Juliet entered the ward expecting a normal, busy day. But the face of her colleague Nethmi who met her by the nurses’ station told her that something was up.
“What?” asked Juliet, responding to Nethmi’s wordless warning.
“Mr Peterson. Bed 19. They took his vascath out last night.”
“Did you tell the nurse to do it?”
“Yes. It wasn’t being used. It was ten days old.”
Already, Juliet’s skin had cooled and the hard ball of nausea was forming, revolving, touching adjacent organs.
“Why? Is it a problem Nethmi?”
“It was in his last major vein. It wasn’t supposed to come out without consultant permission. Didn’t anyone tell you?”
The door to the doctor’s office opened. Juliet glimpsed the rolled-up sleeve of the renal consultant. She steadied herself, and entered. Fear enveloped her.
Fear is a feature of every trainee doctor’s life. In new or particularly challenging roles, it can be a daily occurrence. As the medical writer Danielle Offri observes, our contemporaries in other walks of life rarely feel it –
I sometimes compare career notes with friends who are in the business world, and I’ve asked what their worst fear is. It’s usually something along the lines of making a financial blunder, screwing up a major project, having an investment fall apart, losing a job, disappointing the boss or family, losing money. I have to restrain myself from saying, That’s it? That’s all you are afraid of? That, of course, is the basic fear in medicine, that we will kill someone, or cause palpable bodily harm
Is fear limited to the medical profession? That seems unlikely. A policeman or woman on their first shift, or an established detective on hearing that the woman they placated after a complaint of domestic abuse has been found dead; a navy officer taking charge of their first ship, or facing investigation after a near miss on the high sea; a newly qualified barrister presenting their first defence, or explaining to their chambers how a sure-fire win was ultimately lost. All of these will feel fear in the workplace. It cannot be restricted to doctors.
I have written about the impact of fear before. In 2000 The Lancet published a short piece on the ‘Gut Thump’ (£)– the sensation that grips your insides when you think you might have damaged someone. This phenomenon was described more analytically by Scott et al in their paper on health care workers’ response to patient safety incidents. It is an adrenaline-driven sensation that reveals acute personal anxiety. Why should we develop such a ‘fight or flight’ response to another’s harm? The obvious answer would appear to be – fear of blame for making mistakes.
The NHS has worked hard to ensure that identifying a locus of blame is not the first instinct after a patient safety incident. Most trainees know this, and believe it. Yet, fear remains a common emotion. Despite all the good words about depersonalising blame, the facts seem to show otherwise. We have seen Dr Bawa-Garba go through the full gamut of blame, ultimately being found guilty of Gross Negligence Manslaughter. Despite her success in appealing against the GMCs insistence that she should be struck off forever, the criminal verdict remains in place. The BMA Chair Dr Chaand Nagpaul presented the results of a survey suggesting,
…nearly 8,000 doctors also found 95 per cent were fearful of making a medical error and more than half feared they would be blamed for problems arising from failures in the system.
Blame then appears to be alive and well, a conclusion backed up by in The BMJ with articles such as ‘Back to Blame.’ or an editorial from October 2018 which speaks of doctors who are ‘fearful’ and who
…increasingly work within a culture of litigation and blame, carrying the full burden of accountability…
But I don’t think the average doctor’s acute anxiety on the ward or in the ED arises from a fear of prosecution. It is probably more instinctive than that. It can afflict the most confident and assured of us, in the most supportive of systems. Danielle Offri again;
…fears can easily spiral out of control and overwhelm students and interns. If this happened only rarely, to only those few who entered the medical field with their own pre-existing mental-health conditions, that would be one thing. But the truth is that the fear overwhelms even the most psychologically sound and well-adjusted trainee. At some point it happens to nearly every single person who travels through the medical training process. If you don’t believe me, just ask any doctor you know.
Just ask any doctor you know. It’s true.
Let’s look at Juliet’s fear, in the moment. As the door opened and she glimpsed Dr Padan’s shirtsleeve, what was it precisely that caused the cold sweat?
His anger? – he was not known to blow his top, but this might just do it… the patient is precious, he’s survived three transplants and multiple complications… and I’ve just messed it all up.
Damage to her career? – is it possible that this mishap, seemingly down to her, could result in some kind of formal disciplinary action? Surely not. It’s the first bad thing she’s ever been involved in.
A complaint, from the patient (or, should he die, please no), his family? – but how could they complain about her individually? It’s the whole ward, the whole team surely.
An accusation of negligence, like that paediatric registrar who was in the news? – but this is different, a single lapse, not a whole series of issues like there appeared to be in that case. No, Juliet isn’t truly worried about being singled out and taken to court.
The patient. The patient is going to have to an operation now. His dialysis might be delayed. He might get an infection, he might bleed… – that’s what she fear. His prospects for survival are lower now, his chance of running into complications higher, because of her decision.
Are those who make the choice to put themselves in this position hard wired to feel personally culpable for every bad thing that happens? To an extent, yes. Doctors are highly conscientious. Their performance is rigorously monitored and assessed during their studies, and throughout the early years of training. There is always somebody watching. Assessments are routine and frequent. To progress, evidence of satisfactory performance must be accumulated. Negative outcomes, mistakes, might accumulate and amount to ‘concern’. It is hard to imagine it any other way. Without such assessments poor or dangerous doctors could glide under the radar and get ‘signed off’.
But it may be even more basic than that. I think it is an enhanced sense of connection between one’s own actions and the welfare of the patient. Whatever is happening to them, it’s my fault. If I misread an ECG and they go on to have a full-blown heart attack, it’s my fault. If I prescribe a drug they are allergic to, it’s my fault. If I cut the wrong structure during an operation, it’s my fault. If not mine, whose? The patient’s, for being ill in the first place? The ‘system’, for not guiding me to the right answer? My seniors, for not being there to check my work?
No. It was me.
It in is these reflections, I think, that fear is nourished.
Caroline Elton, an occupational psychologist who has counselled many struggling doctors published a book, Also Human: The Inner Lives of Doctors, and in this Guardian article about it the emphasis is on chronic, long-term emotional strain – an accumulation of acute stressors. In the extract, Elton describes vividly the overwhelming sense of helplessness and anxiety felt by a newly qualified doctor on day 1. The author is almost incredulous that it can be that bad. Again, one wonders if any other trainee, in any other walk of life, experiences anything quite so stressful. The scenario, of nine patients all needing attention and nobody around to help prioritise or lend perspective, points again to that sense of personal responsibility. Everything depends on you. It is hard to think of another job in which your physical action or mental calculation can immediately improve or worsen another human-beings welfare to such a great extent.
How to counter this natural tendency to feel fear?
Firstly, we should ask ourselves if fear should be banished entirely. As a patient, I might prefer my doctor or nurse to feel that sense of risk of trepidation that precedes a significant action. Fear might slow them down, it might make them think twice – is this really the right thing to do? Fear can be a warning that you are drifting beyond your competency, or that you don’t quite have enough information. Fear makes you careful.
In her book Caroline Elton mentions the ‘detached concern’ that doctors were traditionally trained to adopt. This approach has long had its critics (see this book review from 2001 for Jodi Halpern’s ‘From detached concern to empathy – humanizing medical practice’), and Elton suggests that chronic detachment has a more insidious effect on mental well-being than emotional engagement. If we accept that engagement leads to an enhanced sense of accountability/responsibility for our patients’ outcomes, a logical extension is that fear arising from that sense of responsibility is in a fact natural ‘side effect’ of being a good doctor.
But fear gnaws at the soul. If it proves disabling it will do no one any good in the long run. It can take the doctor out of the profession, through the phenomenon of ‘burnout’. Burnout is high on the agenda of professional and public debate at present. This month the author and doctor Siddhartha Mukherjee wrote on it in the New York Times. The article explores resilience to stress, and describes several essential dimensions along which a doctor must develop in order to ‘survive’. Referencing Victor Frankl (1905-1997, a neurologist and holocaust survivor) and Daniel Pink, author of such books as Drive: The Surprising Truth About What Motivates Us, Mukherjee writes:
What allows some humans to acquire resilience in the face of the most brutal and dehumanizing experiences? Frankl traced the roots of resilience not to success or power but to a sense of purpose and the acquisition of meaning. Later writers, including Daniel Pink, expanded Frankl’s concept of meaning along three dimensions: purpose, mastery and autonomy. We acquire resilience when we find purpose in our work. We seek mastery — expertise, skills, commitment and recognition — in our domains. And we need autonomy — independence — in what we do.
Purpose, mastery and autonomy. These things come with experience, but gaining experience will undoubtedly involve error. The challenge then must be to understand that life in medicine will involve periods of acute anxiety in relation to those mistakes, and yes perhaps even fear, but that unless the decisions or behaviour preceding the events are so far outside the norm as to make them cavalier or irresponsible, these episodes will probably improve us. Such bland reassurances do nothing to make a person feel better in the short term, but support and understanding does ensure that over time, be it days or weeks, the doctor involved gets back on track. Speaking personally, the only time I felt real fear as a trainee was when an error led to a meeting in which it was made very clear to me that I was all on my own.
As a supervisor and trainer the hard balance, I find, is that of defusing the situation of ‘blame’ while encouraging the doctor to reflect on what they could (often should) have done better. For in each of these incidents there will be a degree of personal accountability. That is life in medicine – a career of direct accountability for the welfare of others. Somehow we must all find a way of carrying this without being broken, and not only that, ensure that the equally intense positives are recognized and enjoyed.
Dr Padan could not hide his annoyance. The handover session proceeded icily. When the team came to discuss Mr Peterson it was confirmed that his precious vascath had been removed. Juliet looked away. Her eyes watered but she kept it together. Dr Padan discussed the fact that the patient now needed new venous access, and instructed the registrar to contact the vascular surgeons. It had come to that. They were going to have to cut him open to find a blood vessel. Juliet sensed danger, her gut contracted, but then they moved on to the next patient. Only at the end, while the team dispersed onto the ward, did Dr Padan tap her on the shoulder and take her aside.
“Juliet. That vascath. You know it shouldn’t have come out?”
“I know now Dr Padan.”
“I thought we had made it clear in the previous handover that it was not to be removed.”
Juliet’s world spun and closed in on her. Blame settled onto her like black spell materialising from the air.
“I’m sorry Dr Padan. I don’t think I knew. It wasn’t on my list, I usually make a mark or use an asterisk or something if it’s really vital.”
Dr Padan looked along the ward. “Didn’t the nurse in charge challenge you?”
A measure of relief. It was not all on her.
“A shame. It looks like the communication wasn’t very impressive all round.”
“I’m so sorry Dr Padan. Will it make things very difficult…?”
“Yes. Unfortunately, Mr Peterson was in a difficult situation already, three failed transplants, sepsis.” He paused. “Look, Juliet. I’m annoyed at the situation, but I’m not angry, at you. You were right to assume that the vascath should come out, in principle. But in this case there were individual factors that you didn’t know, it appears, or didn’t fully understand. This is a high-risk specialty. It won’t be the last mistake that occurs on this ward. It wasn’t all your fault. OK?” He walked away. Juliet stayed put. Nobody could accuse Dr Padan of having the highest degree of ‘people skills’, but Juliet concluded that this had been his attempt to be nice. His way of diluting the sense of blame.
It didn’t make Juliet feel good, but it was enough. She pressed forward into the day, and made a mental note.
Don’t ever mess with a patient’s vascath without checking again.