Management of clinical departments cannot be achieved through leaflets, PowerPoint presentations and declarations of intent
Photo: Einar Nilsen
«As Minister of Health, I will say to those responsible: You need to come forward with a clarification of this matter. We cannot have an inter-departmental conflict which is reported as an unresolved matter to the public and thus destroy our confidence» said Jonas Gahr Støre, who was visibly indignant on the evening news on 18 November 2012. The background was the tragic story of a seriously ill heart patient, who had been made ready and put under anaesthetic at Ullevål Hospital, but who had to be reawakened and transferred to Rikshospitalet, where he had to wait a week for surgery – and then died. Støre was infuriated, not primarily by the incident, but because Mons Lie, former director of the Centre for Cardio-Pulmonary Diseases at Ullevål Hospital, had written a critical letter on the subject to Otto Smiseth, Head of the Division of Cardiovascular and Pulmonary Diseases at Oslo University Hospital, and the letter had been published in the VG daily and on the website of the Norwegian Broadcasting Corporation earlier that day (1).
«One shouldn’t sweep difficulties under the carpet, but there is a responsibility attached to the way in which difficulties are dealt with,» Støre continued. «And that’s when I react to someone who comes forward with near-accusations of an intention to sacrifice someone in a professional conflict like this. We sometimes witness this in the hospitals, these kinds of allegations. I respect that things can get heated in discussions between colleagues, but there is a considerable responsibility involved when this is brought to the attention of the public.»
All of us, doctors and politicians alike, have «a considerable responsibility» – for the services to patients, for speaking out when we see something going wrong, for how we describe and characterise each other, and for how we deal with conflicts and seek to make a contribution to providing good health services to everybody in Norway. But do doctors also have a responsibility for not bringing disagreement and inconvenient facts to the attention of the public? On the contrary. Doctors and other health professionals should be encouraged to do so. We are far too reticent in going public with our actual opinions and disagreements – as described by Erlend Hem in a recent editorial in our journal (2).
I am often annoyed by all the squabbling between Norwegian politicians. Do they really need to go on like this? After all, they disagree only on minor details! Perhaps we should erase all party boundaries, and let all politicians work according to the same party programme! Surely this would be more efficient? But then, as we know, one-party states have other problems attached …
For years, politicians and health bureaucrats have resented what they alternatively refer to as bickering, prestige conflicts, power struggles or discord between health personnel, especially doctors. The justification for the merger of the Southern and Eastern Norway Regional Health Authorities barely six years ago was exactly an espoused desire to «tear down the Berlin Wall» that allegedly separated Ullevål Hospital and Rikshospitalet. It was «meaningless» to maintain parallel competence in these two hospitals. By merging them, everything would be cheaper and better. Of course, they would need to coordinate and cooperate, especially with regard to highly specialised therapies. And of course, only sufficiently trained doctors should treat ill patients. But why can they remain so utterly confident that it will be optimal for the patients to have only one pre-defined service provider?
Medicine is more akin to politics than to mathematics. There is a knowledge base, but there is rarely any absolute agreement as to how it should be interpreted. What will be considered proper diagnostics and therapy varies with the experience, values and preferences among health personnel and patients. All those who have worked at Ullevål Hospital and Rikshospitalet, at other Norwegian hospitals, in various parts of the primary health services, not to mention health services in other countries and on other continents, know well that there can be a number of highly varying approaches to identical medical problems, and there can be widely differing cultures in the various departments involved. There will often be strong differences of opinion as to how patients should be treated. One could refer to this as improper and unreasonable power rivalry. Or, one could regard the existence of different alternatives as a positive thing – just like having different political parties.
On 13 November 2012, Otto Smiseth stated to the media: «Our quality is excellent. Here, the planning was not up to standard.» Initially, this gave the impression that Smiseth was referring to the planning and preparations for the surgery at Ullevål Hospital, and this had caused Mons Lie to react. Gradually, it transpired that it was the general planning at Oslo University Hospital that had not been up to standard. In his response to Lie, Smiseth wrote: «According to the new strategy, the most complex patients are foreseen to be relocated to Rikshospitalet. This plan has not been implemented to full effect. What remains is a detailed plan, and most importantly, a risk assessment.» (3). In plain language: We have an idea of moving the most complicated patients to Rikshospitalet, but we have not yet looked into how we should do this, nor have we made any assessment of the risk to the patients should we go ahead with it. In brief: The plan has «not been implemented to full effect», and it is a matter of definition whether it has been initiated at all. It is such vague signals that give rise to uncertainty and dangerous situations – not professional disagreement.
It does not matter how many times politicians, bureaucrats and directors at various levels repeat that «we cannot have it like this» and «we will now intervene with more explicit leadership» (implicitly: management from above), when patients, relatives and health personnel have it exactly «like this» in Northern Europe’s largest hospital right now in 2012. Moreover, if their leadership is to become more explicit, it must first be obvious and visible to those who should be led. Management of clinical departments cannot be achieved through leaflets, PowerPoint presentations and declarations of intent, it is achieved through a professionally involved presence. This inspires confidence in the staff members, which is exactly what the patients need. According to VG, the son of the deceased patient found the letter from Mons Lie to be reassuring: «There was no concealment in the content of the letter. It seemed like he wrote from the heart.» (3). It is amazing how those who have been hardest hit are so often able to cut straight to the heart of the matter: Obfuscatory chit-chat and a pat on the back will not inspire confidence in us, but honesty will – even in the face of the worst imaginable outcome.