Today, the Sydney Morning Herald (SMH) reported that the College of Intensive Care Medicine (CICM) withdrew accreditation from St. George Hospital. I’d seen that the ABC Drum was going to be discussing this topic so I held off on writing this blog post until I watched the show, but unfortunately it did not give me any content to discuss further. However, what was glaringly obvious to me was the lack of understanding of what withdrawal of accreditation actually means. The host of the panel kept referring to ICUs “closing down”. This made me concerned that if the host of a news show doesn’t even understand it, there must be many more people in the public who don’t. Furthermore, their guest on this topic was a former SMH Health Editor who is now a medical student. Whilst she was very knowledgeable on reports and inquiries from yesteryear she was unable to give any insight on what it’s like working in an ICU and struggled to give examples of workplace bullying, and what the issues are on the ground level.
I’ll first begin with a brief explanation for those reading my blog post who aren’t from a medical background. For doctors to specialise in an area, they must complete training in accredited units. To be “accredited” means that the unit passes the standards of education and training set by the College of that particular specialty. Depending on the specialty, this may include; the variety of medical cases that trainees are exposed to, the level of supervision, a skills component, and the number of hours dedicated to formal teaching each week. These must be delivered within what is considered a safe work environment, not just physically but culturally. Colleges assess units to ensure that they meet the standard to deliver training to doctors who have been accepted onto their specialist training program. In recent years, units have failed College inspections due to complaints of bullying. These include the Royal Prince Alfred Hospital Cardiothoracics Department and the Westmead Hospital Intensive Care Unit. The Auburn Hospital Plastic Surgery unit also lost its accreditation last year, however the reasons to me are unknown.
When a unit loses accreditation, it does not “shut down”. It means that it is no longer able to take accredited registrars who are on the training program. These registrars will instead work at an accredited unit in a different hospital to complete their required number of rotations. The unit itself still exists, however it must now rely on other doctors to fill the roles of the accredited registrars who otherwise would have been working there. Whilst it is a positive step that Colleges are taking bullying seriously, by withdrawing accreditation it does create a staffing palaver. With accredited registrars no longer rotating through the unit, the replacement doctors are often junior, unaccredited registrars with less experience.
This re-opens the concerns about exploitation of unaccredited registrars. As registrars who are not on a formal training program, consultants do not have an obligation to teach, train, or mentor these doctors. They are also described as ‘service’ registrars because they are simply there to serve. With junior registrars working in a unit, there are implications for the standard of care being delivered to patients. The consultants are responsible for supervising junior doctors, and within a unit that has already been identified as having ‘cultural’ workplace issues, the level of supervision that the new junior medical staff will receive is of concern.
If the hospital is unable to adequately staff the ICU with new registrars, there is potential for current staff being overworked and burnt out, therefore diminishing the quality of care given to patients. It may even lead to fewer ICU beds being available. With less ICU beds, this has implications not just for patients admitted with emergency medical conditions, but those who are booked for elective surgery. Major surgery such as cardiothoracic and neurosurgery often requires a post-operative ICU bed. With fewer beds available, it can impact the number of elective surgeries that can be booked, and therefore increase waiting lists. Thus we can see a potential domino-effect from withdrawal of accreditation – it is not just a celebration that bullying is being tackled.
Moreover, I would argue that withdrawing accreditation does not necessarily reduce bullying. The trainees are no longer there, but the perpetrators are. What are Colleges doing about the senior consultants whom the trainees have complained against? It is hardly heard of that a consultant is fired due to bullying. So, if these bullies are still working in the unit, will the ‘cultural problems’ identified in the audit of the unit really change? One of the changes that the Westmead ICU has supposedly made is ‘engaging a well-being expert’. I would be curious to know how this has led to changes in the experience of registrars who are working there.
I must say, what drew my interest in today’s article was this quote:
We think there may well be something about intensive care that makes it particularly problematic and we are looking at what we can do about itDr Raymond Raper, CICM President
This made me reflect on my time working in two ICU departments, one as a resident, and another as a junior registrar. Undoubtedly, there is a high level of distress in ICU. The nature of the specialty is that they look after the sickest of patients. There are difficult conversations to be had with families of dying patients, including end-of-life discussions, there are patients who deteriorate suddenly and unexpectedly which can be very stressful, and patients in the ICU are often very complex. There is also sometimes a human disconnect with patients because many patients in the ICU are intubated and therefore cannot verbally communicate with you. Some of the patients are also in a lot of pain, which is hard to see. I remember looking after patients with severe burns all over their bodies, who were wrapped in bandages like a mummy, couldn’t speak because they had a tracheostomy tube, and were in a great deal of discomfort from dressing changes as well as from the dressings themselves.
What I found difficult working in ICU is that the consultants and senior registrars rotated every week. This meant that I had a different boss every week who I had to adapt to. Each consultant has his or her own style. In most other specialties, you have a whole term to get to know their preferred way of doing things, which you pick up as you spend more time with them. The difficulty with having a different boss each week, is that he or she may be completely different to the boss you had the week before. I remember there was one week when a consultant preferred that I did tasks as we went along the ward round so as not to delay referrals and ordering of tests. The following week, I had a horrible boss who got annoyed at me for doing that because she thought I was not paying attention to her ward round (when really, I was just trying to be efficient and do jobs as we went around the ICU). That same boss would be highly critical of the registrar who did the night shift, saying insulting things about the decisions that that registrar had made overnight and attacking their competence behind their back. This made me wonder what sort of nasty things she might have been saying about me behind mine.
The other issue in ICU is that some are “closed” and some are “open” ICUs. Simplistically put, a closed ICU means that the ICU is responsible for all the treatment decisions about a patient, whereas an open ICU means that the specialty that the patient is admitted under has the control. Both models have its issues, with conflicts that can arise between ICUs and the main treating team. In an ‘open ICU’, it can be frustrating tracking down the treating team to come and review their patients and make a management plan. It can often feel like you are more of a baby-sitter or ‘co-ordinator’ of care rather than the treating clinician. When a complex ICU patient needs to be seen by many teams, making referrals and chasing them up can also add to stress.
In a ‘closed ICU’, I have observed many a time when a treating team was not happy with the way their patient was managed in an ICU. I remember as a neurosurgery resident noticing that an ICU registrar had prescribed tramadol for headache in a patient who had had a craniotomy for a meningioma (which is a no-no, because it can lower the seizure threshold). The patient then went on to have some seizure activity and was overdosed on phenytoin because the phenytoin level had not been corrected (for a low albumin). By the time I saw him, he had already developed symptoms of phenytoin toxicity… but I digress. The point I am trying to make is that ICUs often have to deal with disagreements with other specialties.
People who are stressed are more likely to get snappy at each other. I know this is not an excuse, but it is what happens. Being more irritable is a sign of burnout, and I feel that the ICU environment can make clinicians vulnerable to it. The nature of the work, potential conflicts with other units, and shift work (adjusting between day and night shifts is unnatural, and hard!), are all contributing factors to an unhappy workplace. So, to answer Dr Raper’s concern, yes I do think there are factors that are unique to working in an ICU that give rise to certain behaviours.
I was saddened (but not surprised) to hear that yet another unit had been scrutinised for ‘cultural’ issues, and I’m glad that the Colleges are making a strong statement that bullying shall not be tolerated. However, with that decision to withdraw accreditation comes other problems. It is not an ideal situation for hospitals, staff, or patients.
Lastly, I am yet to hear if the Bankstown Hospital Plastic Surgery unit has undergone the investigation that was strongly suggested by the President of the Royal Australasian College of Surgeons in response to my own story. Normally a unit will be audited at random, but given that Bankstown Hospital was given a fore-warning, I wonder if the Plastic Surgery unit has been able to do enough to pass the inspection for accreditation. I await the outcome of the investigation.