Two strikes – when the patient ‘Did Not Attend’

The nib of my pen hovers over the ‘outcome’ form*. In the lower third are various options; Follow up x weeks/months, Await results, Discharge, Refer to another consultant, DNA – rebook, and finally, DNA – discharge. DNA. Means Did Not Attend. The patient Did Not Attend their clinic appointment. A stark term behind which there may lie many reasons, some not of the patient’s own making. But the decision to discharge will terminate the patient’s relationship with this clinic, and with me. Responsibility for monitoring them will return to primary care, or may evaporate entirely. Perhaps their symptoms, or the nagging thought that there was unfinished business in the clinic, will draw them back to the GP. The GP will decide whether they need to be seen again by ‘the specialist’, and if so they will need to write a new referral letter. Then they will re-join the waiting list. The process could take months.

NHS Trusts have strict policies on DNAs. After all, 1 in 10 appointments are not kept, and you can’t keep offering them to those who don’t come. The National Audit Office reported that DNAs cost the NHS up to £225 million in 2012/13. Failure to attend means that a slot was wasted. Another patient could have been seen instead. One strike and you’re out, some Trusts dictate. Many consultants are more comfortable with two. The first time could have been an ‘honest mistake’, a slip, a simple oversight. Too harsh then, to strike them from the system on the first occasion. But a second missed appointment must surely mean that either they feel better and do not want to be seen, or they have moved, or they are just too busy and choose not prioritise their health over everyday life.

In a study of 73 patients who had missed appointments, the reasons given were:

• Forgot to attend or to cancel (30%)*
• No reason (26%) [I’m guessing they literally said, ‘No reason.’]*
• Clerical errors (10%)
• Felt better (8%)*
• Fearful of being seen by junior doctor (3%)
• Inpatient in another hospital (3%)
• Miscellaneous other (20%)

I have asterixed the reasons that seem genuinely to ‘deserve’ a discharge. They make up 64% of the reasons (or ‘no reasons’), so at least a 3^rd would be discharged entirely unjustifiably, based on this sample. Those who were subject to clerical error deserve the opposite – a new appointment at their best convenience. I wonder if that happened.

This is Mr Jackson’s 2^nd DNA. I know him. He has been coming to the clinic for three years, with a chronic condition that requires regular review by a specialist. Something must be up. We get on well. He may feel healthy, but his condition could be changing beneath the surface. I worry that if I discharge him he will never come back. The pen moves to ‘DNA – re-book’. But… but… why waste another slot when the chances are he won’t come back. The waiting list is long. Every appointment counts. I could call him up to find out why, but to be honest I don’t have time to chase up every DNA. I’ll write a letter to the GP stating that he didn’t attend and asking the GP to keep an eye on things. And another to the patient himself, to keep it personal. So, I’m not exactly severing all connection, but… I will discharge him. Discharges are important. Senior doctors have a duty to keep the lists turning over. And if he develops a complication, a cancer say, it won’t be my fault.

The Medical Defence Union has just published guidance on this subject. Pertinent to Mr Jackson, they say I should,

• Respect a patient’s decision to refuse an investigation or treatment, even if you consider the patient’s decision to be wrong or irrational.
• Explain any concerns clearly to the patient, as well as the possible consequences of their decision, and document your discussion in the patient’s clinical records

And that,

• Previous knowledge of a patient’s circumstances, including the severity of their condition necessitating referral or follow-up, will need to be taken into account.
• It may fall to a patient’s GP practice to follow up the patient who misses an appointment.

I circle the words, ‘DNA – discharge’. I dictate the brief letter to his GP: “I was sorry not to see Mr Jackson in clinic today. I hope that he remains well. It is important that he attends for regular surveillance. I would be grateful if this can be emphasised to him when you next see him, and I will write separately to him. For now he has been discharged.”

A bridge, a compromise, between bureaucratic imperative and therapeutic relationship. For all I know his family have taken him in to their home up in Yorkshire; or perhaps he has died. I don’t know. Or perhaps he’s decided that these appointments were a bit of a waste of time, as nothing ever seemed to change. He’ll find his way back, if he needs us. I’m sure of it.

Next patient please.

[Fictional patient]

 

* These forms (either paper or electronic), and the options available, vary between organisations.

 

5th collection of articles, out now [click image to explore on Amazon]

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Introduction to ‘When Windows Become Mirrors’

 

  

When Windows Become Mirrors

The 5^th collection of articles from Illusions of Autonomy

 

Dedication

To the readers of my blog who through their interest have encouraged me to keep writing for 5 years, and especially to those who have helped spread the word on Twitter, that powerful but mercurial invention.

***

This is the 5th collection of blog posts from Illusions of Autonomy. When I wrote the introduction to the 4^th, A Hand In The River, I wondered if that would be the last. The frequency of posts had dropped, due I think to my increasingly specialised role – more interesting on the one hand, but less involving in terms of the everyday human and ethical problems that accompany general medical patients. But then things picked up. There were controversies around under-performing or frankly injurious doctors. Increasingly I reflected on the role of the senior clinician, and how you maintain the skills required to be a good doctor while spending less time on the front line. My perennial interest in resuscitation decisions continued to be prodded by difficult situations in my own hospital, and the frequently lethal nature of the illnesses affecting the patients around me led to reflections on how we (okay, I) communicate in busy and pressurised environments.

Windows into mirrors; reflections. The title of this collection comes from the long walks down dark corridors at three in the morning, when, coming from particularly difficult or stressful clinical situations as a trainee, I used to look in the night-blackened windows and see a haggard doctor who was unsure if he had done a good job. At those times, when our patients’ pathology insists on progressing while the pace of the great machine dials down in the dead of night, there is ample time for self-examination.

Part 1: Night & Day – observations on everyday behaviour in the hospital, good and bad…
Part 2: In Court – arrogance, negligence, and other sins
Part 3: Relating to people near the end of life – how doctors get it right & wrong
Part 4: Resuscitation decisions – not getting any easier
Part 5: Assisted Dying – a true battle of attrition
Part 6: Illustrated essays – on the history of truth in medicine, and how doctors respond after doing harm

 

Kindle (99p or equivalent), click here

Paperback (£5.99 or equivalent), click here

 

 

Checklist mentality

 

The case for checklists has been made so well – see this fantastic article by Atul Gawande – yet those responsible for embedding them struggle. They are an effort, an obstacle, an apparently petty imposition. I know it’s the right patient! I know they’re not on Warfarin! I know what equipment we need to do the procedure. It’s all so obvious. Yet, now and again, something goes wrong. Never events happen. (See the recent Health Safety Investigation Branch findings.) The wrong patient is operated on, the wrong tooth is removed, or an allergy is missed and a drug that is dangerous to them is injected. Checklists reduce these events, so what’s the problem?

My experience with checklists has been interesting. I am a proponent, a kind of champion, yet often I huff and puff as, on the brink of putting an endoscope down, the wretched piece of paper is waved at me. Grrrr!

The process of completing the particular checklist that we have developed takes a minute at most. It requires standing still (a problem when you’re in a hurry), focusing the team’s attention on the responses (for what is the point of the patient telling me they are allergic to something if no one else in the room is aware?) and communicating with the patient (a problem for some, especially when in a hurry).

Perhaps it’s this need to pause and be still that frustrates doctors and surgeons. We, they, like to keep moving, to flow through the tasks, to get to the nitty gritty (the technique, the findings, the pathology, the treatment) as soon as possible. It is this habit that is so difficult to break. It is a mind-set. And it reveals something about our approach our surgical lists. They are our lists. They have our names on them. Their character – relaxed, rushed, efficient, friendly, spikey, miserable – stems from our own behaviour and the clinical leads in the room. The checklist is an obstacle to our progress through the day and to a successful outcome. With this mind-set, the fact that it is the patient’s procedure can be forgotten; forgotten also the fact that around the surgeon buzzes a team of highly assistants without whom the procedure could not take place. The checklist is the best, probably only way to ensure that for a moment, everyone is focussed on that patient, and the last opportunity to identify possible harm is heeded.

Gradually, slowly, the checklist should become natural, and depending on your psychology, you feel that something is missing without it. We didn’t to clean our hands before and every patient contact; now, if I haven’t, I feel kind of tainted, as though there is something on my skin that hasn’t been taken off. They are clean of course, but the habit has become so ingrained my mind insists on the slap of antiseptic foam before moving on. In the same way, the checklist should become a door through which your mind insists on moving before embarking on the procedure.

I’m not sure I’m at that stage yet. If there are distractions, or if I am running very late, the checklist can be overlooked, until a colleague holds it up and pulls me back. I know that if harm does occur in relation to a surgical procedure, the absence of a checklist looks bad. Completed correctly, it serves to protect you, as the surgeon. It demonstrates that care was taken, and thought given to the patient as an individual, not as a ‘procedure’.

Most doctors and nurses are already converted. But the checklist mentality remains a change, and a challenge. As Gawande says, comparing the flair and fluidity with which surgeons like to move through their lists with the early astronauts from The Right Stuff,

‘…the prospect [of checklists] pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.’

Expert audacity vs regimentation, again in Gawande’s words. This points to the same psychology I explored above. The audacity, the flair, the speed, all relate to the surgeon.

But it’s the patient’s procedure.

 

‘Stuff happens’: patient safety incidents and 2nd victims

Bad things happen in medicine. Sometimes, as doctors or nurses, the things we do, or the things we didn’t think of doing, cause harm. How we respond to those incidents determines the direction our careers follow. If the response is catastrophic, and the puncture in our confidence or self-esteem proves irreparable, we may drop out entirely. This article explores the idea of the ‘2^nd victim’, that is the health care worker (HCW) involved in events that result in harm to patients. It is based on a Grand Round lecture I delivered at Frimley Park Hospital.

***

‘Stuff happens,’ as Donald Rumsfeld sanguinely commented after being questioned about the looting that took place in the fall of Baghdad. ‘Stuff happens, and it’s untidy.’ He certainly felt no personal responsibility for the adverse consequences of a military decision that he had been invovled in. The looting was a kind of ‘complication’.

That is not the typical response among healthcare workers. Dan Walter, in his book Collateral Damage, describes a terrible complication suffered by his wife, and the panic that he perceived in the young doctor who was involved. A novel cardiac ablation catheter was incorrectly deployed by a trainee, resulting in its spiral end becoming entwined in the cordae tendinae of the mitral valve. When the catheter was eventually removed, bits of heart valve tissue could be seen hanging off it. She developed cardiogenic shock, and had to have an emergency mitral valve repair. Dan Walter approached his wife’s cubicle;

A vivid picture there of the 2^nd victim – although many would say that the author – the spouse –  is the true 2^nd victim here, the doctor the 3^rd. For now though, I’ll stick with ‘2^nd’.

The impact on HCW  has been studied. Scott et al described common symptoms, both early and late, in the table below. First the physical, then the psychological. In some, there is avoidance of particular patients, and chronic uncertainty.

The authors then identified several phases in the natural history of psychological response:

At the end, the HCW ‘thrives’, that is they learn, improve, and possibly use their experiences to help other in similar situations. Others carry on, still feeling the harm and perhaps avoidng certain situations, while a third group drops out. The injury to their confidence is too deep.

As a student and trainee I saw how those around me reacted in these situations. I vividly remember the bloodless expression in the house officer whose patient became comatose after receiving a duplicated prescription of insulin; the SHO who gave Tazocin to someone who was penicillin allergic; the registrar who inserted a central line into the carotid artery accidentally. Having convinced myself that I had prescribed IV salbutamol at 10x the usual dose at three in the morning, I made up the term ‘Gut Thump’. This equates to the adrenaline-driven, panic-soaked reaction that comes minutes after the event.

Much later, after a complication, I charted my own psychological journey starting from the moment I received the CT scan report showing the damage, and I drew it on a graph. Many may recognise this line. The time it takes to reach equilibrium will vary, depending on the sense of culpability, and the outcome of the patient. In this case the patient was absolutely fine, but there was a period during which this was not guaranteed. The road to equilibrium involves communicating, receiving reassurance, and doing stuff to make it better. Also, the understanding of the patient helps.

Van Gerven et al, surveying 913 healthcare workers who had been involved in a patient safety incident, and using an Impact of Event Scale, found,

 

‘…higher psychological impact is related with the use of a more active coping and planning coping strategy, and is unrelated to support seeking coping strategies. Rendered support and a support culture reduce psychological impact, whereas a blame culture increases psychological impact.’

This appears to correlate the intensity of response to the pro-activity shown by the HCW in dealing with things, which is interesting. I would have assumed the HCW who just let things be might feel less of an impact. This might indicate a link between conscientiousness, and psychological injury.

A qualitative analysis of 21 staff by Ullstrom et al, ‘Suffering in silence: a qualitative study of second victims of adverse events’, found that non-judgmental support from peers was vital. One interviewee said,

I really want to highlight how important that support is (…) without it, I don’t know where I would have been now (…), if I would have ever dared to come back and work as a nurse again. (Interviewee No 14, Profession: Nurse, Type of adverse event: Wrong medication dose)

While another spoke about reluctance of doctors to seek external help if they are not recovering,

I think there is an inner resistance towards getting external help. At least, among doctors [the idea is] “I can handle this” (…) but I think that really we should have much more general support. In difficult situations overall. Not only after adverse events. (Interviewee No 18, Profession: Doctor, Type of adverse event: Operation went wrong)

 

*

 

We are encouraged to be open about our mistakes, and our leaders in the profession have shown us their example. The booklet ‘Medical Error’ (published by the National Patient Safety Agency) contained vignettes from the careers of, among others, the then GMC President and the then President of the Royal College of Physicians.

 

Error then, happens to the best of us.

Yet, we cannot accept our role in these errors with equanimity. It takes something out of us. This is normal human behaviour surely – regret, guilt. We are now required to express these feelings to those who have been harmed, as per the Duty of Candour, which became law in March 2015. Following a series of healthcare scandals, the Francis report described a culture of obfuscation, and this was followed by A Promise to Learn… by Don Berwick which enlarged on the idea of transparency, and finally came specific recommendations from the Royal College of Surgeons which preceded Regulation 20.

So now, while handling our response as 2^nd victims, we must take ourselves to the person we have harmed and apologise. This might compound the emotional challenge of the situation, or it may in fact accelerate resolution. It is amazing how a patient’s forgiveness can set an anxious doctor back on track.

It is worthwhile dwelling on how to handle Duty of Candour conversations. I have heard and used various verbal formulations, which to the outside observer might be surprising or evasive… for how hard can it be to say sorry? But… what are you sorry for. Are you sorry you did it? Are you sorry ‘we’ did it, i.e. the team, the department, the hospital? Or are you sorry it happened, in an impersonal way, the same way you felt sorry when you heard on the news that someone got run over last weekend? Which sorry? And while finding your way through the post-incident psychological reaction, do you have the emotional strength to handle the expression of sorrow, whatever form it takes? It is quite possible that a natural feeling of vulnerability and defensiveness will influence the words that are chosen, and make the conversation less candid than intended. On the other hand, perhaps, as in the figure below, those who accept a degree of personal culpability and are affected by that, are more likely to demonstrate candour than the flint-skinned individual who regards adverse outcomes as inevitable complications over which only fate can exert influence.

On the subject of defensiveness, it is impossible to discuss medical error or patient safety incidents without referring to the legal situation. We know, following the recent trials of both Dr Hadiza Bawa-Garba (which occurred after I gave this lecture) and Mr David Sellu, that doctors are not immune to prosecution following ‘omission’ harm events. These names are likely to weigh heavily in the minds of doctors who become involved safety incidents, and are likely to exaggerate the feelings of panic and ‘chaos’ that were described in the Scott paper.

 

This article has focussed on the healthcare workers. The response of the true 2^nd victims, sons, daughters, mothers, partners, have been overlooked, but that subject would require an article of its own, and I am probably not best placed to write it. However, the Duty of Candour has, in my opinion, brought the two spheres of psychological response closer together. The (primarily physically) injured or suffering patient is now more likely to meet the (psychologically) traumatised doctor. The shared experience, and insights into the stresses experienced, may actually improve understanding. But the resources required of doctors and nurses to deal with their own regret and self-criticism, while simultaneously approaching patients or relatives, should not be underestimated.

 

 

 

###

 

Blog compilation books, on sale:

Motives, emotions and memory: exploring how dcotors think

Spoken / unspoken: hidden mechanics of the doctor-patient relationship

A face to meet the faces

A hand in the river

Why did that man receive CPR? An inquiry

 

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

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…’

 

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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.

 

 

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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.

 

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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.

 

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