Accountability, blame and medical error after Bawa-Garba

 

The reaction to the Dr Bawa-Garba case has shown that the medical community finds it hard to accept that individuals can be held personally accountable for underperformance (once we exclude malice, drunkenness or other gross examples). Rather, deficiencies in the healthcare system surrounding the individual should be identified and corrected. Don Berwick was very clear in his report ‘A promise to learn – a commitment to act: Improving the Safety of Patients in England’,

 

NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.

 

Anyone involved in investigating patient safety incidents will recognise that preceding each one there is usually a system-based issue to be found. For instance; under-staffing/surges in demand, confusing protocols, similarly packaged drugs, or allowance of distraction. At the extreme of de-individualisation – if that is even a word – the system can also be held responsible for placing an underperforming or inexperienced doctor in front of patients in the first place. It can also be blamed for failing to identify and support an individual when they enter a situation that allows their deficiency in knowledge, pattern recognition, or prioritisation to manifest as harm. Etc., etc., ad absurdum. So, does personal accountability for under-performance (in good faith) exist at all?

 

Smoking gun

It is well established in the patient safety literature, and in the modern philosophy of healthcare, that personal accountability, AKA ‘blame’, inhibits system-wide improvement in safety. Fear of blame dissuades healthcare staff from reporting errors, thus allowing the same mistake to be made again in the future. Fear exists: the Kirkup review into failings in Liverpool Community Health NHS Trust describes how those involved in clinical incidents were brought in for questioning:

 

‘In practice they were “an interrogation and a frightening experience”. Staff reported feeling physically sick beforehand and approached them with trepidation. Across the organisation shouting and finger-pointing became the norm.’ (Richard Vise, Guardian)

 

An article by Bell et al in the journal Chest, describes how a missed lung cancer diagnosis can be attributed to multiple failures in the system, but the ‘smoking gun’ is to be found in the hand of the pulmonologist who last had contact with the patient. A classic case. The authors conclude that the pulmonologist, who did carry some responsibility, is absolved by his or her active engagement in fixing the system such that the same error cannot happen twice. This is a message we all must take away; our accountability lies in the duty to work constantly on improving the safety of our systems for patients yet to enter our hospitals – through audit, reporting, and being open.

Speaking at the Global Patient Safety Summit in 20016, The Secretary of State for Health Jeremy Hunt aligned himself closely to this philosophy :

‘…to blame failures in care on doctors and nurses trying to do their best is to miss the point that bad mistakes can be made by good people. What is often overlooked is proper study of the environment and systems in which mistakes happen and to understand what went wrong and encouragement to spread any lessons learned. Accountability to future patients as well as to the person sitting in front of you.’

Yet Dr Bawa-Garba’s fate has shown that despite all these words and aspirations, personal accountability for particularly poor performance still exists. Is this justified?

 

Individual accountability within a Just Culture

Philip Boysen, an American anaesthiologist, wrote about how to develop a ‘just culture’ in healthcare, drawing from various industries and organisations, some historical. He acknowledged that blame may still have a role within a just culture;

‘While encouraging personnel to report mistakes, identify the potential for error, and even stop work in acute situations, a just culture cannot be a blame-free enterprise.’

Boysen refers to a paper ‘The path to safe and reliable healthcare’ by Leonard and Frankel, which presents a spectrum of behaviours associated with safety incidents, including ‘reckless’, ‘risky’ and purely ‘unintentional’ error. These result in ‘discipline’, participation in teaching others, ‘retraining’ or at the very least involvement in the investigation.

The UK’s Sign up to Safety campaign, which promotes difficult but necessary conversations as a way of exploring safety issues, breaks down personal accountability along just these lines:

The Boysen paper also refers to an (older) NHS algorithm that poses a ‘substitution’ test after medical error; ‘Would another provider put in the same circumstances in the same systems environment make the same error?’

These are all efforts to unpick and define the place of personal accountability. It seems clear that it does exist, but that censure or ‘discipline’ should come late, and only if you make a mistake while not adhering to policies, or worse, are reckless.

 

What is safe anyway? 

How do we define a safe environment? Addressing factors that permit greater potential for error, such as poor staffing, fatigue and IT functionality are clearly vital, but we are not agreed, yet, on what ‘safe’ looks like. Staffing ratios are a start, but do not necessarily take into account fluctuations in demand, or the effect that one highly complex patient might have on a service. However safe we make the environment, however rigorously we modify the ergonomics to take into account the variables arising from human factors, patients still rely on individual doctors to make the right decisions at the right time. The environment will not protect patients from mis-diagnosis or knowledge gaps; or, in the case of Dr Bawa-Garba, what has been called by some, ‘cognitive failure’.

In recent weeks many NHS workers have been reassured by their trusts that unsafe environments should be called out, and that they are encouraged to speak up. The GMC published a flow chart to help people decide how to raise concerns. Yet we all know that in the immediate term, on a Saturday night when you are two colleagues down because the planned locum fell through and the ward F2 has rung in with the ‘flu, that extra resources are unlikely to arrive. How do we apportion individual accountability here? Is it true that whatever happens on this night, the doctors should not be blamed? Will their errors, should they make them, and however odd they might appear from the outside, be overlooked because they were too pressed? Does personal accountability for under-performance completely evaporate in sub-optimal conditions?

 

Intrinsic accountability: the map of experience

Although the backlash against Bawa Garba’s (clearly excessive in most peoples’ minds) Gross Negligence Manslaughter judgment has suggested that there is no place for blame when things go wrong in substandard systems, we should remember that even in well-provided Trusts with working computers, risk lurks, ready to strike, and those of us who are standing by when it does so will be asked to explain what happened. Being asked to explain feels like blame. That is because we, as doctors, naturally feel responsible. That is our baseline moral state: responsible, slightly fearful (especially in the early years), anxious to make the correct decision. We feel guilty when things turn out badly. We generate our own sense of accountability, and subsequently we may experience weeks of self-examination. Sometimes, we need to be reassured by older hands that it is not our fault. Otherwise we will burn out in the slow flame of self-doubt and fearfulness.

 

As I have observed before, there is a place for this sense of blame. It sharpens the senses and opens the psyche to deeper lessons. The mistakes for which we accept a degree of responsibility leave indelible marks, which over a career coalesce to form a map of hard-won experience, the better to help us navigate the tricky situations to come. A well-known consultant in my field said, on a training day, ‘An expert is someone who has made every silly mistake possible.’; yes, but none of them twice. The same probably goes for Dr Peter Wilmshurt, a cardiologist and well-known whistle-blower who has referred himself to the GMC for a career of errors. This act makes the point; medical careers teem with error. We become good through error. But if we blame our errors wholly on the systems around us, we will not lay down the ink that makes that map. It may be an unpopular view, but I think part of being a doctor is learning how to receive those stinging tattoos.

 

Explore more books on my author page here

Advertisements

Justice and safety: a dialogue on the case of Dr Bawa-Garba

 

Everyone must have a view. Thousands have expressed theirs. Many have committed to funding an independent legal review. None were there. None heard what the jury heard. Most have read the essentials of the case, and we are worried that if we commit a serious clinical error, we may be ‘hounded’, ‘scapegoated’ or ‘persecuted’, first by the criminal justice system, and then by the GMC. But the GMC says this was no ordinary error. The court found her performance to be ‘truly exceptionally bad’. Yet the system in which she worked was limping, and unable to provide the support a doctor should expect. What would have been a proportionate punishment, if indeed punishment was required?

I present a dialogue between two doctors of differing views. This allows me to present both sides of the case, and also to explore my own ambivalence behind a creative framework. Because my response to this sad case is not straightforward, and it is still consuming my thoughts.

If you are unfamiliar with the case, it will help to read this BMJ article. Also useful is the MPTS (Medical Practitioners Tribunal Service) report, and the transcript of the recent High Court judgment.

Dr A, you will soon realise, is hawkish and unsympathetic to her plight.

 

*

 

Dr A. You know, my first reaction when reading about the errors made that night was – What? Lactate 11, pH 7.0, that’s clearly a sign of extreme physiolgical stress, actually of imminent dying… there can have been no sicker patient in the hospital… how could a doctor go off and do something else for several hours before checking up on the child?

Dr B. At the start she treated the child correctly, that has been accepted. But she had no choice but to ‘go off’. She was running the entire service, carrying the crash bleep, and struggling against a failed IT system. If she’d stayed with one child the other patients would have been neglected.

Dr A. It was busy. We’ve all been there. So when the pressure is on you have to prioritise, and if that results in two equally deserving cases needing simultaneous attention, and you can’t give that attention, you escalate.

Dr B. To the consultant you mean?

Dr A. Yes. He was there, there was a meeting in the afternoon. The blood gas results were read out. He could have been asked to help.

Dr B. But he didn’t offer to see the patient, did he, despite having heard the result?

Dr A. So what? A registrar of that seniority would be expected to ask, and assert themselves if they didn’t get the answer they needed. No consultant would refuse.

Dr B. We don’t know what was said. What does your consultant do – offer proactively to see anyone who sounds sick, or wait to be directed by you?

Dr A. A mixture, it depends who it is, keen, passive… they vary.

Dr B. But you insist she was the prime coordinator, the clinical leader in that situation, the one who should have coped. It was all on her?

Dr A. She was the one with the first-hand knowledge of the patient. So yes. I am critical. The enalapril – again, it sounds like a lack of asserting her impression on the plan, i.e. she should have said, don’t give that drug, whatever happens. And the DNACPR error, that seems to belie a mind sinking in the tide of events…

Dr B. So you accept that events, the environment, the circumstances, were also a factor.

Dr A. Yes, of course. We all work in similar circumstances, we always have done. And we cope, or recognise that we are sinking and ask for help.

Dr B. You really are a hawk on this. Do you feel sorry for her?

Dr A. Yes, but this is beyond emotion. This is about safety. And, based on what I have read, there was justification in the gross negligence manslaughter judgement. Moreover, I don’t see how the GMC had any choice but to press the point by overturning the MPTS who, the High Court judge feels, over-reached themselves in downgrading her culpability. You can’t have doctors guilty of gross negligence running acute paediatric services… surely. The GMC are, if you like, accommodating a decision made by a higher power in the land, a jury. It doesn’t matter if a tribunal panel feels it was over-harsh, given the extenuating circumstances, to take away her career and livelihood forever. The GMC have to cut the regulatory cloth to fit the ‘criminal’ form, i.e. strike her off.

Dr B. But the MPTS saw evidence of remediation. She was employed for two years after the incident, seeing children every single day. Clearly, she was not unsafe. She had learned, improved. Isn’t our training all about learning from the mistakes we have made to become better doctors?

Dr A. There is a limit. And by year 6 of specialty training, most of the basic lessons should have been learned. Look at it through the prism of public confidence, which I suppose is what the GMC must do. If she goes back to work, even under supervision, will a parent be told that the doctor on call who is coming to see their child was, in the last few years, found guilty of gross negligence? Wouldn’t you want to know, if it was your child? Or do you have sufficient faith that remediation, and training, are good enough to ensure that those traits that led to a guilty verdict have been abolished for good? The high court said it couldn’t be sure that she wouldn’t suffer another ‘collapse’ in performance one day. I agree. It happened once…

Dr B. But look at any hospital. There is a spectrum of competence. There has to be, because there is human variability. And I do not expect to be made aware of the competence level of each doctor I see. I must have faith, in the training system, in the deaneries and in the Trusts – actually, in the GMC, that each of them is safe. If the MPTS felt that she was safe, and had remediated, why not believe them? Why look simplistically at the jury’s verdict and use that as a permanent, inerasable, measure of performance, one that was made without some pertinent facts.

Dr A. So you wish to re-try the case, in your own head. You would overturn the jury’s decision?

Dr B. Yes. I believe it was unjust.

Dr A. You know better?

Dr B. Perhaps.

Dr A. Naïve. That is not how justice works in this country. The jury has the final word. I’m sorry. You can’t second guess it.

Dr B. Juries have been wrong.

Dr A. Yes, when miscarriages of justice have occurred. But that is not the case here. The High Court examined the question of what the jury were told, and found no problem with it. There has been no miscarriage of justice. No-one is saying that.

Dr B. Yet… it is unjust.

Dr A. Once the ball of justice began to roll, once it became a police matter, there was no going back.

Dr B. So perhaps the thing that should have been done differently would be for her not to have been arrested and tried. Perhaps the very concept of gross negligence manslaughter is wrong. Where there is no will to cause harm, only failure to do well (whatever the circumstances), perhaps we should not involve the courts.

Dr A. But a child died, possibly needlessly, definitely earlier than he should have. How can that not arrive at the door of Justice?

Dr B. Avoidable deaths are all around us. We see them, we discuss them, we learn from them, every week and month. Avoidable deaths are grist of the mill of patient safety. I saw an estimate that there are 9000 per year attributable to poor care in hospitals. We must accept that avoidable deaths will occur, not pounce on them and send each to Law. This is the problem, don’t you see? This is the harm. By raising the fear of recrimination and sanction in the minds of doctors, those weaknesses in our systems, all those near-misses or harms that could signal a fatal accident to come, will go unexamined. Who, having been involved in a clinical incident that caused any meaningful harm, or even death, will now put up their hands to attract attention and bring on a good investigation? Fewer, now. Because if the patient or the family decide to pursue the individual, and by degrees the incident moves into the view of the Crown Prosecution Service, then they could end up losing everything. That is the harm here. The future of patient safety.

Dr A. You ask too much of the GMC and the courts. I would rather base decisions on the definite past than the possible future. It happened. The worst thing that can happen to a patient, neglect, incompetence, happened. On that day she was ‘truly, exceptionally bad’ – did you read the judgement? There are very few people who disagree with that assessment. The MPTS also accepted that there was gross underperformance, as far as I understand. A boy died, despite having signs and clinical features that anyone, paediatrician or not, would have recognised as deserving of the closest attention, and escalation, and absolute prioritisation. There is more to this than her career, and her ability to improve. There is a wrong, of such magnitude that time cannot just be allowed to roll on, allowing her to resume her career.

Dr B. I am surprised. You really have no sympathy, no sense of professional camaraderie?

Dr A. It’s irrelevant. And dangerous. Camaraderie is also called ‘closing ranks’. Just because we belong to the same professional group does not mean that I should automatically support her in this. I know there are bad doctors out there, I’ve worked with them. A line has to be drawn. Look… her qualities have been examined to the utmost, by intelligent people from all walks of life, and mitigating circumstances have been examined, and despite this, her fitness to be a doctor has been found lacking in the High Court. What more can you ask for?

Dr B. Perhaps, one day, you also will find yourself sinking in events, off your A-game, unable to make good decisions, unsupported by a passive consultant… wouldn’t you expect sympathy from your colleagues?

Dr A. I would expect a fair process.

Dr B. And you think the process has been fair here?

Dr A. Harsh, yes… but fair.

 

*

 

Note: today (30.1.18) the GMC has undertaken to examine the role of Gross Negligence Manslaughter cases, ‘ in situations where the risk of death is a constant and in the context of systemic pressure. That work will include a renewed focus on reflection and provision of support for doctors in raising concerns’.

 

 

A few excerpts:

 

The MPTS, quoting a previous tribunal in which a doctor found guilty of gross negligence manslaughter was NOT struck off – “The Committee was rightly concerned with public confidence in the profession and its procedures for dealing with doctors who lapse from professional standards. But this should not be carried to the extent of feeling it necessary to sacrifice the career of an otherwise competent and useful doctor who presents no danger to the public in order to satisfy a demand for blame and punishment.”

MR JUSTICE OUSELEY, in the high court –However […] the Tribunal (MPTS) did not respect the verdict of the jury as it should have. In fact, it reached its own and less severe view of the degree of Dr. Bawa-Garba’s personal culpability. It did so as a result of considering the systemic failings or failings of others and personal mitigation which had already been considered by the jury; and then came to its own, albeit unstated, view that she was less culpable than the verdict of the jury established.’

MR JUSTICE OUSELEY, on systemic failings that were not shown to the jury in the original GNM hearing – ‘There were two “systemic” failings not explored at trial which Mr Hare acknowledged, but we accept his submission that Dr. Bawa-Garba was convicted notwithstanding the difficulties to which they gave rise, and that they could not have affected the verdict.’

MR JUSTICE OUSELEY – ‘Dr. Bawa-Garba, before and after the tragic events, was a competent, above average doctor. The day brought its unexpected workload, and strains and stresses caused by IT failings, consultant absences and her return from maternity leave. But there was no suggestion that her training in diagnosis of sepsis, or in testing potential diagnoses had been deficient, or that she was unaware of her obligations to assess for herself shortcomings or rustiness in her skills, and to seek assistance. There was no suggestion, unwelcome and stressful though the failings around her were, and with the workload she had that this was something she had not been trained to cope with or was something wholly out of the ordinary for a Year 6 trainee, not far off consultancy, to have to cope with, without making such serious errors. It was her failings which were truly exceptionally bad.’

LORD JUSTICE GROSS (sitting with Ousely in the High Court) – ‘Like Ouseley J, I reach this conclusion with sadness but no real hesitation.’

Junior / Senior

 

Trainee doctors tend to know more about patients than their consultants, though consultants, by virtue of experience, usually know better how to treat them.  Sometimes however, a peripherally involved consultant will parachute in and give an august opinion, but without adequate knowledge of the person or the problem. For instance, in my field, the insertion of a feeding tube to bypass a blockage in the gut, when a few more questions on the ward round would have revealed that the patient had three similar tubes in the past, each of which was pulled out due to intolerance or discomfort. The plan is sound, but will not work for the patient in question.

Consultants grow increasingly didactic over time, a characteristic deserving of its own article. The daily process of absorbing information and providing timely, confidently articulated answers, can lead to decisions based on pattern recognition, and without sufficient focus being paid to all the variables. As a trainee, the challenge is to receive such answers, but to adapt them to the specifics of the patient. Taking the consultant’s opinion at face value, and acting on it straight away, may not be the best thing to do.

When I was a fairly experienced trainee (medical registrar), my strategies for ‘pausing’ before converting instructions into action, included:

 

The deflection – ‘That is one option… but I was reading the other day about ______ procedure… do you think that might be better in this situation?’

The prevarication – ‘Right, yes… shall we see how they do on the current treatment, and review again in three days?’

The bureaucratic delay – ‘…there’s an MDT next Thursday, shall we discuss it then…’

The memory slip (high risk, AKA disobedience) – ‘Sorry, we didn’t get around to requesting that scan… do you think they still need it…’

The second opinion – ‘Dr _____ came around, and said she’d seen this before, and we should do x, y and z… is that alright?’

The direct challenge (for senior-senior trainees only) – ‘Actually I’m not sure that would work for this patient, given her underlying x, y and z…’, or, ‘I don’t think he would want that, his wife was saying just the other day that he’s decided not to…’

 

In fact, all of these are high risk approaches, because when the consultant returns two or three days later and the task has not been pursued, and assuming they remember what they asked for, there could be hell to pay. They are also high risk because they are based on the assumption that the trainee knows best. This is unlikely. But it gets to the essence of the (senior) trainee’s role, that of a coordinator of care, a hub into which results and opinions flow, to be assessed in the light of day-to-day changes that they are best placed to observe. It is not arrogance to presume to challenge a consultant’s opinion, but a necessary part of maturing as a doctor. Don’t accept anything without a critical appraisal of its value. Don’t assume an opinion is right unless it makes sense within the scheme of things. This position is a precarious one, as over-confidence or lack of skill in communication can make you look disrespectful.

So much for trainees. What about consultants? Overnight, you transform from ‘junior’ to ‘boss’. During the early post-transition period you may remain sensitive to the nuances of each patient’s illness. But over time, as you are pulled away from the details and learn to trust your team to micro-manage the bloods and the drugs, the day may come when you formulate and describe a great plan, only for the most senior trainee to pause, look at you quizzically, and say, ‘Yes… that is one option…’

 

Click image to explore, or go to my Amazon author page

In too deep: privacy on the wards

Ward patients sometimes comment on, or complain about, the fact that they can hear conversations between doctors and other patients through the curtains. When you’re having a conversation with a patient, you may as well imagine that the room is entirely open plan; curtains provide a visual barrier, but are more of a symbol of privacy, like the sheets hung in overcrowded homes of centuries past. Imagining the bay as a small hall with six or eight beds arranged in it makes you think twice about having any conversations at all, yet to conduct every sensitive conversation in a private room would be impractical. David Oliver touched in this in a BMJ piece last year. Patients would need to be wheeled their beds, or helped into wheelchairs and taken around the corner into a private space, with or without their relatives, on each ward round. Nobody expects this to happen. This begs the question: what kind of conversations are acceptable on the ward, and which should be reserved for a truly private space?

We are used to making special arrangements for breaking very bad news, end-of-life or DNA CPR conversations, and for planned conferences where several family members are expected. To gather four or five plastic chairs around a bed in a cramped space and pretend to be comfortable delving into intimate and existentialists details. But other conversations, the majority, are conducted within in earshot of strangers. Sometimes, a ‘routine’ conversation about treatment (which is still, after all, highly personal), can transform into something else.

Recently, in conversation with a jaundiced, alcohol dependent patient, I sensed a complete lack of understanding about the seriousness of his situation. I was standing next to his bed. Other members of the firm, a nurse, and a student, stood nearby, listening or typing into computers of wheels. We had been talking about the next set of tests, progress, plans. Nothing too personal, nothing too sensitive. Then I took the conversation into a darker place, to emphasise the gravity of his illness.

“I’ll be truthful with you Mr ______. And it’s a lot easier for me to say than for you to do, I know, but if you start drinking again after you get home, you will probably die in the next three months.” It took him unawares. His eyes moistened with the realisation of how close to death he was. The visit ended, and the nurse stayed with him to provide comfort and make our disappearance from the bedside less abrupt. As I drew the curtain back I looked across to the patient opposite, who had of course heard everything. Now he knew as much about the alcoholic patient’s poor prognosis as the patient himself. As patient 2 looked across at patient 1, there was shared, highly personal knowledge. Patient 1 was left totally exposed. It felt wrong. It was wrong. Yet, how could I have done this better? Perhaps I should have paused the conversation and said, “We really need to talk about the future, in private… how about I come back later…” But there was no ‘later’ that day. I could have delegated the task to a very capable registrar, but that also felt wrong. And the conversation just went in that direction, naturally.

Hospital, I have observed over the years, is a harsh leveller. It is difficult for the great machine to tailor and modulate its processes to the individual sensitivities of each patient. What one patient would regard as unacceptable in terms of privacy, another will have no problems with. As doctors and nurses, we tend to apply our own standard to everyone. Yet that standard has probably been lowered by brutal shifts in A&E where people display their vulnerability to all and sundry in waiting rooms and scream in pain or cry inches from strangers. It is easy, as a doctor, to think ‘The priority here is treatment, this is a busy environment, dignity comes second…’

Nurses are the guardians of dignity. Yet doctors can with an irritated scowl or a quick glance at their watch, overrule the gentle suggestion that ‘it might be better to have this conversation away from the bedside…’ I know I have done that. A conversation that I think is ‘ward appropriate’ might, in a nursing colleague’s mind, touch on a subject that no other patient should be allowed to hear. Who decides? Does the acuity of the ward, or the incessant flow of humanity through an Acute Medical Unit, justify a reduction in privacy thresholds?

There is no list of topics that should be explored in true privacy. The patient should, in theory, be in control. To discover a patient’s level of sensitivity, it is necessary to ask at the beginning, ‘I’d like to talk about x, y and z, would you rather we did this somewhere else?’ The danger, perhaps, is that they will say yes! Then it will be necessary to move everyone. Universal provision of side rooms would make this all easier, and it is actually a relief to see people in that environment, on haem-oncology wards for instance.

My advice? As ever, it starts with a patient-centred view, and empathy. What would you feel if you were told you have three months to live in a room where five other patients could, if they were alert enough and unable to switch off their ears, hear every word? Like all things in medicine, quality takes more time, more patience… it requires the machine to slow down. That is not always easy.

 

 

New booklet, 4 interactive ward scenarios – you decide how they turn out! Click image to explore…

or see Amazon author page

Dodging shadows: the mysterious art of detachment

 

I watched a patient die before Christmas. He was surrounded by the full crash team, which nowadays is a fairly large group. As the attempt was abandoned, and another consultant ‘called it’, I withdrew into the background. There was nothing I could do to help. I walked away to prepare my departure for the week-long break (lucky me, most doctors don’t get that), and couldn’t help but think about him. His death. I wondered how it would affect me as I arrived home. The family were looking forward to seeing me, my return would mark the beginning of the ‘real’ holiday. I wanted to enter the house with a light spirit and smile. Yet, the image barely fading on my retina, and still vivid in my visual memory, was of a dead man.

How to separate the intensity of that memory from life outside the hospital? Detachment. That is the word, the process. An ability to cut the lines of emotion that stretch from the wards though the sliding doors, along the train track or the A-Road or the cycle lane, thin but tenacious like the silk spun by a giant spider of Middle Earth. Pull as hard as you like, they don’t snap. Yet, to avoid darkening our homes, they do need to be cut.

Detachment. This process has received a bad press recently. The surgeon who burned his initials onto a living liver was defended by Henry Marsh, who used ‘detachment’ as a justification. Detachment can impede our ability to sympathise and to emphathise. In this example, it permitted transformation of a patient in an object to be signed. Any detachment we achieve on leaving the hospital or the surgery, has to be reversed when we re-enter the building.

So perhaps it’s not detachment that is required. Perhaps it is management, of bad or upsetting memories. By this I mean the ability to live with them. Compartmentalisation. Reduction. Or temporary blindness. A method by which negative emotion can be pushed to the margins of our minds, while the lives of others who have no knowledge of the patients, and therefore cannot truly ‘care’ except in an abstract sense, proceed uninterrupted. Silence is one option. Yet this requires the healthcare worker to conceal his or her thoughts and behave normally. This means acting, and the dissonance between inner reflections and external actions could, in time, be harmful. I have no reliable answer. My own method, as readers of this blog will know, is to turn a thing over, look at it from several angles, and process it through words. That doesn’t work for everyone (there would be far too many blogs!).

My final answer is this: doctors and nurses will always bring the memory of death into the home. To leave it on the street is unrealistic. To bury it is harmful. To talk about it incessantly is unfair on those we live with. The only other option, perhaps, is to develop a special facility – to carry the emotional load with as much sadness and respect as death deserves, while simultaneously accepting that the lives lost do not intersect with those who are close to us. The sadness is of a different quality, with a translucence and impermanence that alters us but cannot rob us of normal social reflexes, or the ability to enjoy ourselves.

 

New booklet, 4 interactive scenarios. You decide! Click picture to explore…

And do look at my Amazon author page

Avoiding the question

Many doctors will have heard the statement, ‘If I had my way, I’d just have an injection and be done with it.’ Sometimes, it is formulated as a question; ‘Can’t you just give me something to put me out of my misery?’ Or the frustrated appeal; ‘Why you don’t let me take a pill and end it all, I don’t know.’ These patients are, on the face of it, asking for physician assisted death (PAD). When I hear this, it is usually from patients who are not terminally ill, so would not qualify for PAD even if the last proposal to parliament had passed into law. More commonly, it is from older patients who remain cognitively sharp but physically debilitated, and in some discomfort – a degree of chronic pain, but to an equal degree the indefinable discomfort caused by each and every day being a trial. Sometimes, I do hear it from patients with terminal cancer.

When I hear those words, what do I do? I play a straight bat; ‘I’m really sorry to hear you say that.’ Then, ‘But as you must know, it’s not legal here.’ The response of the patient is often a shrug, and a slight turning away of the head. They knew it would go nowhere. It wasn’t even a serious request. In fact, they are embarrassed to have put me in a difficult situation. ‘I know doctor, don’t worry.’ I then proceed down the conventional route, making sure that their needs are being met as well as can be. Is there a referral to palliative care? What does the GP know? Is there clear evidence of depression? (Impossible to tell in a clinic visit, unless their affect is so characteristic a non-psychiatrist can perceive it.) But the turning away of the head is a sign, that we will not connect at the existential level to which they wanted to climb.

The consultation continues. We keep to the ‘safe’ areas. But the thing they really wanted to talk about, and which they knew would not be entertained, goes unexplored. For what is the point of talking about it, when there is no chance that it can be achieved? Best, really, to leave it unsaid. To challenge, or ‘manage’ their conviction that it is preferable for life to end, would be like trying to correct wrong-thinking. ‘Surely you don’t mean that… perhaps we should look into your mental state, see if you are depressed.’ Or, ‘Are you sure you’re not saying this because you don’t want to be a burden on your children?’

I have previously considered how doctors might respond to comments like this, if as in Canada, PAD is legalised. In that case, the hastily asked question will no longer be ignored. It will signify a concern, a need, an agenda that cannot go unpursued. To ignore it would be to deny the patient access to a medical intervention that they have a right to access. To ignore it would be to allow the doctor’s personal distaste to redirect the patient’s agenda.

Whenever I hear the question I reflect that in this area, as in no other, our responses are restricted by the law. If and when the law changes, the tenor of the consultations in which the question of PAD is introduced by patients will change. A natural dialogue will take place. The patient’s true agenda will be explored. For now though, the coyly delivered question can bring no meaningful reply.

 

New booklet, click image to explore

Systems and sense

 

 

The controversy surrounding paediatrician Dr Hadiza Bawa-Garba has got me thinking about the relationship between individuals and systems in healthcare. In this case, it has been suggested that system failures, including under-staffing, contributed to a young patient’s death. So important do those factors appear, many feel she should be allowed to continue practising despite a prior manslaughter judgment against her. How do we decide how much blame resides with an individual doctor, and how much can be attributed to the sub-optimal system? I do not know the answer, but it is a question worth exploring.

I cannot recall a single avoidable death where the ‘system’ (i.e. processes, ways of working in the hospital) was not at some level criticised. This is because I have yet to work in a hospital where safety-netting systems were perfect. From slow or inconsistent IT, to lost correspondence, inadequate hand-over arrangements or over-stretched teams… there is always something in the background that appears to diminish an individual doctor’s ability to make the right diagnosis, or initiate the right treatment, in an acceptable timeframe. That’s why it is rare for investigations into avoidable deaths to conclude that a single person’s act of commission or omission was to blame. Blame, of course, is a word we avoid, though as I explored in a previous article, a sense of personal culpability may be important as a driver of self-improvement.

Thinking back to formative errors I made in my own training, I recall an incident of gentamicin induced renal failure. I prescribed it on a Friday, handed over the job of checking the levels (it is toxic if it builds up in the bloodstream), and went off for the weekend. The patient was given it as prescribed (this was back in the day when dosing was written up regularly, but with the caveat ‘check trough levels first’). But no levels were checked. Her renal function deteriorated, and she ended up on dialysis for a while. Disaster.

The system did not help me. There was no gentamicin prescribing protocol; no system of flagging abnormal kidney results to doctors on call; the handover book was a scrawl – so many ways in which better systems could have helped prevent harm. Yet, that was the environment in which I worked. It was my handwriting on the chart that damaged her kidneys. I learned that if a result is important, you need to chase it, and if something needs doing when you’ve gone home, you have find out who is supposed to do it and make sure they are completely aware. You can’t be passive; you can’t leave it to the system.

Take this example, from a Human Factors in Healthcare document. I have underlined the areas where it was felt the system let the patient down, and put into bold those where an individual made an error.

_

A child with a known penicillin allergy was prescribed and administered an intravenous dose of an antibiotic of the penicillin class’

A child was due to have a pacemaker fitted. On pre-admission an allergy to penicillin was recorded. This was noted on both the nursing admission assessment form and the anaesthetic record chart. Prior to operation, the allergy was discussed with the specialist paediatric cardiology registrar, the consultant paediatric anaesthetist, anaesthetic specialist registrar and the cardiology consultant. However, following the procedure the patient’s plan included intravenous and oral penicillin.

How did this happen?

  • Intravenous penicillin is the usual antibiotic used following a pacemaker being fitted. There was no up-to-date protocol on what other antibiotics should be used if a paediatric cardiac patient has a penicillin allergy, which initially caused confusion;
  • There was no clear record of the allergy in the medical notes when the Consultant Cardiologist advised treatment;
  • No system was in place to prevent penicillin prescription when a known allergy was recorded.
  • A number of appropriate checks were not followed prior to administration of the antibiotics.
  • During independent checks, neither nurse checked allergy status, and both were under pressure to complete tasks. The patient’s allergy band was on the same side as their identity band, both of which were covered with a bandage for an intravenous drip.

_

Imagine the child had received penicillin and died from anaphylaxis. Would it seem reasonable for any of the individuals involved in the actions highlighted in bold to have been blamed, censured, or worse, accused of manslaughter?

The cardiologist put penicillin in the post-op plan, despite having been told about the allergy. Neither nurse checked for allergy, not thinking to peel back the obscuring bandage. Somebody put the bandage on without moving the allergy bans. All were at fault. But, an electronic prescribing package that automatically pulled the allergy from the patient’s record and blocked any doctor from writing up a penicillin-related compound would have rescued the situation. Can the absence of such a system be blamed for an error that results in death? Would its lack be used, in court let us say, to extenuate the error medical staff? Or should staff be judged in the context of the environment in which they find themselves?

At what point does responsibility for errors cease to be attributable to systems, and start to accumulate around individuals? There is no visible line or threshold. Regulators and courts must determine what was reasonable in the circumstances, and if a doctor meets minimum acceptable standards within Good Medical Practise. For the trainee, it is important to understand that all systems are imperfect, and to develop a sense for when to drive management forward, well before the backstops provided by the ‘system’ throw up a red flag.

***

Signature

 

What explanation can there be for a surgeon to write his initials on a patient’s liver? It sounds bizarre and disrespectful. This almost surreal, alleged event is sub judice, and I know nothing of the people involved or any details beyond what was in the papers, but perhaps it exposes some interesting psychology.

In the medical specialties that require practical skill, especially surgery, you work hard to become expert. Over the years the movements of the hands and fingers become practised and slick. Operations that appear impossible to the lay-person or junior trainee become routine, yet each patient is different. Each procedure presents its own challenges, hiccups, sudden recalibrations and extempore solutions. At the end of a particularly difficult case, when the patient appears stable and safe, you might sigh with relief, but also experience a surge of pride on a job well done. Congratulations are hard to come by in medicine. The job well done should be the norm, after all. But looking down at the organ, structure, or vessel that now pulses healthily as a result of your dexterity, you might be forgiven for thinking – ‘I did that!’

To mark a job well done with your initials is appropriate in other walks of life – in art and sculpture, in literature, in architecture. The artist owns the piece. A part of them, their skill, their creativity, their experience, lives within its lines.

Can medical procedures be regarded as art? Yes, I would say. The long facial reconstruction, the painstakingly re-joined finger, the delicately implanted heart valve… in the fine skill and seamless results it is easy to identify the hallmarks of the inspired artisan, the committed artist. Perhaps it is understandable that a surgeon who comes to see the results of their skill as art feels the urge to sign it.

However, it is a living body that we are talking about here. What lies under the skin is sovereign to the patient. They will carry it around with them for the rest of their lives. They were born with it. It is wholly theirs. (In the case of a transplanted liver of course, it belonged to another. The act of altruism and donation makes it worthy of even greater respect.) Perhaps that is the line that may have been crossed here – the distinction between what a surgeon can claim to ‘own’, and what is and will forever be sacred to patient.

Birthday party

Lonely birthday by Stephen Davies


It was time. After a week in hospital Mrs G, in her late 80’s, had failed to improve from a chest infection. Her frailty meant that the chances of making it out of hospital were shrinking. We were duty bound to discuss resuscitation. I knew what I thought: there was no way it would work. Before we entered the bay, I asked the team what they thought – all agreed. Was that their true opinion, or where they just following my lead? All one can do is ask. I looked to the senior nurse. She agreed too. It was not a difficult decision, medically. “By the way,” said the nurse, “It’s her birthday.”

            I approached the bed space. Mrs G was drowsy, but a hand on the shoulder and gentle rock caused her to wake. She had all her mental faculties, full ‘capacity’, as we say. I knew already that there were no family members living nearby. I started in the usual way, with a brief examination and review of the latest blood tests. Then I prepared to deliver my line – ‘I thought we should talk about what might happen if you get worse… if your breathing or your heart deteriorates… there’s a chance that your heart could stop suddenly… it’s called a cardiac arrest…’

            Her thin arm lay outside the sheet, and I glanced at the name band. The date and the month… today. There were no cards, no flowers. I paused. Was she even aware? “It’s your birthday,” I said. “Yes,” she replied, in a neutral tone. It had no significance for her. Birthdays are only as special as the people around you.

            Images of her as a young girl waking up in a state of excitement, 80 years ago, entered my mind. The juxtaposition between youthful health, optimism, a life not yet lived, and present reality… was stark. My words, formally raising the prospect of death, would symbolize the end of the dreams and ambitions she had nurtured. Perhaps most were fulfilled. I did not know.

            “Well, happy birthday anyway,” I muttered. She smiled weakly. We moved to the next patient. The tasks we had set ourselves – agreeing limits of care, completing a DNACPR form – were incomplete. “Not today,” I said to the team. “Not today.”

 

***

[Patient details changed.]

From the front

 

Victoria, a new consultant, pushed for the procedure. It was, as they say, a ‘multi-disciplinary decision’. A consensus had been reached and the views of all those involved was clearly documented, but it was Victoria who made it happen. She had seen that Mr S. would go nowhere until a decision was made. Due to the complexity of his situation (a chronic disease with a rare complication), touching several specialties, there seemed to be no leader in his management; no overall owner. So, Victoria, who had met Mr S. several times and felt that she knew him quite well, decided to ‘own’ this episode of care. Through emails, corridor chats and a couple of cameo appearances at specialty meetings, she brought Mr S. to the eve of the procedure.

It was performed rarely, in any hospital, and Victoria, being no surgeon, did not know exactly how it was done. Nevertheless, the surgeon who agreed to do it (reluctantly, she felt) was known to be an expert. There was risk; how could there not be, given the complexity, and the proximity of the pathology to the brain? But the surgeon would explain this while obtaining Mr S’s informed consent. Not that Mr S. had much choice. To do nothing would see him die of the complication at some point in the next 12 months.

Victoria went to see Mr S. on the morning of the procedure. She didn’t see it as her business to delve into the risks, and she knew that Mr S. had given his consent already. A porter was waiting by the nurses’ station with a piece of paper in his hand asking which bed Mr S. was in. It was time for him to go to theatre. So, with the porter circling the bed, Victoria wished Mr S. well and promised to see him in a couple of days. Not tomorrow; that might be a bit too soon. Mr S. nodded. His smile was not full. Victoria got the impression that he had more knowledge of the procedure than she did.

Victoria walked away feeling pleased with herself, for steering her shared patient through the Byzantine processes that can seem to slow the progress of patients in the NHS. Mr S. was getting what he needed, at last.

Next day Victoria headed straight to clinic. She was too busy to think about Mr S. At lunchtime he crossed her mind. He would probably be in the ICU now, recovering; or, if everything had gone very smoothly, on the specialist surgical ward. Over lunch she looked him up on the computer. Yes, still in ICU.

On the way to her afternoon commitment she ran into the surgeon.

                “How did it go?” asked Victoria, brightly.

                “Didn’t you hear?”

                “No. What?”

                “He stroked out, massive embolus came off the aorta. The whole left cerebral hemisphere is swollen, the neurosurgeons had to do a craniotomy overnight.”

                “But he’s…”

                “Alive, yes, but there may not be much…” He tapped his temple.

                Victoria stepped back, and leaned against the wall.

                “Are you OK?” she asked of the surgeon.

                “Me? Yeah, fine. Tiger country, you know, that sort of operation.” He walked away, unflustered.

Victoria was distracted all afternoon. Her body language was automatic, her responses generic. She knew it would not be helpful to anyone for her to visit Mr S. He was being looked after well enough.

On the way home, through the blurred background and streaky lights visible from the train window, she saw Mr S’s future. It was nothing like she had imagined. It was not what she had promised him.

Now she regretted her assertive approach. It was due to her negotiating the blocks, driving the reviews, nudging the co-ordinators, that Mr S. had been listed for surgery. Her prints were all over this process. She felt responsible.

The residual weight of that responsibility, a leaden blanket, slowed her down as she walked home from the station. Her husband asked what was the matter, and she explained. He, a non-medic, saw it another way. There had been no wrong done here. The operation was indicated, all were agreed. It was bad luck… a final bit of bad luck compounding a life afflicted by bad luck. Victoria nodded and smiled. Yes, that was the rational approach.

Because Mr S’s clinical needs had changed, Victoria had no ongoing role in his management. Other patients displaced the acute concern she had developed for him. His name appeared in a morbidity and mortality meeting, but his ‘outcome’ generated no controversy.

Later, long after he had died, Victoria met other patients who needed strong advocacy from someone to take their management forward. Sensing that these patients were entering territory full of risk, Victoria did what was required of her, offered her opinions, and contributed to the consensus. Although the speed of decision-making was often slow – or deliberate, a better word – she was comfortable with that. She did not push things forward. Let management plans evolve at their own pace. Byzantine processes have developed for good reasons. Sure, there might be occasions where she needed to lead from the front and make things happen – in those areas where she was the acknowledged expert – but in other circumstances, from now on, she would go with the flow.