The Student Room Group

Hierarchy?

Im sure that every single one of us here at some point in there career has trusted a CT1/2 more than they trusted their SpR. I had a situation where I trusted my CT, followed the SpR because he has more experience, I was on call, everyone was busy, of course he is in charge, but he was wrong. Ended up in a ridiculous clinical situation because of it! I predicted it! I wanna hear your stories......
Reply 1
I do discharge letters and I am going to do them as a consultant if I work in an inpatient service. It is a very important piece of information with big implications for ongoing care of the patient so why would I delegate this task to a FY1 with no experience of my speciality is a mystery to me. Not to mention that whilst they take hours to produce something that needs lots of editing and correcting (when asked to write one for educational purposes) I can do it in a fraction of the time.

I have worked with a clinical director in medicine who dictated the letters on the post take ward round with patient's input. Not only the clinical info was there but he massively increased income to the department as he understood coding and what to say to get the right tariff applied.

As for hierarchy, it should be flat in my opinion with anyone empowered to speak up if they disagree or see unsafe practice. I have challenged consultants and I would expect the same of trainees working with me.
Reply 2
Im unsure....are you suggesting that I am de-skilled?! I had a very real circumstance where I had a CT telling me to do one thing and a reg telling me to do another, neither were communicating with each other, even when they both eventually ended up coming to the ward because of the seriousness of the situation. The nurses pulled me to one side and asked me to take charge of the situation, even though there was a CT2 and an ST7.....I felt powerless and the patient suffered. How does this fit into your description?! Sorry, but I genuinely dont know! My situation sounds far more like your 'in the olden days' example....and if Im honest I think it is the same almost everywhere. Im an F2 btw
Reply 3
I wasn't implying that you personally resent writing discharge letters but generally speaking there are plenty of doctors who do. It is often seen as an afterthought and a simple scut work. The quality of letters can unfortunately reflect those attitudes.

The consultant led on calls are already here for some. In my speciality consultants are first on in many organizations as there are not enough SPRs to staff the rota, never mind their competency.
My experience is that the hierarchy is worshipped more in some specialities than others, but generally is still applied much more than optimal. I have both worked with very poor seniors, and worked with seniors who were otherwise good but had specific knowledge deficits and as a result i have had to do a bizarre set of investigations/make some very embarrassing referrals. But because responsibility is allocated by years of experience, rather than necessarily by competence, that's what you have to do. Some people seem to think this stops once you reach consultant, that you can have bad juniors but all consultants are right... i think that the opposite is true personally.

I hope to have no qualms about asking advice from someone more junior when the time comes. Certainly I'm happy to take suggestions from e.g. nurses currently.
Reply 5
I just think, from that particular scenario, if either of them had asked me my opinion, and I was the only one the nurses were speaking to, that poor man would have had a more dignified death. I felt the hierarchy really worked against me. It was my reg strangely, medical staffing had ****ed up and we were both on call, I never trusted him the same again though
Reply 6
Original post by Zakadoh
I just think, from that particular scenario, if either of them had asked me my opinion, and I was the only one the nurses were speaking to, that poor man would have had a more dignified death. I felt the hierarchy really worked against me. It was my reg strangely, medical staffing had ****ed up and we were both on call, I never trusted him the same again though


When I was an FY1 I worked in palliative care for 4 months and then moved on to surgery. I can't say that I made my life easy by challenging my consultant or making referrals to palliative care where this was not a done thing in that unit. Interestingly it has become a thing when they have realised the benefits to the patients and their beds started to empty rapidly with people going to a hospice and making space for their elective cases. I could have made my life hell but I took the gamble and in the end it worked out well.
Original post by Zakadoh
I just think, from that particular scenario, if either of them had asked me my opinion, and I was the only one the nurses were speaking to, that poor man would have had a more dignified death. I felt the hierarchy really worked against me. It was my reg strangely, medical staffing had ****ed up and we were both on call, I never trusted him the same again though


If you feel something is being done wrong you should offer your opinion, not wait for it to be asked.

Being assertive when a senior is plainly wrong can be a very difficult situation to handle - i think its my honest answer to 'what is your greatest weakness' - but at the very least you can ask 'are we doing the right thing here'? 'What do you think the prognosis is'? 'Do you think we should talk to palliative care'? Etc. No one can possibly accuse you of overstepping the mark for asking a simple question.

The trouble for me is when you do that but they still want to plough ahead, especially when there is uncertainty within the clinical scenario anyway. Difficult.
Reply 8
I dont have a problem with assertiveness. I really dont. But this was a peri arrest moving into resuscitation type situation. No time to think about anything other than doing my best to follow the plan from my seniors. They were disappointing and ineffective but nontheless, I shouldnt be expected to take charge in that situation anyway. An ST7 should have had all that knowledge at his fingertips
Reply 9
Original post by Zakadoh
I dont have a problem with assertiveness. I really dont. But this was a peri arrest moving into resuscitation type situation. No time to think about anything other than doing my best to follow the plan from my seniors. They were disappointing and ineffective but nontheless, I shouldnt be expected to take charge in that situation anyway. An ST7 should have had all that knowledge at his fingertips


This is not about knowledge but attitude, how the knowledge is applied, wider legal and ethical factors. I'm sure your reg is quite aware of the likelihood of successful resuscitation in elderly with comorbidities. On the other hand, they also know about the complaints and legal challenges to DNRs.

This should all be sorted well in advance. In fact in my opinion, many patients should never be admitted in the first place as it is a total waste of resources. However, until we have discussions and shift in culture relating to allowing natural death this will continue. There needs to be a widespread positive campaign to help people opt for death at home with no heroic measures.
Reply 10
Original post by belis
This is not about knowledge but attitude, how the knowledge is applied, wider legal and ethical factors. I'm sure your reg is quite aware of the likelihood of successful resuscitation in elderly with comorbidities. On the other hand, they also know about the complaints and legal challenges to DNRs.

This should all be sorted well in advance. In fact in my opinion, many patients should never be admitted in the first place as it is a total waste of resources. However, until we have discussions and shift in culture relating to allowing natural death this will continue. There needs to be a widespread positive campaign to help people opt for death at home with no heroic measures.


You are clearly more senior than I am and I respect your experience. But no. This was a **** show and it should never have happened! They resusitated with a DNAR in place.....they ripped it up. His wife arrived mid-resus. We got him back....the only successful resus I have ever seen to be honest. They then implemented another DNAR and we all had to watch him die. It was a **** show.
Reply 11
Original post by Zakadoh
You are clearly more senior than I am and I respect your experience. But no. This was a **** show and it should never have happened! They resusitated with a DNAR in place.....they ripped it up. His wife arrived mid-resus. We got him back....the only successful resus I have ever seen to be honest. They then implemented another DNAR and we all had to watch him die. It was a **** show.


You will probably see more of it. People are resuscitated only for ITU to come over, see some sense and refuse admission for ongoing care. They are then left to die a few hours later. In the meantime team of people has been pulled away from treating people that can be saved and the patient put through a mill for nothing.

Rather than blame the **** show on individuals though it is worth reflecting on the wider systemic factors that influence their decision making. It may be worth asking the reg why they have done what they done at the time.
Reply 12
Original post by belis
You will probably see more of it. People are resuscitated only for ITU to come over, see some sense and refuse admission for ongoing care. They are then left to die a few hours later. In the meantime team of people has been pulled away from treating people that can be saved and the patient put through a mill for nothing.

Rather than blame the **** show on individuals though it is worth reflecting on the wider systemic factors that influence their decision making. It may be worth asking the reg why they have done what they done at the time.


You really arent gunna let me have this are you?! I believe that you are responsible.....if you take the job. Bollox to anything else. You are responsible.
Original post by Zakadoh
I dont have a problem with assertiveness. I really dont. But this was a peri arrest moving into resuscitation type situation. No time to think about anything other than doing my best to follow the plan from my seniors. They were disappointing and ineffective but nontheless, I shouldnt be expected to take charge in that situation anyway. An ST7 should have had all that knowledge at his fingertips


It sounds like there may have been mistakes. Tearing up a DNACPR mid-arrest is certainly a bold step, maybe it was wrong maybe it wasn't. But that happens. Mistakes happen. All you can do is ensure your response to it is the best it can be.

In most arrest situations i have been to there have been periods where its just chest compression, pausing for rhythm checks, and not much in between. That is very much the place to make suggestions. In fact at most arrests I've seen there has been a lot of discussion. There was also the moment the DNA was removed - a quick look of surprise 'really are you sure' will suffice. Maybe that's what you did who knows. Regardless, reflect on the event, know what you would want to do if you did it again, and apply that to future arrests.
Original post by Zakadoh
You really arent gunna let me have this are you?! I believe that you are responsible.....if you take the job. Bollox to anything else. You are responsible.


If you want a generic discussion about hospital hierarchy, let's have one. If you want to vent about your specific incident, I suggest finding someone who you can talk to locally who you can talk about the details with.

We've probably all been in that boat of thinking the senior is wrong, and it should be acceptable to politely question that if you think patient safety or outcome is at stake. Being more senior doesn't mean being infallible.
Reply 15
Original post by Zakadoh
You really arent gunna let me have this are you?! I believe that you are responsible.....if you take the job. Bollox to anything else. You are responsible.


The blaming of individuals has been long proven to be counterproductive and detrimental to patient safety. If you prefer to focus on individuals and their responsibility as opposed to systemic issues be my guest. Shouting and throwing your toys out of a pram is not a very constructive response though when someone is offering a suggestion.

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