FEATURE
How can
the RCOG
support its
doctors?
It is now likely that all doctors will face
at least one formal complaint in their
working life, with potentially devastating
consequences. Yet talking about these
workplace stresses is still taboo
F
ORMAL COMPLAINTS are
only one of the potential
causes of workplace stress
that affect doctors’ health
and limits their ability to
practise to their full potential. Studies
have shown that most doctors under
stress begin to practise ‘defensively’,
which includes overprescribing,
increased referring of patients, overinvestigation, not taking on complicated
patients and avoiding certain procedures.
This kind of behaviour is potentially
harmful to patients.
Alison Wright RCOG Vice President
(UK & Global Membership) tells us, “our
Members and Fellows have been asking
for more support from the College. This
has led us to set up a task force to address
issues of workplace stress, bullying and
undermining, and fitness to practise
investigations on their behalf.
10 O&G SPRING 2017
“The Supporting our Doctors Task Group
is a team of consultants and trainees with
representatives from other organisations,
in particular we will be working closely
with the GMC. We are delighted that
Professor Terence Stephenson will be part
of that task group.”
Prof Terence Stephenson, Chair of
the GMC, said: “The GMC’s role is to
protect patients, but we also want to
support doctors by reducing the stress
and duration of investigations. Through
piloting provisional enquiries and other
initiatives we have managed to curtail
many investigations, and will be seeking
new legislation from government to
reduce the burden further.”
Tackling bullying, harassment
and undermining
There is a distressingly large amount of
literature about bullying, harassment
and undermining during training. It is
generally agreed that these behaviours
are always unacceptable, and there are
clear guidelines about how bullying and
undermining should be avoided and
tackled if they occur.
Bullying and undermining are
generally seen between senior staff
and trainees. However, consultants
themselves can be the victims of bullying.
According to a survey by Carter et al. in
2013, 20% of NHS staff had been bullied,
and 43% had witnessed bullying, but few
had reported it. The main reasons for
not reporting incidents of bullying were
a belief that nothing would change and
a fear of being branded a trouble maker.
Carter noted that the most common
source of bullying was a supervisor or
manager, but for almost a third of those
bullied the bully was a peer rather than
a superior.
www.rcog.org.uk
SUPPORTING OUR DOCTORS
To try to understand more about
the issue the College surveyed O&G
consultants. The results revealed a hitherto
C ASE STUDIES
C A S E R E P O R T, D R X
Dr X, an ST2 at the time of the
incident, was on night call when she
saw the patient. The cardiotocograph
(CTG) was reassuring. Dr X was called
back in the 2nd stage. The baby was
born after episiotomy but was fl at
and required resuscitation. The baby
was acidotic and suspected to have
hypoxic ischaemic encephalopathy
(HIE). Later it was also found to be
septic with Staphylococcus aureus and
died fi ve days later.
There was an internal serious
untoward incident (SUI) investigation
and a debrief with no criticism of
Dr X. However, the SUI was disclosed
to the parents without Dr X’s
knowledge and she later received a
letter from the GMC. The patient had
alleged that Dr X had misinterpreted
the CTG, therefore delaying delivery
and resulting in neonatal death due to
HIE and sepsis.
On receipt of the GMC letter Dr X
had ‘never felt so desperate’ and was
unable to sleep or eat for several days.
She felt unable to work, described it as
a ‘nightmare’.
Dr X contacted her defence
organisation who opened a case and
sent details of their counselling service.
She also contacted the British Medical
Association (BMA) counselling service
and the Samaritans. Dr X reflected on the
case in detail.
During the GMC investigation Dr X
initially continued to feel very worried
for her career. She accepted that the
GMC had an obligation to investigate
and made use of the medicolegal adviser
at MPS as a means of support. She
produced a detailed written reflection on
the case and was relieved when the GMC
expert report concluded that ‘the overall
standard of care provided to this patient
by Dr X did not fall below that expected
of a reasonably competent specialty
trainee in obstetrics’.
unknown incidence of consultants as
victims rather than perpetrators. 44%
of the respondents said they had been
persistently bullied or undermined, and
the toll on the victims was significant,
ranging from suicide ideation and
depression to sleep disturbance and loss of
confidence, which will have an inevitable
impact on patient safety.
Just over half the victims had reported
the situation to management, but only 4%
reported that it had been resolved.
The situation is disturbing and
unresolved. The College, jointly with the
Royal College of Midwives, has issued
statements regarding zero tolerance of
bullying and undermining of trainees and
midwives and has created a number of
resources that are available to members.
However, breaking the taboo and
encouraging staff to speak out will be the
key to creating a supportive environment
where stresses can be discussed,
incidents reported and mechanisms put
in place to resolve them. It should no
longer be acceptable to say ‘that’s just how
she talks’ and put the onus on the victim
to accept an unacceptable behaviour.
How can we work together with
the GMC and medical defence
organisations (MDOs)?
A fitness to practise investigation by
the General Medical Council (GMC)
is one of the greatest fears among
practising doctors: it is the most serious
investigation and can lead to suspension
or erasure from the register.
“The GMC’s role is to
protect patients, but we
also want to support
doctors by reducing the
stress and duration of
investigations”
1
Carter et al, BMJ Open 2013;3:
www.rcog.org.uk
2
Shabazz et al, BMJ Open 2016;6
The outcome
The GMC closed the case with no further
action six months after Dr X received the
initial letter.
Dr X felt relief but also frustration at
the events leading up to the complaint.
3
It’s vital to speak
to others who
have had similar
experiences
Dr X felt the complaint could have been
avoided if the case at the trust level
had been handled better.
C A S E R E P O R T, D R Y
Dr Y, a consultant with eight years’
experience, was involved in a complex
forceps delivery. The baby was born in
poor condition and died the following
day. Dr Y was deeply affected by the
event. She had annual leave already
booked and returned to work at the
end of the holiday.
The parents complained to the GMC.
The arrival of the letter was a great
shock and Dr Y wasn’t aware of the
support channels available to her.
Dr Y immediately contacted her
defence organisation. She then
had a meeting with the parents
who said she had not apologised.
(These accusations were untrue as
confirmed by staff who had been on
the scene.)
The outcome
After nine months the GMC
exonerated her, dealing in detail with
every point.
Dr Y felt relieved that the GMC had
confirmed her competence but was left
doubting her own abilities.
Being cleared by the GMC wasn’t
the end of the case. The mother wrote
multiple complaint letters leading to a
difficult meeting with the parents.
Dr Y’s health was affected and her
GP was helpful in identifying the extent
of her anxiety. She had not experienced
suicide ideation but was aware of a
strong desire to ‘run away’. This was an
acute issue in Dr Y’s life for two years
and it was three years before she really
felt ‘cleared’.
Advice from Dr Y for others
• Don’t return to work too soon
• Take opportunities for counselling
• See your GP
• Talk to others who have experienced
the same thing
http://www.uhs.nhs.uk/HealthProfessionals/Clinical-law-updates/Manslaughter-by-doctors.aspx
SPRING 2017 O&G 11
FEATURE
“Participants find
the processes very
distressing and
anxiety-provoking”
Karen Ellison of the MPS explains
that the rise in the number of
complaints to the GMC seems to be
a consequence of our increasingly
litigious society, and because patients
think that they are better informed
about medical procedures and their
rights because of the internet. She
also believes that complaints are often
made based on the potential financial
compensation, without thought for the
total cost of the case (far in excess of
the award to the patient) or the effect
on the doctor.
The devastating effects of a letter
questioning fitness to practice
are well known. Doctors’ typical
responses include: ‘nightmare’, ‘worried
for my career’, ‘lost my confidence’,
‘questioning my own ability’ and ‘never
felt so desperate’. The investigation
can rapidly lead to depression or other
mental health issues, and in some
cases suicide ideation or suicide itself.
Even if the final outcome is exoneration,
when doctors receive a letter explaining
the decision they often fail to achieve a
sense of closure of the incident. They tell
us they feel there is still a shadow over
their career.
Recent studies (Brooks et al. 2014)
have identified some of the reasons that
current investigative processes are so
stressful to doctors:
• T he legalistic and impersonal language
of the letters
• T he number and uncoordinated nature
of the communications
• A lack of empathy from supervisors
• A lack of clarity about the process
Participants report finding these
processes very distressing and anxiety-
12 O&G SPRING 2017
provoking, citing as key factors a lack of
clear information and the impact that the
tone of the correspondence has.
What can doctors do themselves?
In our ‘blame culture’ many believe
that when a tragedy occurs somebody
must pay. And the increasingly litigious
nature of today’s society coupled with
simplified access to ‘ambulance-chasing’
law firms increases the likelihood that
any mistake could result in a complaint
or even a formal gross negligence
manslaughter charge.
Fear and worry can be destructive; the
best response is to plan.
• Understand the risks involved and
take steps in your practice to ensure
not only that everything is done
correctly but that the notes also record
everything pertinent
• C onsider how you interact with patients
because the evidence is that we make
our decisions about trusting individuals
within one tenth of a second of meeting
• B e scrupulously honest at every stage of
any investigation into your practice –
equally important whether it is a local or
GMC investigation or in a court of law
• C ome forward and seek help
C ASE STUDIES
C A S E R E P O R T, D R Z
Dr Z, an experienced consultant, had
experienced a number of unconnected
referrals to the GMC in 17 years of
practice. The cases he has faced
include a claim of missed diagnosis of
ovarian cancer, an MSc trainee under
his supervision who had cheated in
an examination and complications in
laparoscopic surgery.
He felt that the earth had “opened
up to swallow him” and he began to
doubt his own abilities and insight.
In the case of the MSc trainee, the
GMC required their attendance at a
panel hearing but gave only a few
days’ notice.
In each of these cases he contacted
his defence organisation immediately.
The defence organisation put together
a legal team and provided significant
and reassuring support. Dr Z’s case
was significantly helped by the amount
of support that he had from patients
and colleagues.
The outcome
After the case had continued for over
two years the GMC agreed that there
was no case. Dr Z received no apology
and had no sense of exoneration.
Advice from Dr Z to others
• Join a defence organisation
• You are only as good as your last
operation
• Things go wrong in medicine:
be honest at all times
www.rcog.org.uk
SUPPORTING OUR DOCTORS
Available
RCOG support
Workplace
Behaviours Advisor
• Bullying and undermining
toolkit bit.ly/1yq1uoP
• Improving workplace
behaviour, an eLearning
module to raise awareness of
unacceptable behaviour
bit.ly/2n9GrpB
Supporting Our Doctors
Task Group
If you receive a
GMC letter, it’s
important to see
your GP
If you do receive a GMC letter
• Make sure you understand the GMC
process and where you are within it
• Contact your defence organisation
immediately
• Talk to other people who have
experienced similar situations
• Contact one of the counselling services
• See your GP
How to get back to work
Particular problems arise for doctors who
are allowed to practise with undertakings
or who have been suspended for a period
of time. Return to work may be extremely
difficult or impossible. Mark Slack,
one of the members of the RCOG’s new
Supporting our Doctors Task Group (see
right), points out that there are several
issues involved in returning to work
www.rcog.org.uk
because your colleagues have knowledge
of the event and a prejudgement of the
doctor’s ability is almost inevitable.
It becomes extremely difficult for the
returning doctor to play a full role in the
department. Dr Slack believes that the
best solution to help returning doctors
is to ensure they are moved away from
their previous environment and can
work under the mentorship of a senior
colleague with an honest understanding
of the situation.
In this way, Dr Slack believes that
doctors can be given a second chance: “It
is too great a waste of valuable resources
for capable doctors in their 30s and 40s to
lose their careers”, he says.
The College has established a
task group to develop a strategy
for preventing, minimising
and managing training and
workplace-based stress. It
also aims to remove the taboo
currently felt around such issues.
As well as setting strategy,
the task group will be
proposing and coordinating the
College’s approach to supporting
doctors and their employers.
The areas to be explored and
developed include:
• Partnering and signposting
to other support resources
outside RCOG
• Linking with regulatory,
indemnity and other relevant
national bodies
• Working with the GMC to
ensure fair, efficient and
effective fitness to practise
investigations
• Exploring ways to improve
the effectiveness of trainees’
assessments and greater
flexibility within the training
programme
• Providing support and
information on how to manage
workplace challenges
• Overseeing and directing the
RCOG Peer2Peer Support
programme
READ MORE Find out how the GMC
supports doctors on page 14
SPRING 2017 O&G 13