In this imagined scene I explore the reasons why junior doctors rarely blow the whistle on poorly performing senior colleagues. I have not been in this situation, and the words I place in the mouths and minds of my protagonists are based on supposition. Of course, real whistleblowers would be able to shed a more penetrating light on this dilemma. Their descriptions would have far more validity. But many junior doctors will have observed poor practice, and they will have considered the question – should I tell somebody? Perhaps this post goes some way to explaining why they hardly ever do.
Readers of this blog will know my methods – I take the true essence of a problem and enlarge it in my imagination. I do not pretend to justify actions or omissions here. It is merely an attempt to explain how people think.
A junior doctor called Michael observes that his consultant, Doctor G, has made what he believes is the wrong diagnosis on three separate occasions. Michael thinks he has detected a pattern of medical inadequacy. The first time, Dr G failed to detect or interpret the signs of early septic shock on a post-take ward round. Two hours later the patient was in intensive care, on quadruple strength noraderenaline, having been transferred in a state of peri-arrest. On the second occasion an elderly patient with leg weakness was assumed to be ‘off legs’ due to a urine infection, but the following day, after the man had been examined more thoroughly, a spinal cord tumour was found on an MRI scan. He was rushed to a neurosurgical unit for emergency decompressive surgery. And on the third occasion a patient with liver cirrhosis was, in the view of the junior doctor, written off without serious consideration being given to organ support and transfer to the intensive care unit.
Michael brooded on these examples. One evening he begins to moan about Doctor G in the pub. He relates the three incidents. His friend, another doctor, nods with common feeling. Michael realises at once that this consultant had an established reputation, a bad one, among other juniors .
“So what has been done about it?” he asks.
“The guy’s been there for years, he’ll be retiring in another couple.” says his friend.
“He trained in a different era. Half the diseases and treatments that we see now he didn’t even learn about.”
“That’s no excuse.”
“What do you expect the trust to do?”
“Take him off the rota. Patients are being exposed to him every week.”
“And what would that cost? They’d have to employ another consultant.”
“Does it matter?”
“No, of course not. But can you prove that he has actually caused a patient to suffer or die.”
“Well we have just discussed cases where that has obviously happened. I can’t believe nobody has ever said anything.”
“So are you going to do it? Whistleblow?”
“I’m tempted to. Who should I talk to?”
“You’re educational supervisor. That’s who I would go to. Is he friendly, your supervisor?”
“She’s a she. A surgeon. I’m not sure she would have a strong opinion on the medical detail.”
“It doesn’t matter. She doesn’t have to. She just has to acknowledge your concern. She’ll have an obligation to go up the chain. What about the GMC?”
“What will they do?”
“I’ve heard there’s a hotline they’re setting up.”
“You know what I think would happen if I told them?”
“I think it would ruin my life.”
“Because for the rest of my time here I would be thinking about what was going to happen.”
“In what way?”
“Well…I’m sure they would be discrete, but they would need evidence from me. I would have to provide some reports or they would have to come down and find them. That would become the focus of my life. Makes me feel ill thinking about it.”
“We had something like this on the ethics station in our exam. If there
was a real, imminent risk of patient safety the answer was easy. You have to remove the doctor from the clinical environment.”
“Yes, but that was for doctors on drugs, or drunk .”
“What’s the difference? A danger is a danger. If you really think he’s a danger then you should go to someone. The medical director or something like that?”
“Didn’t you work out with them a while back? Didn’t you notice anything?”
“Yes, I thought he was crap.”
“So did you go and speak to anybody?”
“No. He wasn’t that crap.”
“But now you know, having spoken to me, that he is that crap. We agree. I’m sure if there were a few others in here we’d all agree. Shouldn’t we all do something about it?”
There is a silence. What is going through their minds?
Perhaps this: it was not clear to either that Doctor G was a genuine danger. For prior to their arrival in the trust, just two and half months ago, this doctor had been employed for over 20 years without serious complaint. So why should it come to them, these young doctors at the beginning of their careers, to raise the alarm? Surely, if no-one else had detected his deficiencies it was more likely that they were wrong. Perhaps their inexperience had led them to misinterpret the things they had witnessed. There was more to medical decision making than they currently understood. It was more subtle than right or wrong…
And after all, did those patients really suffer more because of Doctor G’s decisions? The man with septic shock recovered eventually. The liver patient, a dyed in the wool alcoholic, was always going to die anyway. The intensive care docs were bound to have said no. And the patient with the spinal cord tumour was making a slow recovery; those extra hours without a diagnosis had not rendered him permanently paralysed. You could argue that it was responsibility of the A&E staff, or the admitting medical registrar, to examine him more thoroughly and detect the tell-tale sensory level. Can you expect consultants, who see each patient for ten minutes after they have already been the hospital for up to twelve hours already, to make every diagnosis, to make no errors? And hadn’t the consultant seen another 15 patients on that post a ward round, making the right diagnosis and the right decision for the overwhelming majority?
Michael begins to feel better, more settled. The dangers, to himself, melt away a little. He isn’t betraying his patients’ trust by avoiding the confrontation. Doctor G is different. He has strengths… and weaknesses. Clinically suspect, perhaps, but part of the old guard. And, when it comes down to it, Michael is pretty sure he does a lot more good than harm in the hospital.
“Where do you rotate to next?” asks Michael’s friend.
“Life might be a bit more straightforward there.”
“I know it will.”
“ Two weeks.”
“Head down mate.”