Why I always get an ISBN for my research reports

Julie Mooney-Somers

Mooney-Somers, J, Erick, W, Brockman, D, Scott, R. & Maher, L (2008). Indigenous Resiliency Project Participatory Action Research Component: A report on the Research Training and Development Workshop, Townsville, February 2008. National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, NSW. ISBN: 978 0 7334 2647 6.

See that bit at the end, that’s my first ISBN. I can’t recall where I got the notion from, and I wonder now at my presumptuousness. I don’t think it was standard practice in my research centre to get ISBNs for research reports. But I had just come out of a horrid job that I’d stayed put in to get publications (it didn’t really work). I was in a new job and determined to get as much on my CV as I could. The first output was a report on a training workshop. I was thoroughly engrossed…

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Regulations have improved since thalidomide but drug scares are still possible

Wendy Lipworth, University of Sydney

The thalidomide tragedy, which resulted in thousands of deaths and disabilities in the late 1950s and early 1960s, changed medicine forever. One of its outcomes was the establishment of more robust mechanisms for the regulation of medicines and medical devices.

Regulatory bodies – including the Therapeutic Goods Administration (TGA) in Australia, the Food and Drug Administration (FDA) in the United States and the Medicines and Health care products Regulatory Agency (MHRA) in the United Kingdom – now decide which products pharmaceutical and medical device companies can market. They also monitor the safety of medicines and devices once they are on the market.

There is no doubt that the tightening of regulation has prevented countless deaths and disabilities, and saved many lives. But regulation cannot always protect us from harm and events disturbingly similar to the thalidomide tragedy continue to occur. Let’s look at two recent examples.

Vioxx pain drugs

In the 1990s, a new class of anti-inflammatory medicines emerged – the “COX 2 inhibitors”. These pain drugs were touted as being less likely to cause gastric ulceration than existing treatments.

One of these, rofecoxib (Vioxx), manufactured by Merck, was later withdrawn from the market, when it emerged that it increased the risk of myocardial infarction (heart attacks).

Vioxx increased the risk of heart attacks.
Reuters/Mike Segar

It emerged that the company had deliberately misinterpreted and concealed some of the information it had about these risks, thus delaying the withdrawal of Vioxx from the market.

Questions were also raised about conflicts of interest – on the part of academic researchers who collaborated with Merck in running trials of Vioxx, members of the data safety monitoring board whose job it was to monitor trials of Vioxx, and members of FDA committees who assessed Vioxx.

A number of class action lawsuits have followed, including one in Australia in 2010, which ruled against Merck. This decision was subsequently reversed, but this was because the judges decided it was not possible to causally link the particular claimant’s heart attack to his use of Vioxx.

Merck has subsequently come to a settlement agreement with Australian patients.

DePuy hip replacements

Yet another class action lawsuit concluded in Australia this June. The action was brought against DePuy International Ltd and Johnson & Johnson Medical Pty Ltd, which were accused of being negligent in their design, manufacture and supply of a particular kind of hip implant.

The story leading up to this will sound familiar: a promising new medical device – the DePuy ASR hip implant – was developed and marketed in the mid-2000s. The company claimed these implants would would reduce friction and wear, and improve patients’ mobility.

DuPuy was accused of not properly testing the product.
terekhov igor/Shutterstock

Complication rates soon proved to be much higher than expected. Around 2,000 of the 5,500 Australians who received the device have required, or are expected to require, revision surgery.

The device was finally withdrawn in Australia in 2009 and worldwide in 2010.

The company has subsequently been accused of not testing the implant adequately, and of knowing – and denying – that its device did not meet manufacturing specifications.

As with the Vioxx case, concerns have been raised about possible conflicts of interest on the part of some of the surgeons who recommended the implant to their patients, and the regulators who evaluated it.

Is there more to come?

These two eerily similar events raise the question: can we do anything to reduce the likelihood of similar occurrences in future?

There is certainly scope to tighten our governance of the pharmaceutical and medical device industries, and the behaviour of those who interact with them. We can also make our regulation of new medicines – and devices and surveillance of existing products – more robust.

There are, however, several important limits to our capacity to prevent harms from medicines and medical devices – all of which help to explain why history keeps repeating itself.

First, pharmaceutical and medical device companies are commercial entities which invest billions of dollars in developing new medicines and devices. Tight regulations are in place and outright fraud is fortunately very rare.

The commercial imperative is, however, powerful. As a result, there is always the possibility that studies of new medicines and devices will be designed, and their results interpreted and disseminated, in a manner that overstates their benefits, and underplays their risks.

Conflicts of interests may affect the reporting of scientific data.
Bullstar/Shutterstock

Second, most patients who are injured by medicines and medical devices sustain these injuries in the course of routine medical or surgical therapy – either because of unpredictable adverse events, such as allergic reactions to antibiotics, or because of unintended medical errors.

The adage that “all medicines are poisons” is, unfortunately, true, and we need to accept that even the best physicians and surgeons are only human and will inevitably make mistakes.

Third, we need to balance our desire for innovation and access to new technologies against our desire for safety and control. While there is definitely room to improve regulation and surveillance, we don’t want our clinicians and regulators to be so risk-averse that health technologies cannot make it onto the market or survive once they get there.

Finally, while we might like to think that academic researchers, clinicians and regulators are committed solely to their the pursuit of knowledge, patients and the general public, the reality is they all need to earn money, and attract funding for their work. This inevitably creates a situation in which their “primary commitments” compete or conflict with other loyalties or with self-interest.

We need to accept that “conflicts of interest” are part and parcel of all social roles. Therefore, there will never be a group of people whose only commitment is to protect patients.

When this sobering fact of human nature is combined with the dangers of the commercial imperative, the inevitability of unpredictable side-effects and medical errors, and the need to balance our desires for safety against our desire for innovation, the future looks uncertain.

The best we can hope for is that our systems of checks and balances will continue to be refined so that the “thalidomides of the future” will be caught and addressed as early as possible.

Stay tuned for other instalments in the thalidomide series this week.

The Conversation

Wendy Lipworth, Senior Research Fellow, Bioethics, University of Sydney

This article was originally published on The Conversation. Read the original article.

Speaking with: Aric Bendorf on how to increase organ donation rates in Australia

William Isdale, The University of Queensland

Roughly 1,600 people are currently on waiting lists to receive an organ transplant in Australia. But for many, the wait will be unsuccessful due to the low number of donors.

Australia was once a world leader in organ donations, but today its organ donation rate is lower than much of the developed world. The country ranks 20th in the world for donations, despite having a higher than average rate of potential donors, and sits below world leaders such as Spain, Belgium, France and the USA.

Australia’s approach has been to focus on signing up more people to be donors and on encouraging families to consent to donation after the death of a relative. But if Australia wants to be world-leading, that’s not enough.

William Isdale spoke with Aric Bendorf about what needs to change if Australia is to, once again, become a leader in organ donation.


Subscribe to The Conversation’s Speaking With podcasts on iTunes, or follow on Tunein Radio.

Music: Free Music Archive/Kai Engel – The Idea

Additional audio: Sunrise (Channel 7), Organ and Tissue Authority, The World Today (ABC Radio National)

The Conversation

William Isdale, Research Assistant, T.C. Beirne School of Law, The University of Queensland

This article was originally published on The Conversation. Read the original article.

On Not “Getting Out of the Way”: A Reflection on Steven Pinker’s Critique of Bioethics

Title:

Last week well known psychologist, linguist and author Steven Pinker published an op-ed in the Boston Globe, under the title “The Moral Imperative for Bioethics”.*

The article begins with an explicit mention of the CRISP-Cas9 technique for “editing” genomes, and a brief tour through the many diseases which modern medicine and biotechnology is seeking to treat. He goes on to say that research in these areas is essential, a point he frames in terms of reducing the global burden of disease. He then says:

Biomedical research, then, promises vast increases in life, health, and flourishing. Just imagine how much happier you would be if a prematurely deceased loved one were alive, or a debilitated one were vigorous — and multiply that good by several billion, in perpetuity. Given this potential bonanza, the primary moral goal for today’s bioethics can be summarized in a single sentence.

Get out of the way.

Now this is pretty striking, and unsurprisingly many commentators, including myself, were furious. However, I thought I would let the dust settle and see what emerged from the discussion on social media, an email discussion list I am a member of and elsewhere. The stories in Nature and PopSci were reasonable, and Alice Domurat Dreger, Julian Savulescu, Stuart Rennie, Christopher Mayes, Matthew Beard and Russell Blackford make good points.

One point of common ground here, and indeed with Pinker, is that there really is a problem with much bioethics regulation – the processes of research governance and ethics committee oversight. It can be slow, cumbersome, unpredictable, perverse, contradictory and so on. But even so, no one is suggesting we dispense with it altogether – only that it be improved. Pinker himself says:

Of course, individuals must be protected from identifiable harm, but we already have ample safeguards for the safety and informed consent of patients and research subjects.

He also points out, later on in his article, that biomedical technologies which sometimes seemed very promising often fail:

Biomedical research in particular is defiantly unpredictable. The silver-bullet cancer cures of yesterday’s newsmagazine covers, like interferon and angiogenesis inhibitors, disappointed the breathless expectations, as have elixirs such as antioxidants, Vioxx, and hormone replacement therapy.

It is interesting that several of the technologies he mentions didn’t just fail, their failure was often covered up by manufacturers and the regulatory system designed to catch these failures arguably didn’t intervene quickly enough. He doesn’t mention this however; his argument the quasi-libertarian one that scientists should be allowed freedom to explore and innovate without excess regulation. He is less good at noticing the ways in which such innovation takes place in economic conditions which make regulation essential to cope with market failures.

He has two basic arguments for the need for bioethics to get out of the way:

First, slowing down research has a massive human cost. Even a one-year delay in implementing an effective treatment could spell death, suffering, or disability for millions of people.

And:

Second, technological prediction beyond a horizon of a few years is so futile that any policy based on it is almost certain to do more harm than good.

To the first, while on its face it looks plausible, if his second argument is valid, then the problem is we just don’t know whether the research we are doing now actually will save all those lives. Indeed, by investing in this research and not that we may be wasting all those lives he points to. We just don’t know. As to the second, it is almost trivially true, but nonetheless these predictions are what policy-makers and research funders and investors (not forgetting the rest of us) have to make. But he says:

In the other direction, treatments that were decried in their time as paving the road to hell, including vaccination, transfusions, anesthesia, artificial insemination, organ transplants, and in-vitro fertilization, have become unexceptional boons to human well-being.

In other words, some of our bets paid off, some didn’t, and sometimes some of us bet the wrong way on the basis of moral objections which in hindsight look ridiculous. It’s not clear to me why bets the wrong way on other grounds than moral ones get a free pass, but only moral qualms get mocked in this way. I am sure we can make a list of bets the wrong way where moral qualms ought to have played a part and didn’t so we ended up with disastrous consequences for millions. Again, he doesn’t talk about that. The trouble with consequentialist (or decision theoretic?) reasoning of Pinker’s type is that you have to count all the consequences of all the options, not just the ones which favour your own biases. Indeed, if you are going to be a consequentialist you have to be rather good at predicting outcomes (not as bad as he says we are, in other words). But in any case, he reserves special opprobrium for moral reasoning, thus:

Biomedical advances will always be incremental and hard-won, and foreseeable harms can be dealt with as they arise. The human body is staggeringly complex, vulnerable to entropy, shaped by evolution for youthful vigor at the expense of longevity, and governed by intricate feedback loops which ensure that any intervention will be compensated for by other parts of the system. Biomedical research will always be closer to Sisyphus than a runaway train — and the last thing we need is a lobby of so-called ethicists helping to push the rock down the hill.

My initial reaction to the Pinker article was heated. I have spent my entire working life as a bioethicist (roughly speaking, from my first postdoc, as I was not in bioethics as a graduate student or before) with people claiming that what I do is variously a waste of time, a waste of money, ideologically suspect (from any and all directions), intellectually sloppy and so on. Sometimes these criticisms have been levelled at me personally (fine, I can bite back if I need to, and I’m not perfect and sometimes the criticisms have been fair), sometimes at my work (that’s the academic life, I can take it) and sometimes they have been levelled at me and my peers _merely_ because of presumed attitudes, beliefs and values I must have simply because I am a “bioethicist” and “this is what bioethicists think”. Sociologists often do this (not all sociologists…) and historians of medicine often do this (not all historians…). It’s tiresome. If someone wants to know what _I_ think there are various ways of finding out, but a priori judgements of what I “must” think because I am a bioethicist really… get my goat.

My initial reaction to Pinker’s article was that it was an egregious piece of grandstanding which if it had come from the wilder shores of twitter we’d call trolling. However, that would be to attribute motives and intentions to Pinker I cannot verify. What I can say is that it is in a reasonably well established genre of writing which appears quite frequently in the professional medical press (for example, an unsigned editorial about 15 years ago in the Lancet titled “the ethics industry”), and it is perfectly reasonable and sensible to look at the writing as a genre piece, focus on its rhetoric, implied audience and so on. We should also look directly at the arguments, and when I’d cooled off and read Julian and Alice’s pieces I can see that there are arguments in Pinker’s article which have merit and I agree with them. But still, the rhetoric matters. Just as if I am parking my car and someone comes up in my face and shouts “get out of the way” I am liable to take that as a verbal assault even if he then gives me some good and compelling reasons why I might like to move my car a little. This person knows the effect of getting in my face and shouting at me, and it has little to do with the merit of his argumentation. Authors of style guides are pretty good at knowing how rhetoric works too. So are linguists and psychologists.

Never mind. I will get over it. I don’t have to take it personally, after all I don’t recognise myself in his description of bioethicists, so presumably he’s not talking about me anyway. (He wouldn’t know me from Adam).

Turning once more to the arguments, the one argument which has not been touched on directly, and I think is important, is that he says bioethics should not thwart:

…research that has likely benefits now or in the near future by sowing panic about speculative harms in the distant future. These include perverse analogies with nuclear weapons and Nazi atrocities, science-fiction dystopias like “Brave New World’’ and “Gattaca,’’ and freak-show scenarios like armies of cloned Hitlers, people selling their eyeballs on eBay, or warehouses of zombies to supply people with spare organs. Of course, individuals must be protected from identifiable harm, but we already have ample safeguards for the safety and informed consent of patients and research subjects.

Several commentators have questioned whether we can be that sanguine about how well bioethics does the latter. But it’s the former that bothers me. He’s making an asymmetrical argument: we should discount hypotheticals about bad things; but instead be guided by hypotheticals about good things. To my way of thinking they are no less hypothetical. There’s a branch of the sociology of knowledge which explores this in some detail, the sociology of expectations, and one of the main findings in that field is the biomedicine relies on creating narratives about plausible social futures of technologies in order to attract investors and research funders, persuade regulators and so on. No one, nowadays at least, ever chucks money at researchers saying, go and do something interesting, tell us when you’re done.

So my more general point is that bioethics is _precisely_ a way of telling stories about new technologies and exploring them and seeing what we make of them. There are other ways to do this – for example, as Pinker’s own example shows, making films, writing novels and stories, and so on. Or indeed writing business plans, IPOs and suchlike. This is how humans think stuff through. It’s part and parcel of how we make technologies. It’s not an extraneous factor, that can be shoved out of the way. So, once again, rhetoric matters, and not as a bit of optional packaging, but as part of the real work itself.

Some day I am going to write a book about this. Maybe I should thank Pinker for getting my introduction going with a bang.

Richard Ashcroft

Professor of Bioethics
School of Law

Queen Mary University of London

@qmulbioethics

*Pinker has since made further comments found here.

Richard visited VELIM in February 2005 while he was on an Australian Bicentennial Fellow visiting the Centre for Applied Philosophy and Public Ethics, University of Melbourne. He and Dr Ainsley Newson were colleagues at Imperial College London.

It’s time for the government to stop shooting the messenger

Sydney Health Law

The constant attacks on Professor Gillian Triggs represent attacks on the human rights and civil liberties that Australians value. Since 1986, the Human Rights Commission has been the watchdog for human rights for Australia.  The President and her Commissioners are necessarily independent of government and have a duty to fearlessly advocate for human rights protections and to criticise laws and policies that undermine the rights and freedoms Australians enjoy.

The current barrage of orchestrated attacks on Triggs is supposedly on the basis that her comments are politically motivated. Of course they are. Human rights lie at the core of our political system: they require government to protect their population and provide a political environment in which they can flourish. If human rights weren’t political they would make no sense at all.  The problem for the government is that it wants to ignore human rights yet remain immune from criticism.

The…

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Politics, Power and Children in Detention

Politics are all around us, playing out in national, local and even domestic governance. Politics have to do with the polis, the people who make up groups of any kind. In that sense, politics are unavoidable. Our relationships with others always contain a political element. Party politics are a subset of politics in its broad sense. Party politics are partisan, ideologically informed patterns of thought and action that suggest how politics should translate into governance in a way that is consistent with a set of underlying values. They condense around different beliefs in power relationships between governors and governed, in the rights and statuses of the different groups that make up the polis, in the control and dissemination of information, and in the responsibilities of government and individuals towards one another.

Accommodation in the Nauru offshore processing facility.

Accommodation in the Nauru offshore processing facility.

Party politics is made up of what Gallie termed ‘essentially contested concepts’. No one, for example, disputes the existence of the multitudes of people fleeing poverty, instability, persecution and fear. Nor do they dispute the reality of the moral and practical problems they pose for the countries to which they try to flee. But the agreements end at about this point. Some interpret this mass movement as a challenge to their sense of humanity and to their obligations to observe human rights. Others, while acknowledging the human problems of displacement, feel that local territorial rights and laws take precedence, and that the welfare of the host countries is paramount. Turning unregistered and unscreened refugees (“illegals”) away is, in that ideology, a better and safer and fairer alternative to dealing with them by taking them in.

Australia has been foremost among western countries in ‘turning back the boats’ and in making off-shore detention inevitable for those who do manage the journey, pointing to the success of that policy in preventing drownings and restricting the numbers of refugees who reach Australian territorial waters. By contrast, Italy has done its best to rescue enormous numbers of people fleeing North Africa, and to find some kind of accommodation for them. Neither side can be said to have found ‘the’ answer to a massive humanitarian crisis. Italy’s resources have been overstretched. The Australian mode of management appears to contravene United Nations conventions on refugees.

Party-Politics & the Report into Children in Detention

Into the middle of this dilemma, which is partly political in the broad sense and strongly party political in a narrower sense, came the Report into Children in Detention, chaired by the Australian Human Rights Commissioner, Gillian Triggs. The Report found more than 200 children to be in off-shore or Australian detention under conditions that harm their development and infringe the UN statements on human rights. The Commission’s findings seem to be supported by doctors who have visited the detention centres, and by various leaks from people who have worked in Nauru and Christmas Island. The Australian Government’s response has been to deny the accuracy of the report, to attack Triggs’s integrity, to accuse her of partisan reporting, and to call for her resignation.

The report calls for the early release of children from detention, and for proper acknowledgement of their rights, particularly their rights to grow into reasonable adulthood, equipped with education and some sense of identity and stability. It makes many comments about the suffering of adults, but its focus is on children and the overwhelming impact that violence, insecurity, uncertainty, heat, lack of space and lack of hygiene will have on their lives.

The report does not deal so much with the original party-political decision to turn back the boats. It does take issue with both political parties’ decisions to enforce mandatory detention, and it does so predominantly in the context of the impact of that policy on children.

Triggs & the Ruin of Party-Politics

It makes disturbing reading. Presumably that is why it has provoked such extreme responses from both sides of party politics.

On the right, party politicians and right-wing newspapers have belittled Triggs and accused her of bias against them, of dishonesty and inaccuracy. They question the timing of the inquiry, which began soon after the election of the LNP in 2013. They have recommended imprisonment for anyone who leaks relevant information to the media, such as those who supplied some of the information that Triggs relied upon.

On the left (and in the centre), politicians, commentators and media have called for the report to be taken seriously, for secrecy to be lifted and for legislation to protect refugee children. For these people, the timing of the report is irrelevant because its contents demand some major response. At the same time, those who oppose the present government’s theories and practices have used the report as a lever to destabilise the government’s refugee policies more generally, pointing out that what happens to the children is a consequence of what happens to “illegal” refugees at large.

All these conflicts of interpretation and accusations of dishonesty signal the presence of an essentially contested concept. The big concerns for us are:

  1. That politics in the broad sense have been confused with a much narrower party politics;
  2. That the present government’s refusal to allow access to the detention facilities effectively disables any public debate;
  3. That the punishments threatened against anyone who reveals ‘classified’ information about the centres are Draconian;
  4. That the government’s vigorous attacks on the report and its author suggest that they had a pre-formed notion of what the report should say.

Essentially contested concepts make up a significant part of our ‘political’ lives – they always have and they always will. What is important is the way in which these contests are handled. A totalitarian government will settle them one way; a liberal democracy will try to find another.

Ignoring the Real Issue

What is at stake in this confrontation is not Gillian Triggs’s credibility, but the public perception of its preferred mode of government. Apparently, more than 50% of the population approve the present government’s approach to refugees or believe that it should be more extreme. We can only hope that they understand that Triggs, in her appointed role as Human Rights Commissioner, was writing about children in detention, and that government decisions to discredit her well-supported findings by political force majeur raise serious concerns about the reality of our much vaunted participatory democracy.

Emeritus Professor Miles Little, University of Sydney

Miles was the Founding Director of the Centre for Values, Ethics and the Law in Medicine (1996-2003). He was also the Foundation Professor of Surgery at Westmead Hospital in 1978 and a Co-Founder of the World Association of Hepatic, Pancreatic and Biliary Surgeons (1987). Since 1996, Miles is an Emeritus Professor of Surgery at the Sydney Medical School. At the VELiM, he continues to teach and is directing the Cancer Survivorship Project. Miles interests include Medical Sociology and Biomedical Ethics. He is also a published poet.

Let’s stop the bullying of trainee doctors – for patients’ sake

Kimberley Ivory, University of Sydney and Karen Scott, University of Sydney

Size matters. At least, that seems to be the media’s belief when it comes to analysing social problems. The grimmer the stories, the uglier the experience, the more bodies at the bottom of the cliff, the better.

And last night’s episode of ABC TV’s Four Corners didn’t disappoint, with its expose on bullying among surgeons and the devastating consequences this entrenched practice has for its victims, both in the short and long term.

Despite casting their net wide, the show’s producers found only three medical professionals who haven’t spoken out about this issue before, and only two chose to be identified. Imogen Ibbett and Vyom Sharma have now joined the growing ranks of doctors, such as Dr Caroline Tan and Dr Talia Steed, in breaking the silence around the destruction of careers and health that doctors cause among their own.

But noticing the growing pile of bodies at the bottom of the cliff is only helpful if it triggers the essential questions – who or what is pushing them off and what can be done to stop it?

Not just surgeons

The program notes that this is not just a problem for women, or surgeons or even just the medical profession; it’s a public health issue that demands action. Indeed, women can also be perpetrators as Imogen Ibbett’s allegations against Helen Maroulis clearly demonstrate.

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But most significantly, the show highlights the risk bullying, scalpel-throwing surgeons, misogynist physicians, and harassed and cowered trainee doctors pose to the lives of patients.

The problem starts early, in medical school; both local and international research persistently show most medical students experience mistreatment during clinical placements in hospitals.

Our recent – about to be published – research found 74% of Australian medical students experienced mistreatment during clinical placements and even more witnessed it. Similarly, a 2014 US study found 83% of medical students experienced some form of mistreatment during medical training in hospitals.

A large number of students reported use of “pimping”, an aggressive form of questioning based on an abuse of the Socratic teaching method, described in Four Corners, which is used to shame students for their lack of knowledge. Studies have also highlighted negative environments involving belittlement, disrespect and being “constantly ignored and told to disappear.”

Although student reports of mistreatment may be interpreted by some senior staff as just over-sensitivity, research shows students perceive negative events in a similar way to physicians and nurses. Unsurprisingly, under-reporting is common.

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Mistreatment of medical students is at odds with the explicit teaching about professionalism in medical training, leaving many confused. But some others become medical teachers who “mete unto others what was perpetrated against them”. The effects of all this “teaching by humiliation” can be profound and enduring.

Medical students’ mental health has been shown to decline throughout medical training. And this can lead to poor self-confidence and burnout, binge drinking, stress and depression, and substance abuse, broken relationships, suicide and early exit from the profession.

Mistreatment can create cynicism and reduce empathy, which may directly affect patient care. Students are also distressed when they see doctors mistreating or being disrespectful to, or about, patients.

Impact on patients

Patients can clearly be directly affected by the way the autocratic medical culture affects working practices and ineffective communication causes health-care errors and poor patient safety outcomes.

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In fact, this kind of culture poses an extreme threat to patient care, like the notorious “Butcher of Bega”, Graeme Reeves. After 35 formal complaints of bullying and harassment were made about Reeves by other doctors, nurses and patients over a 15-year period starting in 1985, he was deemed “a person unfit to remain on the register of medical practitioners” in 2004. Behind him lay a trail of dead and mutilated patients and aggrieved and frustrated doctors and other staff.

But much bullying and harassment is subtle, insidious and harder to prove and act upon. Indeed, Four Corners shows how one doctor’s tormentor can be another’s mentor. Dr Imogen Ibbet finds Dr Tan’s tormentor, Chris Xenos to be professional and respectable, for instance, but feels very differently about Dr Helen Maroulis’ behaviour.

And all the bad behaviour is difficult to police because mistreatment is often so subtle and secretive it can be impossible to deal with, especially when the victim is made to feel both responsible and powerless.

In the program’s attempt to look for solutions, it’s confronted by the apparent buck-passing of responsibility between the Australian Medical Association (AMA), the professional colleges and the workplaces where bullied doctors work.

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Four Corners and BeyondBlue have nailed the problem that’s pushing people over the cliff: workplaces that have allowed a culture of humiliation, bullying and harassment to prosper with inadequate pathways for action. And the fence that’s needed at the top of the cliff to prevent the falls is now also becoming apparent.

If bullying is a workplace issue, and the workplace is funded on the public dollar, then the public needs more say in hiring and firing practices. Nothing can change until young doctors are safe in the knowledge that the people they need to complain about no longer have absolute control over their careers. And there’s an example that can be followed.

Training to become a specialist in general practice is no longer directly under the control of either of the general practice colleges. Rather it’s contracted out to 17 regional training providers. The role of the general practice colleges now is to improve practice quality as a whole, build collegial relationships, and provide continuing education and opportunities for its fellows and members.

This may be a model we need to emulate for all medical speciality training. While it will never be possible to completely remove the apprenticeship model from medical education, it’s possible to ensure progression decisions are made by those at arm’s length from training and that merit, not nepotism, prevails.

The Conversation

Kimberley Ivory is Senior Lecturer, Population Medicine and Sub-dean Student Support, Sydney Medical School at University of Sydney.
Karen Scott is Senior Lecturer, Education, Discipline of Pediatrics and Child Health at University of Sydney.

This article was originally published on The Conversation.
Read the original article.