John Wright, "Putting a surgeon under: a personal story of hospital politics"
Brian Martin, Background to publishing of "Putting a surgeon under": responses of individuals to a draft of John Wright's article.
This article is located on the
Suppression of dissent website
in the section on Documents
JOHN SAXON WRIGHT is a blunt, uncompromising man. A traditionalist, he believes that once a patient is referred to a surgeon's care, the surgeon should be responsible for that patient until the care is complete. In the operating theatre he believed his power was like that exercised by the captain of a ship. He gave the orders; the others were there to contribute their talents but, when necessary, obey the surgeon.
During the 1970s and 1980s this belief increasingly ran contrary to a new theory -- that the high-tech world of modern surgery and the development of new drugs had given anaesthetists an extended and more interesting role. No longer were they there only to administer the anaesthetic; they now claimed a commanding role in the management of the patient in the post-operative period, in "intensive care".
Not only did this give them extra power and prestige but additional money. In the schedule of fees, a surgeon had been obliged to include a sum for post-operative care, but many now tacitly handed over this right to the anaesthetists. Today some anaesthetists prefer to concentrate on post-operative and other intensive care. In the United States, this extended role for anaesthetists has become formalised. There, anaesthetists obtain an extra qualification in intensive care, call themselves "intensivists" and specialise in this area. This has not met with general approval among surgeons. In a recent American College of Surgeons Bulletin a professor of surgery from the Harvard Medical School urged his colleagues to take the extra qualification themselves. "Now is the time to resume responsibility and recapture our proper leadership role," he wrote.
Wright, too, objected to anaesthetists taking over a major role in the post-operative period. He did not want control to go to anaesthetists automatically, but only with the surgeon's authority and liaison. As he says, "I feared that without someone in ultimate control, the care of the patient would deteriorate to being management by a committee of several experts."
In 1983, Wright brought to a head his long-standing conflict with the anaesthetists at the Prince Henry hospital in Sydney. Wright, head of the children's heart surgery department wrote to one Prince Henry anaesthetist saying, he recalls, that "although I respected his professionalism we had such different ideas about how we should do things that it would be best for patients if we did not work together any more."
Previously Wright had clashed with Sir Harold Dickinson, chairman of the hospital board, by complaining to the administration that facilities for the treatment of children at Prince Henry hospital were "sub-standard". Wright wrote: "I find a decision to deliberately perpetuate inferior standards quite unacceptable." Dickinson replied that he found Wright's characterisation not only wrong but needlessly offensive. "While this remains your attitude the appropriate course would be for you to resign."
Dickinson now instructed the late John Delaney, the hospital's chief executive officer, to interview Wright. According to Wright, Delaney told him that he had been making trouble and that he should withdraw the letter about the anaesthetists. Wright refused. According to Wright, the head of surgery, Professor G. F. Murnaghan, said that the anaesthetists' version was that Wright was incompetent and that this was the source of the trouble. Since Wright was not willing to withdraw the letter, Wright was told he should go on leave for six weeks -- or be stood down -- while an inquiry was conducted. At the end of the six weeks Wright went back to work with an order from the hospital that he should avoid surgical cases that could cause friction with the anaesthetists. In fact, Wright continued to operate on the most complex cases. But Wright says a colleague told him privately: "The anaesthetists haven't forgotten." This prediction proved correct when, two years later, in mid-1985, unknown to Wright, the director of theatres, Dr George Davidson, told the chairman of the department of paediatric surgery, assistant professor A. C. Bowring, that members of his staff were no longer prepared to give anaesthetics for Wright's operations. There remains some mystery over what happened to this complaint. In any event, in November of that year Wright was formally appointed director of the new department of children's heartsurgery at the Prince of Wales.
Wright was delighted with the appointment. He had advocated for some time that the only proper location for children's surgery was in the hospital that housed them, the Prince of Wales, and that therefore it should be moved from Prince Henry. What Wright did not known was that the anaesthetists and others had opposed such a department in the Prince of Wales on the grounds that it would put an excessive strain on resources and would draw off money, staff and equipment from other departments. At Prince Henry there was concern that such a move might further weaken the status of Prince Henry and compromise a fight which had been going on for two decades -- and is still going on -- to preserve this hospital. On the other hand, a new department might well be an advantage for the Prince of Wales at a time when it was under threat of being moved to cater for the growing population needs of Sydney's western suburbs.
"Unaware of this, I spent a month on top of the world," Wright says. "Then a feeling of insecurity set in. On the orders of the head of paediatrics, John Beveridge, others took over the pre- and post-operative treatment of patients, which was against all my practice and beliefs." Wright also considered that the department had deficiencies which worried him. He told the hospital executives that some assistants, anaesthetists and intensive-care workers did not have as much experience as he would like.
"There was no response to those complaints," Wright says, "so on 27 June,1986, I went to the hospital's chief executive officer, W. G. Lawrence, and told him that my view was that some inexperienced senior and junior staff were making crucial decisions about patients without reference to me. I said that unless this situation was reviewed, the new department should shut down." Lawrence had replied that Beveridge, then a close personal and professional friend of Wright, had it all in hand. On July 10, according to Wright, Beveridge came into Wright's office and told him that two anaesthetists did not want to work with him any more.
Within hours Wright was suspended from operating. Five months later he was sacked. He was 57 and retirement would not have been unusual for a medico in his high-pressure and physically-demanding job. But Wright felt that important principles were involved. For example, the hospital had not told him what the accusations against were or who had made them or given him an opportunity to respond. So he decided to fight.
When it came to a choice between one senior surgeon -- no matter how long his service -- and the whole of the department of anaesthetics, the administration chose to sacrifice Wright, according to a later judgment delivered in his case. The question was: how best to do it? It seems that the hospital at first decided to question Wright's competence. But when Wright went to the Supreme Court in August 1986 to challenge his initial suspension, the hospital was ordered to provide the doctor with details of allegations and complaints against him. Then the hospital, perhaps realising the difficulty of winning on the issue of Wright's incompetence, changed its approach and on legal advice decided to fight on its right to dismiss any employee with or without a reason. If pressed for a reason, it could simply cite the fact that some anaesthetists did not want to work with Wright.
This is, in fact, what the Supreme Court agreed with when in June 1987, in his second court action, Wright sought unsuccessfully to compel the hospital to give him back his job. The judge, Mr Justice Bryson, said his decision that Wright could not demand reinstatement was not a reflection on Wright's ability. "A decision to cease to employ a surgeon in work which retains some of the character of experiment and adventure passes no judgment on his general competence," he said.
But by then the damage had been well and truly done. During the first Supreme Court hearing, when the hospital was still using the tactic of questioning Wright's competence, its lawyer, Peter King, said on instructions that the hospital had suspended Wright out of concern for patients' lives. This accusation was widely reported.
But all the hospital provided in court by way of proof of Wright's incompetence were statistics that suggested the mortality rate in certain operations Wright had performed exceeded the average. King said of four operations Wright had performed involving aortic valve procedures, two had resulted in death, whereas the mortality rate for this operation was normally less than 10 per cent.
At that stage the hospital had still not held a formal inquiry into Wright's competence. It now moved to do so. In November of 1986 it co-opted an expert surgeon, nominated by the Royal Australasian College of Surgeons, to assist an inquiry by the non-expert laymen of the hospital's medical practices committee. This was Roger Mee, director of the paediatric cardiac surgical unit at the Royal Children's Hospital, Melbourne.
Dr Mee attended hearings of the medical practices committee and made his report in December. He came down in favour of Wright and was highly critical of the hospital's case. He said:
Dr Mee concluded: "I believe that Professor Wright was working under less than ideal conditions, that it is quite inappropriate to expect the same results from this unit as may be achieved in a much larger unit such as the Mayo Clinic, Toronto Children's Hospital, Boston Children's Hospital, or my own unit." He said he had been able to support the contention that there was a lack of confidence in Wright's competence only because he had heard this opinion expressed at the committee hearings. "But from the data examined I am unable to determine ... whether or not Professor Wright is solely responsible for the lack of confidence" (emphasis by Mee).
But the hospital board meeting at 8am on December 19, 1986, decided to turn Wright's suspension into a sacking yet not to pursue the competence issue. The medical practices committee did not make any finding on Wright's surgical competence and the hospital has not referred to it again, in court or elsewhere.
Wright himself had to take legal action to get a copy of Mee's report, only to find that it could not be admitted as evidence in his court case because the hospital had asked for the report only after deciding to dismiss him on grounds of lack of confidence. Wright was thus unable to undo the damage caused to him by the hospital's earlier allegations of incompetence. To this day Mee's report is not mentioned in the NSW health department's dossier on the Wright case and all his attempts to persuade the department to add the report to its files have failed.
The significance of the hospital's new tactic -- to fight Wright's application for re-instatement on the right of the hospital to hire and fire whom it liked -- remains generally unappreciated. In its finding, the Supreme Court ruled that a hospital doctor, no matter how eminent, was, in effect, just another employee. His contract of employment could be "terminated by either party on reasonable notice, without stating or without there being any reasonable ground."
Wright was beaten. No-one of his seniority had ever been dismissed in such a manner.
He began to pick up the pieces of his life. Many of his friends and colleagues who had read the reports of the affair found it embarrassing to meet him and, with few exceptions, fell away. Wright said: "The general feeling was that while there was smoke there must be fire."
Now Wright is back in Macquarie Street with a new and successful career as a medico-legal consultant, but the scars remain. "My reputation has been vandalised. It is ironic that after I had gone, the hospital acted quickly to correct every single component of the list I compiled, and Dr Mee compiled, of what was wrong."
Two requests for the hospital's views on the Wright case -- one by letter and one by telephone -- were not answered.
I read with interest Phillip Knightley's article on the dismissal of Professor John Wright (IM June) from Prince of Wales Children's Hospital. The allegations by the hospital's barrister in a Supreme Court hearing that "mortality rates in certain operations Wright had performed exceeded the average" was of particular interest to me in the light of the following experience.
Seven years ago, returning from a holiday in Fiji, I sat next to and befriended a Fijian woman and her one-year-old daughter, flying to Sydney for urgent cardiac surgery for her baby. The child was desperately ill, and had been referred to a cardiac surgeon. The child spent several weeks in hospital for appropriate investigations. The surgeon decided not to operate on her as she was too ill. Arrangements were made by the hospital to send her back to her village in Fiji -- surely to die!
I knew Professor Wright socially and begged him to review the child's condition, and if possible give her a chance to live. This he agreed to do, explaining to the mother there was a less than 50 per cent chance of success.
Today that child is a wonderful healthy little girl of eight, doing well at school and even participating in school sports. Professor Wright saw the chance of a future for this poor child as more important than his mortality rate.
It would appear to me that Professor Wright is a victim of personalities and politics.
In reply to Phillip Knightley's article, The Doctor is Out (IM June), I would like to express my shock that such a dedicated surgeon as Professor Wright could have his career ended in such a way.
My own association with Professor Wright began 11 years ago when he operated on my son at the age of seven months. This association continued as my son's cardiac problems were an ongoing concern.
[Professor Wright was sacked without any reason being offered to a court. The hospital (Prince Henry and Prince of Wales are jointly administered) relied on its legal right to terminate a surgeon without giving a reason.]
My son's surgery was carried out at Prince Henry Hospital and he was receiving outpatient treatment through the Prince of Wales Hospital until the time of Wright's dismissal.
At Prince Henry Hospital the sub-standard conditions of which Professor Wright complained did exist. The ward in which these children were housed was dark, damp and airless. No consideration had been given to providing for the needs of these children, physically or emotionally or educationally -- a consideration you would expect in light of the amount of knowledge available in the area of early childhood development.
Pre and post-operation patients were transported to theatre via open roadways in all types of weather. There was no intensive care unit at Prince Henry for these children.
After surgery the children would be taken to an intensive recovery area; however, they could not remain there for long periods as there were not sufficient beds, staff or equipment to allow surgery on other patients to proceed. Very sick children would be transported to Prince of Wales Hospital; others would go back to the general ward. There was no specialty staff in these wards and very little equipment to assist in the treatment and monitoring of these children.
There were always chronic staff shortages. It was not uncommon on some shifts to have only two nursing staff attempting to care for 28 heart babies. Staff were dedicated and did the best they could under the circumstances. They often cried tears of frustration at not being able to provide properly for the children in their care.
Complaints were made but there were never any changes. Parents and staff eventually gave up, such are the emotional drains which accompany such action. Professor Wright, however, did not. Along with Wright we were elated when we learnt that after a fight which stretched over several years our child would be able to share in the benefits of a hospital (Prince of Wales) which was designed to cater for the needs of small children. We assumed that when our son's medical condition required further surgery he would return to the Prince of Wales Hospital. Professor Wright, however, was dismissed before this eventuated so my son's recent surgery was carried out elsewhere.
We did, however, from previous visits to Prince of Wales experience problems mentioned in Knightley's article. On several occasions we were forced as parents to make complicated medical decisions which we did not have the knowledge to make. The experts could never agree on the treatment they thought my son should receive. Eventually, in an attempt to retain some sanity, we chose to have only Professor Wright treat our son.
Our son is a happy, contented child who bears no emotional signs of the ordeal he has undergone. I attribute this to the emotional support which Professor Wright has offered to our family, and to his expert medical care.
Over the years we have met many families who share the same admiration and gratitude for Professor Wright as we do. His sacking is a sad loss to these children and to many children who now will never be given the chance that our children have been given.