23 February 2022

On balance, I still favour trust

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Should you desire an experience “to die for”, I can recommend a day in a witness box.  

Imagine the scenario: it’s at the sharp end of a high-profile commission, broadcast via live television, to a coterie of leering viewers spurred on by a righteous media frenzy. I was required to appear, and I discovered that having an eloquence of lawyers publicly dissect your actions, with the benefit of their own twenty-twenty hindsight, truly does focus the mind. It happened to me in 2005, twice.  

The first time was at the Bundaberg Hospital Commission of Enquiry, the second at the Queensland Public Hospital Commission of Inquiry. I was a mere bit player in a much larger piece of modern history covering clinical governance in Australian public healthcare. But first, some background. 

Expert analysis in 1998 showed that there had been 30-35 preventable deaths in children undergoing cardiac surgery at the Bristol Royal Infirmary in the UK between 1991 and 1995. This was based on comparative data collected from other UK centres. It was a clear failure of executive oversight of medical care, and a new term – clinical governance – was coined and made its way into the modern health lexicon.  

One more thing became clear: Bristol was a disaster. It would take a similar disaster in Australia to make clinical governance mainstream here. 

Clearly, there is a cost attached to delivering high-quality clinical governance. Cash-strapped public health services in Australia, facing austerity measures and annual efficiency dividends, generally believed that the return on investment from clinical governance activity could not be justified on a purely fiscal basis. Not all measures were in themselves expensive – a simple Google search is cheap. But then someone had to come up with this rather roguish idea first. Now it has become a staple part of any pre-employment probity check.  

Recruitment and retention have always been challenging within regional, rural, and remote health services. In 2003 I volunteered to be the Acting Director of Medical Services (DMS) at a particularly difficult time for the Bundaberg Hospital. During this brief stint, I recruited the now infamous surgeon Jayant Patel.  

It later transpired that Patel had lied to me on his application and during his job interview, and that he supplied misleading references. My acting role ended the week that Patel commenced work at the hospital. I felt thankful that I could go back to doing two jobs instead of three.  

There followed a long-running legal and media sensation, featuring daily “Dr Death” headlines. The bare facts: Patel was extradited in 2008 to Australia from the US to face charges stemming from his tenure at Bundaberg Hospital. He was convicted in 2010 in the Queensland Supreme Court on three counts of manslaughter and one of grievous bodily harm, but these convictions were quashed at a High Court of Australia appeal. Patel received a two-year suspended sentence after pleading guilty to four counts of fraud in relation to his Queensland registration, and the state’s Civil and Administrative Tribunal banned him from practising medicine in Australia. He returned to the US in 2013.  

But I felt that for most of his colleagues including me, this was a public-distracting sideshow; the real story was about patient safety and clinical governance across all Queensland public hospitals. Individual departments may well have conducted audits of morbidity and mortality and other quality measures. But these activities were clinician directed and driven by specialist medical colleges for the purpose of mandated continuing professional development and so on. As such they were opaque to the executive management group of hospital services.  

But plainly in Bundaberg, there was inadequate clinical scrutiny of Patel’s surgical performance for two years.  

For my part, the Commission of Inquiry found that some of my actions fell short of the expected due diligence standard for a professional medical officer in that position. I was therefore referred to the Queensland Medical Board. My defence team noted that I was not a qualified specialist medical administrator. In addition, I was carrying out these duties while still trying to do what should have been – and subsequently became – two other full-time roles. The Board reprimanded me and barred me from taking on a role as a DMS unless I undertook further training. 

As an Acting DMS I had failed spectacularly. I apologise unreservedly to anyone harmed by my failure. But I did consequently learn a lot. Medical administration was a much more sophisticated enterprise than I had imagined. The days of a hands-on clinician conducting the additional duties as a side hustle, like the medical superintendents of old did, were well and truly over. The role required further specialist study, like an MBA or a Master of Health Management at least. A period of appropriate supervision by a Fellow of the Royal Australasian College of Medical Administrators is needed as well. That’s called progress. 

At the very least, my “learning by immersion” experience taught me four things:

  • You can delegate a task but not accountability.  
  • An orientation to any new position is critical (providing one exists).  
  • Documentation is better than no documentation, if for no other reason than it spreads the pain.  
  • Read every piece of correspondence carefully before you sign it.  

My major transgression involved the latter. Under pressure I had made a conscious decision to trust my support staff. With his final coup de grâce, the all-slaying barrister weighed in with “Doctor, have you heard the Italian saying, ‘to trust is good, but to not trust is better’”? I was mortified. Crushed. Shamed with nowhere to hide.  

Now, there was no way that I would ever want to be a DMS, particularly after this experience. I was young and only trying to help in a prickly predicament. I still enjoyed my direct clinical work with patients too much. But still being young I bristled at being told what I could not do. To me, this directive was like a red rag to a bull. So, I undertook further study anyway – if I was going to have to work with a DMS to advocate for and advance the care of my patients, I would have to know how they thought. Learn their language. I am so glad I made this decision. 

After four years of part-time study I was awarded a Master of Health Management. I found it invaluable. So many more mental models to chose from when problem solving. So many more useful insights to draw on when negotiating a way through the complex business of healthcare delivery.  

I recommend that every mid-career medico do a masters to revitalise their practice, whatever it is, because it’s a natural antidote to overconfidence, something I’ve observed far too often in too many of my colleagues. This even has a fancy name: the Dunning-Kruger effect.  

I learnt that medicine is too important to be left only to doctors, just as the law is far too important to be left to lawyers. Personally, it taught me humility. Still, a tiny part of my psyche senses gratification that I unwittingly contributed to a change for the good.  But did we go too far? Do we need another correction? 

At the graduation ceremony, I was chatting to the lead professor responsible for the program. His cautionary words were “you still know nothing”, and he advised me to read te 1959 paper “The science of ‘muddling through’” by Charles E. Lindblom and its companion article “Still muddling, not yet through written 20 years later.  

Light bulb moment: I finally understood. The intent of clinical governance is both laudable and necessary for system safety. Good clinical governance is about finding a sweet spot, and sweet spots constantly shift. Patient safety relies on a harmony of openness and accountability balanced with clinician trust and autonomy. True, trust needs to be earned.  

Clinical governance is at its best when owned by practitioners at the clinical coalface.  

Shifting the public accountability of clinical governance to the executive leadership group and a board will ensure that it gets done. However, this can also unintentionally create further administrative distancing between clinicians and management. These two groups are taught to speak different and distinct languages.  

It is too often the nature of administrators to focus on processes as a surrogate measure of outcomes, as they are more accessible and quantifiable. The business of clinical governance now begins to look like an exercise in protecting the organisation from reputational damage by amassing a bamboozling amount of data. This analysis often lacks quality patient outcomes. Some clinicians now may feel exposed to being thrown under the bus.  

The endgame, in my view should be to have positively engaged clinicians. Have them feel valued and trusted, rather than discredited. 

Who said that? 

After my devastating day in court, I googled the quote that the barrister had barbed me with. If I had only known its origins, I would have been able to retort “Yes, I have heard it. It came from Benito Mussolini.”  

My resolve is that all things being equal I will always choose trust over mistrust in the first instance.

Can clinical governance go too far? Did we overcorrect? Are we now merely collecting data instead of clinical intelligence? And does that create a perception of micromanagement and therefore mistrust?  

In the long run the ROI on trust versus distrust surely favours trust. Afterall, it didn’t end well for Mussolini.   

Associate Professor Kees Nydam was at various times an emergency physician and ED director in Wollongong, Campbeltown and Bundaberg; he continues to work as a senior specialist in addiction medicine and to teach medical students attending the University of Queensland, Rural Clinical School; he is also a poet and songwriter 

Lindblom, Charles E. (1959), The science of ‘muddling through’. Public Administration Review, 19, pp. 79–88 

Lindblom, Charles E. (1979), Still muddling, not yet through. Public Administration Review, 39, pp. 517–526. 

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