Raising concerns

A persistent problem

BMJ Careers spoke to trainees who recalled how senior colleagues had turned up drunk for work, of situations where they thought a consultant wasn’t performing well but felt too intimidated to tackle the issue, and of consultants refusing to listen to juniors’ concerns about their choice of treatment for patients.

These incidents may be less frequent now that trainees are no longer dependent on one consultant for references and recommendations. Mark Porter, chair of the BMA’s Consultants Committee, believes hierarchical relationships in medicine “are definitely not what they were.”

“Professional deference to those higher in the hierarchy is less these days. Individual junior doctors don’t depend so closely for professional advancement on the say so of individual consultants because assessments are more broadly placed.

“There are also more consultants than there used to be, so trainees no longer have one boss about whom they daren’t say a word.”

However, while Professor Howard says today’s generation of consultants “are more liberal and enlightened and trainees are more assertive and self aware,” he believes “there is an imbalance of power in the relationship between the consultant and trainee.”

“The perceived threat for juniors is that if the consultant doesn’t approve of you they can still cause problems by threatening to ruin your career.

“Work based assessments and appraisals give trainees even more anxiety because they might feel that unless they are able to please their boss, he or she will find some way to slow down their training programme.”

He suggests trainees find it hard to express concerns about a senior to their colleagues because “they often identify senior doctors as being part of the same ‘gang’ and find it difficult to talk about a consultant to their peers because they’re worried they will pass details back to them.”

Jon Van Niekerk, a consultant in general adult psychiatry for the Greater Manchester West Mental Health Trust and former chair of the psychiatric trainees committee for the Royal College of Psychiatrists, stresses that although trainees reporting concerns is not a common occurrence, their inability to take it further is still an issue.

“Even in psychiatry, where the hierarchy is not as explicit as some specialties, juniors still feel: ‘What if I come across a situation that is too combative and will it harm my career progression?’ The belief that it’s ‘not my place’ to challenge a senior still exists.”

Reporting responsibly

Although recognising the difficulty of raising concerns about senior colleagues in any working environment, Jane O’Brien, head of standards and ethics for the General Medical Council, urges doctors to do so because of their obligation to put safety first.

Failure to report concerns can not only have serious, even fatal, consequences for patients, but is also detrimental to doctors, Professor Howard believes. “Not feeling able to report bad practice can mean trainees’ mental health can suffer. Bullying and incompetency can disillusion young potential, which is massively damaging to the profession,” he says.

Although questioning the actions of a senior colleague can be intimidating, patient safety is of paramount importance so juniors must voice their concerns, says Tom Dolphin, vice chairman of the BMA’s Junior Doctors Committee. When faced with an immediate doubt about a procedure being carried out by a consultant or senior staff member, a confrontational situation can be avoided by raising the concern as a learning point.

“You can question the senior colleague’s actions by saying: ‘I don’t quite understand why you have taken this approach and can you run through for me the reasons why you decided to do this,’” he says.

“Then, if an answer comes back that doesn’t seem right to you, draw on examples of previous patients where other doctors have acted differently, to encourage the consultant or senior member of staff to reflect on their practice,” he advises.

Dr Porter suggests juniors who are worried about a consultant’s practice should find a senior professional they can confide in. He says that the chosen confidant is then obliged to take those concerns seriously and to consider whether the problem is simply a misunderstanding or whether further action should be taken. Suitable senior colleagues to talk to are a trusted mentor, another consultant a trainee has worked with, a college tutor, a clinical tutor, a programme director, or a clinical director.

Should serious concerns still not be dealt with, trainees may want to consider raising issues with an appropriate external body such as the GMC. The organisation advises that before providing any information that might breach confidentiality, doctors should discuss the issue with their defence or professional association such as the Medical Defence Union, their royal college, or the BMA.

Doctors who complain about their colleagues should not underestimate the stress it can cause, but there is support available to help them get through that difficult period, advises Dr Porter. Sources of advice include the BMA’s Doctors for Doctors stress counselling service and specialty specific associations.

The role of consultants

Consultants should be supportive of juniors who have worries about senior doctors’ practice. “Raising concerns in a responsible way is part of being a good doctor and there is a requirement placed on them by the GMC to make sure reporting concerns is acknowledged, encouraged, and supported,” says Ms O’Brien.

To encourage an open working culture, consultants need to build closer working relationships with trainees, suggests William Allum, chairman of the Specialist Advisory Committee for general surgery. He says the mentoring of junior doctors by senior clinicians should be encouraged, and he would also like to see professional skills and judgment, as well as clinical skills, becoming part of the training curriculum.

When questioned by a junior about their practice, consultants should try not to see this as a challenge or a threat. “It’s important to have a culture where everybody feels able to ask a question if they think something might be wrong, and for them not to get ‘slapped down,’” says Dr Dolphin.

“Admitting to making a mistake is not a weakness, but a sign of strength and professionalism, and most of the time consultants can teach, and trainees can learn from this experience,” he says.

But whether working in an open culture or in an environment where the senior consultant’s behaviour is intimidating, he urges juniors not to hesitate to raise concerns—otherwise they might live to regret it.

“You must think what’s best for the patient. If you were right about your concerns, then think how terrible you would feel if that patient comes to harm.”