The recently released Furiosa: A Mad Max Saga (2024), directed by George Miller, builds on the 2015 blockbuster Mad Max: Fury Road. Both films explore a post-nuclear desert world, where an underclass is beholden to an overlord who meters out water – now the most precious resource – in cruelly small quantities to assert his control. In Furiosa, the titular character leads a war against rival kingdoms of the Bullet Farm and Gas Town, each their own totalitarian dystopias populated by beleaguered proles.
If you’ve visited or worked in an Emergency Department recently, the same thought may have crossed your mind as it routinely does mine: ‘It’s like Mad Max in here’. Moreover, interactions with colleagues from different departments within the hospital might have felt like you were being forced to go to war with the registrar from Bullet Farm (orthopaedics) or Gas Town (gastroenterology). The constant back-and-forth drama of referring a patient for admission under a specialty service that feels like you’re trying to raise money from the Shark Tank investors for a new line of incontinence underwear, or selling your left kidney and half your spleen to radiology to please, please just do the bloody CT.
MRI? On a Saturday? You’d better be sacrificing a goat in the middle of a pentagram on a full moon.
It’s Mad Max in here.
In the last six months I’ve left the hospital system to pursue a career in primary care. While having its own challenges, the sense of tension in professional interactions has dropped remarkably and I no longer feel as if putting on my scrubs is akin to putting on war paint. The breathing space this has given me has afforded some reflection on the strained dynamics of workers in a hospital system and why conflict is so ubiquitous in our daily interactions.
Tribalism and medicine
Dr Victoria Brazil, an emergency physician and medical educator, distils the experience of ED-inpatient interactions with eye-watering accuracy.
In a keynote address at SMACC 2014, she discussed how a sense of tribalism is commonplace within medical specialties, effectively pitting department against department. This ‘us vs them’ attitude is borne out of the comradery we feel with our immediate colleagues being unified against a common enemy. The example she uses is of emergency doctors in conflict with an inpatient service such as vascular surgery. War stories, or titillating tales of heated exchanges with ‘the enemy’, abound in the tearoom, further perpetuating this comradery within our own silo. Of course, there are countless other examples within the hospital system. Obstetrics vs theatre coordinators fighting for an emergency C-section in the middle of the night, urology vs infectious diseases (‘give me meropenem’ vs ‘give me stent removal’), and psychiatry vs well, the rest of the hospital.
Brazil suggests a way of avoiding unnecessary conflict and improving not just the subjective experience of the clinician, but for future patients who may be the victim of delays in care caused by historically difficult dynamics, to include a re-thinking of the ‘I’m right’ point of view. By taking ego out of the equation and conceding that the ‘enemy’ may also be right, more constructive discussion, and - crucially - decisions, might take place. She also recommends basic pleasantries such as introducing yourself, being attentive to non-verbal cues such as posture, and conceptualising your tribe not just as that of your own department but of an entire organisation – one that strives for excellence through collaboration.
I fundamentally agree with all of Brazil’s solutions however I think there is one important factor that has not been addressed which I suggest drives everyday conflict even more than simple cultural indoctrination.
The elephant (not) in the room
Much like the crumbling society in Mad Max, I believe the root of nearly all the conflict can be traced back to resource scarcity. There are few other areas in society where this is more evident than in healthcare, and more specifically within the confines of the hospital system. Waiting lists for surgeries that blow out for years, limited numbers of diagnostic services such as CT, MRI and ultrasound, an ever-dwindling number of inpatient beds despite exploding populations, and finally scarcity of the most precious resource of all: personnel.
Think back to the last argument you had with another clinician or member of hospital staff. Think back to the last time you asked for something for your patient but were rejected. I would propose that the vast majority of the time, the reason was not because it was not clinically indicated – but rather that there was an extreme scarcity of it. In many cases this scarcity includes clinical reviews by doctors that are too busy and laden with competing demands to be able to attend to the patient you believe deserves their expertise. Similarly, the reason your scan request has been rejected is not because they don’t need it: it’s because the supply simply isn’t there.
I suggest that a lot of institutions cloak these resource scarcities under the guise of a special kind of distributive justice: a trap we must not let ourselves fall into. The solution to an inadequate radiology department is for the requesting doctor to simply employ ‘better clinical judgement’. The solution to a rejected inpatient consult from a specialty team, is for the referring team to just get better at their jobs. In the hospital’s eyes, we must concentrate our hardest to decide who of our sick and needy really deserves help the most. The stress of this decision-making compounded with defence mechanisms employed by the clinician (‘I’m saying this because I’m right and you’re wrong’ instead of ‘Honestly, you’re right but there’s no room at the inn – even the barn’s full) causes a culture of inter-departmental conflict as we scrabble over the last drops of water hitting the sand at the bottom of the Citadel.
I once worked in a hospital where a radiologist had to be called for permission to request every single CT. We all knew it was because there was only one scanner, in a place that served a population of nearly a quarter of a million people. Radiology registrars were trained to be a ‘wall’ to the heaving masses needing their services. If we ‘really’ wanted something, the intern would be sent to grovel to one of them in person. A senior would arm them with an arsenal of compelling rebuttals if refused: like strapping a pistol and a grenade to an infantry soldier about to jump out of the trenches. The intern was made to feel lesser and inadequate by the rejecting service, made to think their clinical acumen was lacking when really this was a diversion of blame to frontline workers in an environment with lack of access to timely resources.
The very real shortage of material and personal resources becomes less noticeable however, when the habitual resentment of ‘the other’ takes hold and teams learn to interact with other teams not in a collaborative manner, but in a confrontational way. Such behaviour is learnt because every interaction has necessarily become an instance in which the clinician must advocate their hardest for their patient, like a defence lawyer picking holes in the prosecution’s witness.
The hospital’s obsession with attempted efficiency dividends and cost-cutting ignores the reality that the hospital is under more demand than ever, with a burgeoning ageing population – and one that is suffering worsening economic and health inequality. How can we really say that we don’t need more ENT registrars accepted onto training, and more ENT consultants in more theatres, when the average waiting time for a near-deaf child to get their grommets is well over a year?
In Victoria, how can we now be talking about tightening up hospital budgets and potentially pausing elective surgeries, breast screening and closing ward beds when ambulances remain ramped for unconscionable amounts of time outside our major centres.
When we argue passionately amongst ourselves about whether 89 year-old Doris who’s had her third fall in 2 weeks should come in to hospital, we seem to have forgotten – as if taken by some collective amnesia – that this is really what it is all about: well-meaning individuals swept up in a system of austerity which with every minute or dollar spent on one patient, means another patient misses out entirely. One need only look at how federal and state governments allocate budgets to see where the efficiency dividends really should be being made.
Is it any wonder that Mad Max director George Miller was once a doctor, before he joined the film industry?
That video is very good. As an evil inpatient registrar myself, I wonder whether personnel issues could explain the “race to the bottom” that has steadily degraded the quality of ED referrals and their management. Perhaps they’re not cutting corners because of laziness or incompetence after all!
As a former ED nurse who left for all of the very reasons that you've spieled with such air-punching precision, I feel all of your sentiments with every fibre of my being. As a wise man once said -
"...can't we all just get along?" - Jerry Springer