Op-ed : my view on why there is an obvious problem with management of the Aus #covid crisis response, and how we can improve. Why are front line docs not buying the plan from the boffins? How to fix this? A cracking read.

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The brief answer, IMHO, is that we have a serious clash of two vastly different medical cultures. Neither culture should see the other as the enemy when frustration boils up – the enemy is always the virus.

The front line culture is modern, highly networked, often social media savvy, collaborative, a diverse multidisciplinary team. This team knows the best results come from brainstorming problems with a hive mind of connections, often online and involving international experience, respecting all inputs, rapidly iterating them and distributing resource and decision making. All members are equal in calling out issues as they see them, and contribute ideas to solving complex problems. Evidence base is the currency for respect here.

Pandemic central command culture on the other hand is paternalistic. It operates by command via multilayered bureaucratic structures. What it says goes and cannot be questioned as there is no process for that. Evidence is not required, as the decisions have authority. Information goes up through filters, is processed by distant experts, and decisions come back down through filters.

An excellent example of how this might look is the stockpiling. People on the ground get frightened because they receive news from many sources. The politicians, who they do not normally ever engage with, tell them to “just stop it”. The people do not listen because they do not respond to paternalism or respect that type of management. The politicians then start to look like frustrated Dads whose kids won’t listen to them any more. The people are used to evaluating evidence for themselves and drawing their own conclusion. A better way to settle them would be to validate and empathise with their concern, and assuage their fear by guaranteeing food supply.

The front line docs are used to regarding government involvement in day to day matters as a necessary evil. This may not always be true but it is often their perspective. They resist and question many government interventions, as they seldom play out well in the real world. Think pink batts.

Both cultural groups have the same intention, both are composed of very clever people, though the CMOs are not diverse, so lack that advantage. Only one that I know of has significant social media presence. The same one that has displayed a more nuanced understanding of why people might stockpile in times of fear. They are also public servants who must deliver options to elected non-expert politicians, who then make decisions at many levels. Including now a new National Cabinet. These politicians struggle to balance scientific reality with fear about the economy and tourism. At at time when by definition no-one will be able to leave home.

The top down commands, when received on the front line, often simply cause angst and astonishment as they are from this different paternalistic culture and cause cognitive dissonance. Then when questions are asked back up the line, the central command or a subordinate responds with “just do as you are told, we have consulted the best medical minds in the country”, which is entirely unsatisfying.

This is the worst possible alternative to a Centre for Disease Control that is independent, well connected, has a clearly articulated transparent plan, with evidence that is there for all to see. Decision making on local issues should be devolved to local clinical leaders. Too late for that now.

Front line doctors know exactly what the centralised body are doing : they are balancing risk of intervention against risk of disease load (ie $$ & panic vs deaths), then giving an output for action across a very large and highly variable system. The model assumes things about front line readiness and capacity, based on reports from state executives & Ministers. These assumptions are likely wrong according to the people who work in GP, ED, ICU. The execs feeding information up to their bosses are reluctant to report failure of delivery, but prefer a “we have plans” narrative.

Doctors, just like stockpilers, do not respect and often don’t comply with black box decisions, where they can’t evaluate the judgements about their local conditions, based on a transparent process. It is just not how we work these days, not having done so since the 80’s.

If central command get it right, then people will fall in line, but when some of the decisions are clearly dumb, for example “the Grand Prix is going ahead and I’m off to the footy”, and the comms and optics are terrible the front line has the awful realisation that this is going to go badly. That is the point at which they start to reach out for help.

Things that have lead to the front line doctors questioning whether the command approach is correct include:

– the statement “we have the best doctors in the country so just cooperate“.
This is going to make us think, well they’re no doubt good, but I don’t remember the medical Olympics where they gave out those medals. Who among them is fresh from working in an ICU, ED, General Practice?
What chance is it, that they know more than the combined Clinical Leads of our major teaching hospitals, or the thousands of real world doctors who are discussing in depth and challenging their decisions every day online? Do the CMOs believe it when our state Health Minister says that we are “prepared for community spread”? Because we don’t.

– when dealing with unknown exponentially spreading diseases (this one is 12 weeks old) we normally would practice an abundance of caution, more-so when carnage is evident overseas. Many of the decisions so far seem based rather on care and concern for “avoiding panic” and “protecting the economy”. To front line doctors it seems self evident that both these aims are better served with transparency, collaboration and fixing the disease as top priority. It is only a bias to optimism that fools politicians into thinking it won’t be as bad as we know it will be. They are “protecting the economy” based on the fallacy that this may not turn out as bad as doctors think. This will likely damage the economy more, ultimately, if deaths are, as expected now, massive and as a result of system failure.

– there have been constant multiple repeated mistakes in communicating testing, isolation, travel and personal isolation requirements. Doctors have lost respect for this process. Sit reps are contradicted by media statements which are contradicted by politicians on TV. COVID clinics have been slow to deliver and suffered from lack of tests, which seems inexplicable given that other countries seem to run very successful large testing regimes. These are essential to trace and control cases and actually understand community spread.

– politicians have attacked doctors, patients and made patently wrong clinical claims prominently in the media.

Solutions

Command and control was rejected in modern clinical medical practice long ago.

Far better to be transparent now about all the facts, all the assumptions, involve working front line staff in a collaborative decision making process, and get the politicians out of the room. The decision makers should have professionally moderated online access in Whatsapp to every doctor, subdivided into appropriate groups to provide real feedback.
Then listen to the front line in an iterative way and adjust. Make the comms tight and two way. This is how the Hong Kong civil resistance organised itself from the ground up with no commanders.

Distribute resources and decision making direct to front line, and bypass the command line which is incredibly inefficient. Allow local innovators to use their incredible brains to work out problems central command has not even contemplated. They will then spread word as to what works online. They are doing this already but if unfettered in decision making, they could save many lives.

Doctors on the front line can contribute also by being respectful to the central command, and politicians, it is not their fault that they have a different culture at this time. It is a problem of structure not personal failing. Avoiding conflating the people with the problem. Displaying empathy, understanding and willingness to collaborate from both sides can take us forward together over the next few weeks. And hopefully save some lives.


11 comments

  1. Excellent summary of the situation. You have consolidated a number of thoughts and answered numerous questions I have had on the matter and this made for engaging understanding of the cultural dynamics that created this situation. One question: Why not start this whatsapp group / coordination effort if one does not exist already? Central command is not going to be authoritative when the surge starts. Why not provide a means for doctors to network and share what they know about C19 en-masse? Ultimately the decision about how to treat will lie in their hands and they are likely to bias frontline understanding and successes.

  2. Dr Miller
    I am a GP who is still working with minimal protective gear
    There is obvious fear in the patients eyes and I myself am fearful of patients who display cold symptoms
    The government is handing out more money to various sectors of the country
    However GPS are contractors and not entitled to paid sick leave or any other entitlements
    Can you please advocate for us
    I myself have a chronic lung condition and elderly parents and a 95 yo grandma
    I have to work to support my kids as there is no work from home options
    At the very least we need more protective gear and provisions made for us if we get sick
    Regards
    Dr Sonja Coetzee
    PS I like your take no prisoners attitude

  3. Thanks for a really excellent summary of the current situation and and a clear voice for the emerging divide of opinion that we’ve been seing.

  4. Interesting thoughts Andrew. You capture my sense of astonishment and frustration quite well. Sure feels like we’re getting bad advice. At the most basic level, it is irritating to hear mention of “the medical advice” as if that were monolithic, when it is clearly not. I think we have not been doing enough to stop this, and I have felt that way for a couple of weeks now.

  5. Thank you so much for simply and eloquently explaining the current concerns. As a GP I am used to receiving excellent communication from our public health unit. It is timely and honest, and in return we are their eyes and ears on the ground, included as a remote part of the team. Once this pandemic management switched to a centralised command centre model our avenues of information dried up, at a time when we desperately needed more information not less. When I have asked for more information and to be included in discussions I have been harshly silenced and told to do as I am told and trust someone else has it in hand. As GPs we don’t suddenly stop caring and contributing to our communities in an emergency. They turn to us for information. We want to help communicate the facts and the plans, but for us to do this we need to be included in the communication. I have certainty been guilty in these frustrating times of being disrespectful of our leaders. I recognise they have a difficult role, and I do not envy them that in the current time. I will attempt to practice the kindness and compassion for them that I ask others to show to us as we face this together.

  6. Thank you so much for simply and eloquently explaining the current concerns. As a GP I am used to receiving excellent communication from our public health unit. It is timely and honest, and in return we are their eyes and ears on the ground, included as a remote part of the team. Once this pandemic management switched to a centralised command centre model our avenues of information dried up, at a time when we desperately needed more information not less. When I have asked for more information and to be included in discussions I have been harshly silenced and told to do as I am told and trust someone else has it in hand. As GPs we don’t suddenly stop caring and contributing to our communities in an emergency. They turn to us for information. We want to help communicate the facts and the plans, but for us to do this we need to be included in the communication. I have certainty been guilty in these frustrating times of being disrespectful of our leaders. I recognise they have a difficult role, and I do not envy them that in the current time. I will attempt to practice the kindness and compassion for them that I ask others to show to us as we face this together.

  7. Great article. There’s a sense of safety from you explaining things clearly and openly, despite you not putting on a “we’ve got this under control” false bravado.

  8. Excellent piece. Thank you for the information. Please keep telling it like it is and thank you for your efforts so far.

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