Being mindful of 
medical hierarchy

Medical hierarchy may present a challenge, and at times a possible reluctance, to open discussions about patients. Dr Rachel Birch, medicolegal consultant at Medical Protection, discusses possible reasons for this and provides helpful strategies to overcome this.

Most doctors would agree that a medical hierarchy exists in the hospital setting, with junior doctors and specialist registrars making up most consultants’ teams. In many ways, in general practice, once a GP has qualified and completed their training, they may be considered as equal as any other GP. However, few would disagree that newly-qualified GPs can, and do, still learn a lot from more experienced GPs. As such, there exists a more subtle form of medical hierarchy within general practice.

It is important that sessional GPs are aware of this, especially when there may be disagreement about a patient’s care.

Case scenario

Since completing his GP training last year, Dr A has undertaken monthly locum GP sessions in a 2-partner practice. Last month he saw a patient in his early twenties with a significant depressive illness. He prescribed SSRI medication, but booked the patient a review appointment with his usual GP, Dr H in ten days. He wanted to ensure the patient was followed up, in case of an initial worsening of his mood.

Today the patient has come in to see Dr A for review. Although he is slowly starting to feel a little better, he confirmed that his mood had worsened before starting to improve. He did not attend the appointment to see Dr H- one of the receptionists had apparently telephoned him to pass on the message from Dr H that he should see Dr A after 4 weeks instead.

This is the second time that this has happened and Dr A is concerned that Dr H has not appreciated that he booked the review appointment because he was worried about the patient. He wants to raise it with Dr H, but is unsure as to how to go about it- Dr H is the senior partner and the local LMC secretary.

Approaching the discussion

Some recently-qualified GPs may have concerns about how to diplomatically question a much older and more experienced colleague. Whilst medical hierarchy can be positive and helpful if they wish to seek advice or learn from their colleague, in this situation there may be a reluctance and a worry that they may be perceived as being critical.

There may be various potential barriers to initiating a discussion with a senior colleague. Is there a perceived power imbalance, for example? Effectively the partners will be employing the sessional GP, and this could cause some GPs to worry that their job may be at risk. This is more likely to be a concern for salaried GPs doing regular sessions than a locum who does occasional work at a practice.

The personality of the senior colleague could also present a challenge to the GP, who may be afraid of how their colleague will react to their questioning. Other perceptions of power imbalance could be related to gender, or due to part-time versus full-time working.

Whilst contemplating the discussion may be stressful for the GP, it is likely that the stress of not addressing their concern, in the interests of patient safety, won’t go away until the discussion has been held.

General Medical Council guidance

The General Medical Council expects doctors to take part in quality improvement activities to promote patient safety. This includes taking part in reviews of your own work, taking steps to address any problems and regularly reflecting on the care that you provide. This is as true for a senior GP as a newly-qualified GP.

"Whilst medical hierarchy can be positive and helpful if they wish to seek advice or learn from their colleague, in this situation there may be a reluctance and a worry that they may be perceived as being critical."

The GMC also advocates a culture that “allows all staff to raise concerns openly and safely.” In terms of communication with colleagues, it is expected that doctors will work collaboratively together, respecting each other’s skills and contributions, and treating each other fairly and with respect.

Practical tips

With this in mind, Dr A should ensure he is prepared for the discussion, and has reflected on exactly what he wants to say. Does he want to outline the way that he prefers to treat patients with depression, or would it be better first to ask Dr H to explain his reasoning?

An informal approach is usually best, and Dr A should avoid telling Dr H that he believes his actions were wrong. Instead, it would be preferable to ask him to discuss the patient, and, as part of that discussion, Dr A can address the issue of Dr H cancelling the patient’s review appointment. It is important to remember that Dr H may well know the patient better than Dr A, and it is possible that there was a valid reason for his actions.

Nevertheless, the discussion should provide them both with an opportunity to reflect on the best care for the patient.

The reverse scenario

Imagine a different scenario now, where you are an older, experienced locum GP and are approached by a young GP trainee who has concerns about the care you have provided to a patient. How should you respond?

It is first important to appreciate that it may have taken the GP trainee a great deal of courage to approach you. You should be calm and listen to what they have to say- you may even wish to thank them for bringing this case to your attention. Remember that they are going through their GP training at the moment, and their knowledge in certain areas may be more up to date than yours. It is impossible to know everything, and you may find that your discussion is in fact a learning opportunity. Conversely, you may find that your experience is a learning opportunity for them. You may wish to reflect on this discussion in your next appraisal.

Promoting a culture of openness and responding to constructive criticism is essential for patient safety. It is important that medical hierarchy does not inhibit, but instead enriches any discussions about patient care.

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