secondary aim of showing us how it should be done. A man we were unsure of. He put his hand on the man’s belly and said, “clearly this man needs a laparotomy” and moved on to the next, issuing instructions to prep theatre. A laparotomy is a big op for an old man –he was in some pain, but not extreme, a hard stomach, a little confused. But I wouldn't have dreamt of doubting the boss. Wanting everything sorted before he was sent for, I stuck a catheter into the patient. 3 litres later, his hard abdomen had disappeared – though we had his post-obstructive diuresis to deal with by then. The consultant backtracked on his operation plan without a nod or a word in our direction, feigning other busyness. We were too wary of the negative effects of a bruised consultant ego to let out even a hint of our smirks.

Yet I am aware that some of my worst mistakes in ten years of doctoring – not including last week’s farce – have been due in the main to the undue influence of hierarchy. The hospital system is analagous to the army in its raw recruits, cannon fodder; the painful clawing up the ranks – the indecencies visited on one by one’s superiors repeated in turn by you when you attain that great height. We used to call it “turning consultoid”. The great jump to consultant, independent practice: in command of a battalion. However, there is a place in medicine, as there is not, I imagine, in battle, for less than blind obedience. For the most junior recruit to pipe up, But Sir, the patient’s blood is not clotting.. and be heard. Battles would hardly have been won had the foot soldiers lined up with their points for debate. The hierarchy is still at its most rigid in surgery, although there are attempts to soften this with positive feed back and an assessment process: unhappy trainees may yet escape a tyrannical boss. In the old days, you daren’t object or your reference and reputation would be forever ruined. This persistence of respect for seniors may well be prevalent in surgery due to the inevitable pre-eminence of skill and the need for speedy operating: those rare ER-like occasions where you are running to theatre, hand on bleeding patient, shouting orders. Aiming to move to team working from hierarchy, I wonder if it will ever truly succeed.

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Today, I spent a long while reading Jonathan Kaplan’s The Dressing Station - dealing with death and disease in famine and war while waiting prosaically to inflict my tube on nervous clients and apologise. Bathos.
Some are definitely more sensitive than others, the irritable bowel syndromes particularly. It has always worried me that in our consent we mention “discomfort” (told not to refer to “pain”) and yet we have a patient rolling in agony despite enough sedation to quell a hippo and it seems only the letter of the consent stands. Then, five minutes later, the pain abates and it is no longer prodding them into wakefulness, allowing the drugs to kick in and they slump into unbreathing. My recent course taught me scoping with no pain but now, after a day when everyone suffered, I wonder at how we get inured to others’ pain; I wonder if I learnt enough.