The Inconvenient Truthers: doctors speaking out

One of the main jobs doctors have is to advocate for health. Hands up, who agrees?

You all have your hands up, right? But right now, the ability of Kiwi doctors to speak out about health issues that they see affecting their communities is being garrotted.

When I first started this column I thought it was about exploring the big picture issues in health in Aotearoa, from an insider’s perspective. (It is). But very quickly, I saw that it also had a different function.

This may be the only ‘opinion’ column you’ve ever read that is peer sourced (posting my topic a month out on a private social media group for over 6,500 NZ doctors and asking for input), evidence based (yes – I read lots of articles while writing, both general media and health research) and peer reviewed (I send my draft to colleagues with expertise in that topic, to check I’m in line with reasonable medical opinion). Doctor training is hard to shake off.

I’ve had an outpouring of help and information whenever I’ve asked for it. It turns out that there’s a need for an outlet for doctors to say their truths and share their views publicly, but safely.

Feeling safe is a rare feeling among most of my colleagues right now. There are many reasons for this – sparse or nonexistent resources make everyone feel like they’re stretched thin and walking on eggshells, knowing that errors leading to patient harm are more likely. But there’s also a real fear that just speaking out will draw a large target on their back.

For this piece, I asked my colleagues two simple questions:
1. Would you feel comfortable speaking to media about important health issues that you are expert in, and if not, why not?
2. Do you feel that explicitly or implicitly, clinicians are being discouraged from making public comment?

Within hours of my request, two things happened: I got dozens of messages from them wanting to speak privately; and significantly less people than usual publicly ‘liked’ or commented on my post.

The other notable thing was that every conversation I was having, with colleagues at all levels from junior doctors through to senior health leaders – was consistent: it is very unsafe right now to speak out if you have a job or contract in the public health system, or even in primary care.

“I would never feel comfortable speaking out publicly, to media. Even posting in a private chat group I’m very careful with what I say as I fear backlash. I’m just a small fry, a small cog in a massive machine trying to make things work day to day. Absolutely, there are many controls in place to hold our tongues. No matter what our opinion there is always someone more vocal and likely with more authority (maybe enough to threaten our livelihoods) holding the opposite. It’s not worth it, our boats are rocky enough as it is.” – Anonymous

The standard hospital contract states that employees cannot speak to the media on health issues as a representative of the hospital without prior approval, but their right to comment as individuals is protected. It is also specified that they can comment as representatives of other organisations, such as unions. The group contract (SECA) agreed to between Health NZ and ASMS, the senior doctors’ union, requires senior doctors to take action if they see an issue affecting patient safety, then requires them to report it further if not enough is done. Clause 40 of the SECA states: “In recognition of the rights and interests of the public in the health service, the employer respects and recognises the right of its employees to comment publicly and engage in public debate on matters relevant to their professional expertise and experience.”

However, doctors are now being actively discouraged from making public comment on issues that affect patient safety. It tends to be insidious at first: a doctor talking a little too loudly in hospital meetings about lack of resources might receive a private ‘guidance’ from a senior colleague that their training pathway/job might be affected. Or, there might be comments that they are ‘outspoken’ and subtle social pressure exerted: ‘you’re too loud’.

Other pressures are applied if the doctor is from another country – ‘you don’t understand the culture here’. There’s also the good old ‘you’re not being a team player’. In short, everything except the actual issue – that the doctor is telling an inconvenient truth.

This is usually enough to make the doctor pull their head in. But if it doesn’t stop them, there might be an invitation to a ‘disciplinary meeting’ where ‘concerns’ are raised about their performance. I have heard several instances where a screenshot of a private social media post was sent to a manager. For example, a comment about the dire staffing situation saying that senior nurses were fleeing to Australia – common knowledge I would think – resulted in the senior doctor being summoned by management and being told off ‘like a naughty child’.

An investigation into reporting culture in the UK concluded that ‘Whistleblowers … raised serious concerns which were not only rejected but were met with a response which focused on disciplinary action against them rather than any effective attempt to address the issue they raised.’

Whistleblowing? I thought this was simple health advocacy, also known as doing our jobs.

A journalist I know commented that she’s found it really hard to get comments from doctors, even anonymously. Surely, answering a media question about what is needed for better health isn’t a criticism of a specific political party. Nonetheless, the environment seems to have markedly changed since the coalition government got into power, with many of the ‘in principle’ freedoms in the SECA ignored. The same journalist told me that after she interviewed a health worker in their role as a union delegate, the worker was called into a ‘please explain’ meeting by the hospital. This was so unpleasant that the worker refused to speak to any journalist for months.

“I guess as a government employee we are meant to be politically neutral … a difficult thing to be as an outspoken and passionate doctor. I will be evaluating my future career pathway. The current government is particularly challenging to work in as a doctor. Others in the past or future may be less challenging and make the issue of whether or not to speak out less pressing.” – Anonymous

Hospital managers have started taking the view that doctors are ‘public servants’ and as such are not allowed to express ‘political views’. Apparently, the coalition government views any criticism of their health system demolition reforms as being too political. This thin skin in response to what is meant as constructive problem solving seems unique to this government.

On March 18, the National Public Health Service Director Dr Nick Chamberlain told public health doctors that any advice they wanted to offer about issues in their regions needed sign off at a “national level”. Health Minister Simeon Brown added that he wanted medical officers of health to stop “leading advocacy campaigns” on public health issues.

Instead, he said their focus should be on “technical advice” and immunisation campaigns.

When public health doctors pointed out that health advocacy and advice giving was most of their job, David Seymour moved on to schoolboy insults and denial. He said he was ‘cheering on Simeon putting those muppets back in their box’ then doubled down, saying our profession has ‘too many whining busy-bodies.’ In other words, stick to your real job of holding the health system together by your toes and fingernails and don’t you dare complain.

But those public fireworks distract from what’s really happening. Many doctors are being muzzled. HR ‘processes’ are becoming systemic and weaponised as ways to control otherwise powerful professionals.

“Any parliamentary submission or even emailing my MP would make me identifiable … it makes one wonder how deep the rot and influence in the system goes and if we are risking our jobs by speaking out. Quite a few people do not have permanent long term contracts (eg casual, locums, specialty trainees who move between hospitals or reapply for jobs each year, those having to find new positions due to the recent resetting of the health system) and one feels concerned about whether having a black mark against your name might make you less likely to get a job.” – Anonymous

“When a group of us (junior medical staff) tried to put together a statement that a planned hospital build risked ending up with inadequate space and services for the population, we were sent a firmly worded email….it seems (Health NZ) has a firm stance on political
neutrality and making statements like that would likely jeopardise our current roles / future training applications.”
– Anonymous and paraphrased to remove identifying details

These statements are a powerful distillation of the fear and the multiple small ways in which people are discouraged from speaking up. We are then unable to advocate for ourselves as well as others.

When more forceful silencing is needed, weaponising formal disciplinary processes has been well tested in other countries. On their website, a UK medical defence law firm states: ‘“It is not unheard of for doctors who raise serious concerns to be victimised by being put through performance management processes without any basis, or be referred to the General Medical Council (GMC) … there is clear evidence that (hospitals) often react adversely …and there are many reported cases of doctors losing their employment.”

The GMC, the NZ equivalent being the NZ Medical Council, is a body that has the power to investigate complaints and stop doctors from working if they have concerns. Although many complaints are ultimately found to be without just cause, the investigation process is onerous, requiring multiple legal statements, and can last for months to years. Needless to say, these cases are often well publicised through the grapevine – make an example of one person and thousands are deterred, right? Being required to respond to a complaint even when it is likely it will ultimately be dismissed is very stressful on top of the already pressured work environment. Being under such an investigation is known to increase the risk of suicide among doctors. Who would risk it?

“When many of us are ‘burning’, on the way to burnout, there just isn’t the mental or emotional capacity to speak up or speak out. It is just too hard.” – Anonymous

This environment of fear has many downstream effects: how can we communicate openly and according to the principles of care if everyone is feeling gagged? Clinical decision making requires good communication; we need to be able to talk openly about systems issues if we’re to reduce clinical errors. How can we advocate for the things our health system needs to be urgently better at if we can’t even call out what is happening? How can we continue to practice ethically and fairly? How can we demonstrate how to be a good doctor to those we are supposed to be teaching? These things are medicine 101. It is likely that politicians’ fragile egos are costing lives.

Further food for thought: many of the doctors I was speaking to were considering changing their jobs or moving countries. At least three colleagues I know personally have taken early retirement rather than continuing in a system where they couldn’t speak out about their concerns with underresourcing and being unable to do their jobs well.

This is compounded with poor support from management on planning and provision of baseline health services, active lagging or denial of overtime payments and dragging their feet on recruitment of extra staff while also lying about it. People simply decide to quietly walk away, but they feel terribly guilty and also get ‘survivor’s guilt’.

“I have never seen anything like the current environment. I would love for the public to demand monthly updates of each department in each hospital to do a summary of how many SMOs have been lost in the past two years, senior registrars lost to Oz , admin staff not replaced, nursing shortages, escalating numbers of patients, wait times, etc. I think it is all so much worse than people can even imagine.” – Anonymous

Many of those leaving are pressured into signing a ‘non disclosure agreement’. Those that sign, regret it as it means they are unable to speak out at all or say why they left; meanwhile the organisation will say whatever it wants including smearing their former employees’ reputations.

There’s also the feeling that when it comes to health policy, there’s a tilted playing field:

“Those in large corporates and with political lobbying access always seem to get in (to policy makers) anyways – large corporate GP businesses in the primary health context and private hospital specialists in the hospital and surgical context.”
– Anonymous

“I wonder if so many of us feel hopeless about speaking out, that we have seen politicians and health ministers informed about the state of our healthcare system over and over again. There is never any engagement that feels genuine and there’s a sense that the work we do and the fears we have for the future of the system (and ourselves) are completely irrelevant to the political plans of the day.” – Anonymous

Dr Ruth Spearing, the only person who agreed to be named for this article, offers a note of hope that I will end on. She reminds me that through many government cycles, the same issues of under-resourcing and unsafe or inefficient systems recur – and that doctors speaking out can indeed lead to policy change, even if the politicians will never admit that that was an influence. She and others also point to the insulating effect of unions, strong networks of advice and support, and groups of allies who work together, often for years and despite clear attempts at intimidation, to bring an issue to public attention.

“I became chair of the Canterbury Hospitals’ Medical Staff Association in 2003 and for the next 14 years I was the name attached to the opinion pieces that the Executive Committee wrote. We challenged major issues including the UK Public Private Partnership model, patients being treated in corridors in ED, frozen meals from a private enterprise for all Inpatients. We made progress on every issue we challenged, at least at the time. Speaking out is SO important. I would lie if I didn’t say that I didn’t feel a sense of fear at times, but it was definitely worth it.” – Ruth Spearing

As I write, the bullying from political figures has become more blatant. In the past Seymour has used proxies such as the Taxpayer’s Union or conservative media hosts to do the bully work. In the last few weeks Seymour has been bullying more directly. Dr George Laking, a respected medical leader, was targeted in an immature meme accusing him of having ‘Regulatory Standards Derangement Syndrome’ simply for pointing out that the proposed Bill would result in unfair distribution of health care. If we needed any more evidence that his party is borrowing from the Trump playbook, this is it.

Unfortunately for him, intimidation won’t work, at least in the long run. Governments change, and in every conversation my colleagues made it clear that they strongly value speaking out, even if they don’t have the personal power to do so. For now, public commentary seems to require privilege: for example, those who don’t rely on public hospital roles for income or career advancement, or those who are retired. It also, it seems, needs rock-solid mental health and strong support in the form of families, communities and unions. We would value the public’s support too.

It’s the public who will suffer if we don’t speak out.

Dr Renee Liang MNZM is a New Zealand paediatrician, poet, essayist, short story writer, playwright, librettist, theatre producer and medical researcher.