Medical error

Fear and medicine – friend, foe, natural bedfellow?

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.”

“So?”

“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?”

“No.”

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.

 

***

See also ‘Stuff Happens – patient safety incidents and 2nd victims’

 

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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 [link subsequently taken down] and the transcript of the recent High Court judgment. [On 13.8.18 the Court of Appeal overturned the High Court’s judgement]

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.’

Not in my name

 

A recent coroner’s report caught my attention (highlighted by HSJ’s Shaun Lintern via Twitter). A patient died from a ruptured aortic aneurysm, and during the investigation it was discovered that it had been seen on a CT scan four years earlier. However, the patient never came to hear of it, the GP was not informed, and no follow-up was arranged. The coroner now requires the Trust, through a letter to the Secretary of State for Health, to review its arrangements for flagging up ‘non- cancerous but significant and potentially life-threatening findings’ on scans.

The aspect that worried me was that the consultant, who had read the report and was intending to tell the patient in clinic 5 days later, never saw him. He was seen by a trainee, and the trainee either did not see the scan result or did not understand its significance. This made me think about clinical decisions being made in consultants’ names, but without consultants being aware of them. Does this really happen? Yes.

Consultants lead teams. In some clinics, 30 or 40, even 50 patients will be seen in a consultant’s name, but because the consultant is only able to see perhaps a third of those personally, the rest will be seen by trainees. Those trainees will have some specialist knowledge, but they may be three or four years out of med school. As trainees, they are supervised, but the level of supervision will vary.

During my training, I never saw a clinic where trainees discussed all of their patients with consultants. Rather, consultants relied on trainees to use their judgment and ask questions about challenging cases when they felt it was necessary. Then, as now, many patients were seen, investigated (and perhaps discharged) without the consultant having been directly involved in the decision. This is more common in bigger hospitals, where there are more trainees and larger clinics. It may sound alarming, but just as junior doctors see patients in the emergency department or on the wards, and make important decisions day after day, so they do in clinic too. (In fact, the terms ‘junior’ and ‘trainee’ sit uncomfortably with experienced professionals in their thirties.) Nevertheless, if a trainee misses the point entirely, or overlooks a subtle sign or important result, there is always the possibility that a dangerous conditions could slip through the net.

On the wards, every action and decision is made in a consultant’s name. I remember explaining to relatives, and on one occasion a coroner, why certain clinical decisions were taken by another – perhaps at night when I was not even in the building – but ‘in my name’. When pressed by both whether I thought those decisions were ‘right’, I had to pause. If it had been me on the ward at that time, I might have interpreted the information differently. I might have prescribed a different drug, or referred to another specialist sooner, but… it wasn’t me. It was a trainee, and they did what they thought was best. It wasn’t wrong, but it wasn’t necessarily, in retrospect, as right as it could have been. If there were errors in judgement, short of outright negligence or something amounting to an incident that requires reporting and the duty of candour, it will be dealt with through their educational supervisor. It would seem wrong to allow the full weight of responsibility to lie on the trainee’s shoulders. After all, I have to remember – a few years ago, that trainee could have been me.

So what is the consultant’s responsibility here? Are they truly responsible for the patient’s outcome, even though certain important decisions are not in their control.

Well someone has to be responsible. Consultants stay in one hospital for a whole career (usually), while trainees move on. In the case of the missed aneurysm there was a delay of four years before the error was noted. The trainee who may or may not have seen the result, or who failed to chase up the results of the scan, would have moved on. They are out of the frame. It was the consultant who had to explain what happened to the coroner. In that case, ‘the system’ took the blame (the way in which x-rays were reported and flagged). This is often the case, and in a blame-free culture that encourages reporting of error, it often has to be the case.

The system is often inefficient. The system may have intrinsic gaps which are unsafe. As doctors, we complain about the system all the time, but perhaps this is where our responsibility truly lies. To be open to the possibility that the system we are working is imperfect, and to accept of our role in improving it. That is why consultants must also be continual improvers of quality. It is not enough to moan. If weak areas are identified, we must engage in strengthening them. If we find gaps, we must close them. We must complain, escalate, and help to fix. That is the quality that should be scrutinized, rather than the (superhuman) ability to detect and personally manage every patient who passes through our service.

 

Interactive Ward Ethics 2: Dangerous

This is the second interactive post, and the scenario places our long suffering but excellent medical registrar, Nina Charan, in a no-win situation. She observes a colleague, another registrar, making a complete mess of a delicate medical procedure, and has to decide how to deal with it. Should she ignore it, manage it herself, give him time to improve, or escalate her concerns immediately? What may look obvious, from a patient safety point of view, becomes more challenging when you think about the psychology and emotional risks.

The choices you make for Nina will lead her into various stressful consequences, although some will result in a satisfactory outcome.

I recommend using the back arrow on your browser to move back if you want to take another route. There is a route map in the Summing Up section.

Click here to enter ‘Dangerous’.

Patterns and pride: diary of a medical anecdote

…There is, it seems to us,
At best, only a limited value
In the knowledge derived from experience.
The knowledge imposes a pattern, and falsifies,
For the pattern is new in every moment
And every moment is a new and shocking
Valuation of all we have been.

T.S. Eliot, East Coker (Four Quartets)

Day 1
It was a good day today. There are not many occasions when you recognise the clues, feel bold enough to make a diagnosis, and see admiration in the eyes of your colleagues – some of whom didn’t even know who you were.
The patient came in with fever, he was referred as just another pneumonia or a urinary infection, but I noticed that one of his blood results was unusually high. The eosinophils. This led me to ask about his travel history, because these cells often go up when there are parasites in the system. And indeed he had travelled, a fact that no one else had thought to ask. I looked up the country in which he had spent time, and worked out what sort of parasites could be involved. But I knew which one already. The symptoms seemed to fit what he was describing, to the letter. Fever, abdominal pain, some weight loss, and especially breathing difficulties that he had developed just before coming to hospital. It all fit.

strongyloides
So I looked up the treatment, called the pharmacist to make sure we had it in stock, and prescribed it. By the end of the day he was already feeling better. It made all the study seem worthwhile. But it was a special memory that served me so well today. I had seen a patient just like this one during my elective, in Africa. I even wrote about it in the report that we had to hand in, so it stuck in my brain. Strongyloides. I suppose, over a whole career, many such images and stories will find a place in my memory, to be retrieved at a later date. Nothing wasted, they all find a niche. A good day.

Day 2

I went straight into see him as soon as I arrived. He was grateful, and asked how long it would take him to get better. I said I would refer him to the tropical disease specialist, as they see more of this sort of thing. And of course I explained that we needed to confirm the diagnosis, even though I was pretty sure about it. I reviewed his blood tests, and saw this kidneys weren’t working so well. He must have got very dehydrated before he came in. His breathing had settled slightly, but he was still struggling. I didn’t want to come across as an expert, because I have only ever seen one other person with this. But he’s on the right track.

Day 3
I was disappointed today. His kidneys were worse, despite the fluids that I prescribed. My consultant didn’t have any new ideas, she was pretty happy to go along with my explanation. But she was keen to see confirmation of the diagnosis. The antibody tests will take days, they have to be done in London. She asked me whether it could be any other parasite, or any other type of infection full stop. Perhaps she doesn’t quite trust my impression. It made me think, and reflect. But I’ve seen the list of parasites, and none of the others that he might have acquired in Africa present like this. So I suggested that we push on with the current treatment. It worked last time, I explained.

Day 4
Weird. He was confused today. This parasite can affect the brain though. I spent 45 minutes on the phone trying to get through to a tropical disease expert, to see what they thought. They agreed, yes, Strongyloides can go into the brain. So I arranged a scan, and it’s happening after hours tonight. The anti-parasitic agent we’re giving him will kick in soon.

Day 5
I went to see him but he wasn’t there. I ran into another SHO in the corridor who had been on call overnight and he told me he’d been transferred to the intensive care unit. I almost ran. When I got there I found him unconscious, on a ventilator. He was surrounded by other doctors. There was a neurologist, examining his eyes. I asked what was going on. He had blown a pupil, I was told. It didn’t make sense. I saw a nurse returning from one of the computers. She was shaking your head. ‘What!’ shouted one of the other consultants, a rheumatologist. ‘They must have done it!’ he said. I faded into the background, but I continued to listen. What angered him was the fact that during the patient’s entire admission, no one had sent off a vasculitis screen. As soon as I heard that word, vasculitis, my heart dropped and the muscles in my legs grew week. I had to sit down behind the nurses’ station. I realised that I had made a huge mistake. For vasculitis is another main reason for eosinophils to be raised. I knew immediately what is the diagnosis was. Churg-Strauss syndrome. I had missed it completely.

Day 9
I met with my clinical supervisor today. I had asked for the meeting. I told her what happened. I could tell that she thought my mistake was a bit stupid. She asked me what my thought processes were on the day the patient came in. I explained the whole story, how it rung bells in my mind, how the words that he used, and the clinical examination findings, had taken me back to a vivid moment in my training. And I had questioned the data, and I had tested the hypothesis, and it all seemed to fit.

‘But what about the differential diagnosis?’ she asked

‘I… I…’

‘Did you develop one?’

‘I did, I think. I’m n…’

‘Did you write it down Emma, in the clerking? Did you test for anything else?’

‘I didn’t think I needed to. It was so clear.’

‘Well, to be fair, the patient saw a lot of other people, and more senior than you, before he got really ill. No one really challenged the diagnosis. There’s a lesson for all of us. But it shows you the power of a positive diagnosis. Especially one that appears to be supported with confidence. You’re a junior doctor, but you see how much weight people give the opinion of anybody who seems sure of themselves. Yes, diagnoses should be challenged by more senior doctors as they review patients, but it is not uncommon for them to defer to the opinion of the first doctor who really got their teeth into the case. And that was you. You made a plan, it made sense, the patient even got a little bit better at first. Sometimes, I think, there is really one chance to set things into motion in the right direction, and that’s on the first day of admission. It’s a big responsibility. Am I making you feel any better?’ She smiled. Then she asked, ‘What would you do differently next time?’

‘I won’t be so confident.’

‘That would be a shame, if you are right.’

‘Well if I really think I’m right, I will make my case confidently. But I will make sure there are caveats, and that other avenues aren’t closed off right at the beginning. Perhaps in this case, because he had raised eosinophils, he should’ve seen a rheumatologist anyway, even if I really thought he had an infection.’

‘I’ll tell you what I take away from this. The power of anecdote. In your mind there was a clear story, and narrative that you had seen played out before, one with a happy ending. You were sucked back into that memory. If you’re like me, your memory works best when it’s embedded in stories. But I guess that might be a disadvantage, if you can’t stand back and approached each case with pure objectivity. Attack each case with fresh eyes, but use the stories that you recollect to remind you of all the possibilities.’

‘I hear you.’

‘And one more thing. The Procrustean Bed.”

procrustes‘The what?’

‘His confusion. It challenged your hypothesis, it didn’t make sense, but you rationalised it, and made it fit your idea – a parasite in the brain. Procrustes chopped or stretched travellers who encountered him until they fit the size of his bed. You not only fell into the trap of anecdotal memory, but you tailored your interpretation of the data so as to support it…’

‘There is one more thing.’

‘Tell me.’

‘I was pleased with myself, on the first day. I elated, to make a difficult diagnosis.’

‘That may be the most valuable lesson of all. It’s seductive, the warmth that being right gives you. But don’t worry, you’ll experience enough reverses in your career to learn that pride is never to be entertained. I think you’ve learnt enough from this particular case, don’t you! How is he by the way?’

‘Getting there.’

– – –

Note: This case report from the CLEVELAND CLINIC JOURNAL OF MEDICINE explores the clinical scenario in more detail.

spokenunspokenPAPER

Intersection

intersectionfigure2

This is a brief tale of two patients who never met, but whose lives became briefly entwined with huge consequences.  Until the day that saw both became ill their life lines had not intersected before. Suddenly those lines veered from their usual course and dived across the city towards a bland, anonymous nexus…the hospital. They arrived within an hour of each other but were too preoccupied with their own symptoms and fears to become aware of one another in adjacent cubicles. Their relatives passed in the corridor, and may have stood in line together at the coffee machine. The patients, an elderly man and a thirty-five year old woman, were seen by different doctors. His angina settled with morphine, oxygen and nitrates; her asthma attack eased with nebulisers and infusions. She was transferred to the medical high dependency ward for monitoring, he to the coronary care unit. Their lives diverged once again as they were transported to different ends of the hospital.

At 2am his angina leapt back up for attention. The nurse looking after him turned up the nitrate infusion, but bleeped the doctor on call as the pain score rose from 7 to 9. The doctor responded and began to make his way to the ward. He knew that the ECG was essentially unchanged – the nurse had told him so, and he trusted her interpretation. She had seen a hundred times more ischaemic  ECGs in her career than he had. But he had a plan – intravenous beta blockers, to slow the heart and make the myocardium less hungry for oxygen.

As he turned the penultimate corner his bleep went off again. He spotted a phone hanging from the wall and called the number. It was HDU. A young woman with new onset asthma was deteriorating. Oxygen saturations were dropping, she was confused, peak flows were unrecordable…every red flag he could think of was being waved.

The coronary care nurse knew what needed to be done. Her patient’s pulse was 95 beats per minute, but a simple injection could bring it down to 65 and ease the pain. He was clutching his chest, pressing on the sternum as though to reach into the cavity and tear the source from his body. And now, on the cardiac monitor, she saw definite signs of ischaemia. Where was that doctor?

The doctor turned the final corner…and entered the high dependency unit. The asthma patient was close to collapse. He laid her down, began to assist her breathing with a bag and mask, and calmly ordered the nearest nurse to summon the entire medical emergency team.

On the cardiac ward the nurse had gone so far as to draw up the beta blocker in readiness. She was quite prepared to tell the doctor what to do if necessary. Then she would phone the on-call cardiologist herself to discuss emergency angioplasty. Nervous now, she walked from the bed space to the desk, in order to bleep him again. He had said he was on his way, and, though she couldn’t be sure, she thought she had heard his footsteps approach up the corridor five minutes ago. He must have got distracted.

‘Good call,’ said the anaesthetist on the emergency team, ‘…she needed intubating. I’m glad you didn’t hang about.’ The junior doctor felt good for what he done. He had recognised the red flags and had responded to them efficiently. As he left this scene of minor glory (he had qualified only 18 months ago after all) the crash bleep sounded. He and the rest of the crash team ran to coronary care, leaving behind only the anaesthetist who continued to ventilate the asthma patient.

They worked on the elderly angina patient for 25 minutes, but his heart could not be coaxed back into life. The many injuries it had accumulated before and since the bypass operation 18 years ago meant, for reasons we don’t fully understand, that once its lifelong habit of beating had been interrupted it would not be restarted.

His family were shocked, but not surprised, if that combination of reactions makes sense. They knew nothing of the junior doctor’s genuine intention to see their father, nor of the badly timed phone call that caused him to turn around and walk away from the coronary care unit. There is no way of knowing if his arrival would have made a difference…but it might have. So here we see how the life lines of two patients eventually crossed, the exact point of intersection being in that corridor, where the beige plastic phone hung on the wall, when the doctor on call decided to prioritise the needs of one before the needs of another.

A hospital represents a huge exchange in which hundreds and thousands of life lines touch each other every minute, altering in subtle ways the medical decisions, therapeutic actions and clinical outcomes of complete strangers. This sounds strange…and not a little wrong. A patient’s outcome should depend on several things, but not on the nature of their neighbour’s competing condition! On any given day the care a patient receives will be influenced not only by the vagaries of their own illness, the expertise of the doctor they encounter and the compassion of the staff they meet, but by numerous factors beyond the essential medical dynamic. The concentration and character of life lines running through the great nexus will also determine what happens. This fanciful representation may reveal a degree of caprice that we would rather not admit to, but we witness caprice every day, in nature and disease, in human response, in physiological or pharmacological idiosyncrasy. It is unavoidable. While we marshal these random factors into a logical, safe and personal management plan to the best of our ability, it does no harm to remind ourselves that the job of picking apart those life lines and prioritising their needs can never be an exact science.

 

[The cases are fictional]

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The eyes and the ears: why Adam blew the whistle

Previously I wrote a dialogue between two junior doctors. They discussed why Michael would not report, to some higher authority, the dangerous incompetence of a consultant. In this second dialogue, Adam explains to his friend why he phoned the GMC to report dangerous staffing levels. This dialogue seeks to illustrate why a doctor might feel compelled to act, rather than just watch, shake their head and move on.

This is imaginary, obviously. It is intended to describe the thoughts that a whistle blower might have.

Adam and his friend sit in a beer garden. Adam occasionally looks over his shoulder to check who has taken the adjacent table.

“Was it you?” asks Adam’s friend.

“What?”

“Who called the GMC.”

“What did you hear?”

“That someone blew the whistle on A and E.”

“What else did you hear?”

“That it was about staffing levels, lack of support…it was you wasn’t it?”

“Why do you think it was me?”

“Because you’ve been going on about it for ages.”

“That’s the point I guess. I wasn’t seeing any changes at all. I was out of ideas.”

“So did you actually complain first, officially…through proper channels?”

“I told the clinical lead that I thought we were too thin on the ground. Several times.”

“And what did she say?”

“That it ‘will get better’. That ‘when the deanery send us more juniors we’ll be fine’. Mañana, mañana.”

“Did you have examples, of poor staffing leading to bad outcomes?”

“How can you get that evidence? We’re working on the ground, struggling, we work our arses off to keep the ship afloat, some people die, most don’t, how do I know if any particular death is directly related to not enough staff? How do I know if our department has got more deaths or delayed diagnoses that average? I don’t have that overview.”

“So how can you justify blowing the whistle? You don’t know that the department was actually under-performing.”

“If you follow that line of reasoning, no-one would ever stand up and say anything, they would have no confidence in their own opinion. ‘I’m just a cog in a machine, I’m not driving the machine’. To justify NOT saying anything you have to have complete faith in the driver. Do I have faith in the driver? I don’t know, I don’t know the people who run the hospital . All I know is that sometimes it’s hell in that department and patients are falling off their chairs in the waiting room.”

“And despite not knowing, you made the call. Where did you develop that confidence in yourself?”

“It’s not confidence. It didn’t come easy. I waited for months and months before making that phone call. Nearly a year in fact. But nothing was changing.”

“It has now.”

“I know.”

“You should feel proud.”

“I don’t. I just feel sick when I walk through A and E. At least staff move through it so quickly the current set of juniors don’t recognize me as the troublemaker. The consultants do. But a few have told me that they are pleased I did it.”

“Weren’t they embarrassed?”

“No, I don’t think so. They thought the same as me. When someone actually does it…does something positive, everyone suddenly says ‘Yeah, I agree, it’s unacceptable…’. Like the emperor’s new clothes, everyone pretends it’s fine, they can manage, then someone pipes up and the truth becomes clear to all, undeniable. Weird psychology.”

“But why did it take your call? The Trust knew about the situation, the department was aware…not just from your comments…but it took the fear of a GMC investigation to do anything.”

“I honestly don’t know.”

“Has anyone from senior management spoken to you?”

“Yep.”

“And…?”

“It was all very reasonable, understanding, respectful in fact.”

“Fake?”

“Actually no. We got into a good discussion. He made me feel relaxed, and we went into it in some detail.”

“Such as?”

“The bigger picture. He allowed me to push him…to draw him out…to reveal HIS thoughts about whistleblowing. It wasn’t the greatest example of whisteblowing in history was it, really, more of an alert I think…so I don’t think he minded talking about it. So we got into the bigger picture. He encouraged me to think about scale, to think about the hospital as a unit, providing care to all of its patients and to the whole community. Elective and emergency. Babies, kids…not just the sort of patient I was seeing. Those in charge have to decide where to put the resources, where to place the staff…”

“So only they have the overview, and the knowledge…”

“Perhaps, but it went further. I said yeah, you have to make hard decisions, to ration basically, but you in turn are being rationed, by the government, who have demanded that you save x million this year as a share of the £20 billion of efficiency savings. He liked that.”

“He didn’t really agree to pass the buck onto the government did he?”

“Not as such. But perhaps he should have. I might have sympathised with him.”

“You can take the bigger picture further you know Adam.”

“How?”

“To society as a whole. Why does the government demand we save £20 billion?”

“Because the economy is screwed. Austerity.”

“Yes, that’s the environment we live in. But within that environment the government has decided to squeeze the health service because it has a duty to maintain other parts of the state at the same time. Defence, social security, prisons…so in their eyes, the bigger picture demands that Trusts feel the pain. That’s the price of austerity, of long term economic stability. We don’t have that overview, the really big overview.”

“You really believe that? No wonder you didn’t make that call. You’ve intellectualised it to death.”

“Perhaps.”

“I said I sympathized with the big picture, but ultimately it doesn’t cut it. Because it’s not our business to care about the bigger picture, don’t you see? Resources are be sent down according to the best judgements or intentions of our political masters, or moved around the Trust by our senior managers, but we must concern ourselves with what the effect of those decisions is at ground level.”

“Humour me a minute Adam, I’m not criticising you…but why whinge about those decisions? We live in the big picture. We are citizens in a democracy, we, as a society, voted for austerity and hardship. We ARE cogs. That’s the state we’re in, we should just do our best within it. ”

“It doesn’t matter. We, as doctors, work in a small world, the hospital…and we are there to make patients better. We are the ones with the eyes and the ears to tell the ones who move those resources around that their decisions are proving destructive. We are the ones who must tell them if minimum acceptable standards are not being maintained. Who else is going to spot that? If not us, who?”

“But doesn’t everyone think that their little domain is under resourced, straining to maintain minimum standards? We can’t have all of them ringing the GMC helpline.”

“I agree. And that’s why it took me a year. I challenged myself over and over again, told myself it was just me, just a bad run of shifts, that my seniors had recognised the problem and were dealing with it…but nothing happened! So I did it. I reassured myself that it was up to me to tell them that here, in this case, the balance wasn’t right.”

“Eyes and ears.”

“Yep. That’s what Francis said.”

“And mouths too.”

 

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The cusp: ethics of the learning curve

learningcurve

 

There is a moment in medical training when you think you are ready to go it alone. The difficulty is deciding when that moment has arrived. Independence, working without supervision, is a watershed moment.

Imagine this situation. A gastroenterology registrar who believes that she is ready to deal with bleeding ulcers receives a phone call. A patient is bleeding in the ER. She makes arrangements to bring the patient to the endoscopy unit. She decides not to call her consultant because he has said on a number of occasions that she is ready. He has ‘signed her off’. The patient now awaits her; she takes the endoscope and passes it into his mouth. She finds the ulcer quickly and knows what to do. But it is bleeding rapidly, and the views that she obtains are not very clear. She knows what to do. She washes the ulcer, tries to clean the blood away, but still it bleeds. She begins to feel nervous…even more nervous. She asks for a needle with which to inject adrenaline, hoping that this will slow the bleeding down. Then she might see enough to apply some definitive therapy, a clip or thermal coagulation.

She waits for the endoscopy nurse to get things ready, and watches the patient. The elderly man is sedated, but his pulse rate continues to climb despite the blood transfusion. The registrar knows that she would rather her supervisor was here. But then she reflects – this is what independence is about. Coming out of your comfort zone, absorbing the stress, dealing with the situation, making the decisions, …enlarging that zone… making yourself better so you can treat the next patient with even greater confidence and skill. But what if that process involves putting this frail man at risk? She readies herself for the next part of the procedure. She knows that if this goes well she will emerge from that room a better doctor.

The scenario can now go one of two ways…

A. She injects the adrenaline and as she had hoped it has a constricting effect on the blood vessels, causing the flow to slow down. Now when she washes the blood away it takes longer to ooze back, and she can see the culprit in the middle. A raw artery that has been eroded by acid. She chooses to use the heater probe and asks the nurse to make it ready. She passes it down the channel of the endoscope until she can see it emerge on the screen. With one hand she controls the wheels on the endoscope to optimise the position, and with the other she presses the heater probe onto the vessel. Then, with her right foot she presses a pedal on the floor and sends electricity into the probe, creating a tiny zone of intense heat until the vessel is ‘cooked’. Thinking that she has sealed artery she pulls the probe away. But the bleeding is even worse now. She must have torn the wall away. Quickly she calls for a clip and the nurse passes her the kit. The registrar pulls out the heater probe and quickly, calmly, replaces it with the clip delivery device. Soon she sees the metal jaws, grossly magnified, floating around the field of scarlet on the TV screen, and although the view is flooding with blood again she can still glimpse the artery. Before the window of opportunity has passed she pushes the clip onto the artery and asks the nurse to deploy. The clip closes down on the artery and stops the bleeding immediately. The field clears and she places two more clips above and below. The patient is stable.

“Well done,” says the nurse “that wasn’t easy. You could tackle anything now.”

B. She continues to wash away the blood, but the view is terrible. She injects adrenaline and it slows things down, improving the view. Now the time is right to use the heater probe. She places its tip on the ulcer, right on the vessel that is spurting blood, and presses the pedal. The heat dissipates into the pool of blood, and makes little difference. She knows that a clip is the next best thing, but she needs a better view. She readies the clip, and through the other channel of the endoscope she squirts more water. The view improves and when the time is right she deploys the clip. For a while she thinks that the job is done, she sighs in relief and smiles at the nurse, but 30 seconds later the bleeding erupts again and all views are lost. She takes out the camera, bleeps another member of staff to come and help look after the patient, and rings a surgeon. He arrives quickly, but argues that the patient is too frail to undergo an operation. The registrar argues back, saying that she can do no more within the scope. They debate the pros and cons of various other treatments, and in the end agree that surgery is the only hope. The patient is anaesthetised and in the operating theatre 40 minutes later. The ulcer is located and sealed. But he does badly after the operation, and develops a chest infection. He remains on a ventilator, and in the end, seven days later, dies.

The registrar describes all this to her consultant. From the description he can see no reason for her to blame herself.

“You did fine.” he says, “You knew when to give up, that’s half the skill.” He doubts that his presence would have made much of a difference. But the registrar knows that the patient’s greatest chance of survival would have been afforded if he had not had to have an operation, if the most experienced person had been there to treat the ulcer…if she had not proceeded on her own.

*

As a trainee approaches the top of a learning curve the moment comes when they have to decide if it is safe to go it alone – the cusp. The patient who comes into hospital on that day will have no idea that they represent a significant moment in the career of the doctor who is called to perform their procedure. They will have no idea where they lie on that learning curve, or that they might form a stepping stone to independence and immaturity. This would not matter if their risk of harm was no greater than that of any other patient having the procedure. But it is the result of this risk analysis that forms a perfect example of how we balance individual risks versus societal benefits in medicine.

The concept of the learning curve was introduced to many members of the public in a horribly vivid way during the Bristol Heart scandal. One of the paediatric heart surgeons involved said,

“I believe that the reality of the learning curve may be illustrated by the evolution of surgery for transposition of the Great Arteries in this country … in the late 80s and the very early 90s it was generally understood and accepted that when a unit introduced the Arterial Switch operation for neonates there would initially be a period of disappointing results.”

I am not concerned with such extreme examples here, but the essence pertains. In order to achieve complete expertise it is necessary to accept a degree of ‘trial and error’. Or is it?

*

A thorough enquiry into this subject was undertaken by a US paper, the Dallas News, following controversial reports coming out of Parkland Memorial Hospital, the primary teaching institution of University of Texas Southwestern Medical school. This hospital seemed to take a liberal attitude to the surgical training, crediting its juniors with autonomy to proceed with many operations unsupervised.

One faculty supervisor who quit in protest said the mainly poor, minority patients of Dallas County’s only public hospital had effectively become “clinical fodder.”

Apparently,

The head of UT Southwestern’s general surgery residency program once said it was “OK for residents to make mistakes” on patients “even if they could have been avoided with better faculty supervision,” according to notes taken by a faculty surgeon and later included in court records. Tim Doke, UT Southwestern’s spokesman, challenged the accuracy of that account. But Anderson has testified that some faculty believed “that’s how people learn,” though he said he disagreed with the philosophy.

In this case (and the newspaper report makes excellent reading, as does this graphic summarising mortality), one supervisor became uncomfortable, and complained after he was called into a gall bladder operation too later, after a irreversible damage had been done to the bile duct.

This controversy crystallises an ethical dilemma in medical training. As the journalists put it, “There’s good for the patient, and there’s a societal good. We can’t exist as a society without physicians learning on the ground.”

A questionnaire study published in the BMJ found that 86% of surgical trainees or young consultants had performed procedures for the first time without direct supervision. This appears to be the reality of medical education. Attempts have been made to resolve the dilemma, another BMJ paper seeking to lay out a framework based on respect for the individual, beneficence and non-maleficence. In their introduction Jagsi and Lehmann explain that…

The burdens of medical education are not currently distributed fairly. In one US study, students saw disproportionately high numbers of non-white patients and patients with Medicaid (public insurance for the indigent).Another study found that children of doctor parents were less likely to be seen by trainees than were other children.

220px-Immanuel_Kant_3

Immanuel Kant (image from Wikipedia)

However, the approach laid out in this paper does not really equip trainees with a practical method of making decisions on the spot. Another paper (Journal of Medical Ethics) approaches the problem by applying Immanuel Kant’s Second Formulation of the Categorical Imperative,

‘‘Act so that you use humanity, as much in your own person as in the person of every other, always at the same time as end and never merely as means”

In reality however,

This conflict arises because, at least presently, medical practitioners can only acquire certain skills and abilities by practising on live, human patients, and given the inevitability and ubiquity of learning curves, this learning requires some patients to be treated only as a means to this end….Accordingly, until a way is found to reconcile them, we conclude that the Kantian ideal is inconsistent with the reality of medical practice.

To resolve this conflict,

…supervisors might undertake to delegate only under conditions where they can be as sure as possible that the procedure would be done as well as they could do it themselves. If this assurance can truly be given by the supervising doctor, then the conflict is solved.’

 

This seems unrealistic. So are the patients who take their place on our learning curves nothing more than a means to an end? The paper begins with a quotation from Atul Gawande’s book Complications: a surgeon’s notes on an imperfect science

‘To fail to adopt new techniques would mean denying patients meaningful medical advances. Yet the perils of the learning curve are inescapable—no less in practice than in residency’

Le Morvan and Stock seek to challenge the perception that patients are guinae pigs in four ways;

1) Discontinuing unnecessary use of patients without consent – they suggest that we introduce a consent process where possible. The example of pelvic examinations by students on anaesthetised patients is one such example.

2) Continuing to develop medical simulation models

3) Enhancing supervision, but…”We are sceptical that such an approach, applied stringently, is practical for all procedures. It is hard to imagine—for example, that an experienced surgeon can honestly say that his trainee’s first liver biopsy will be performed just as well as he would perform it himself. Moving in this direction, toward a more conservative educational model, would, however, reduce the extent to which patients are used as means only.”

4) Changing expectations, or universalising the problem. If the involvement of trainees is taken into account when the statistical outcome from a procedure is calculated, patients waiting for that procedure are not actually being disadvantaged by having performed by a trainee. This argument does have a whiff of sophistry about it, but I have found myself using it before. As a patient and a parent I would want the hospital’s best qualified person to treat me or my children (although I am probably too polite to demand as much), but as a trainee I often muttered to myself, in response to a patient’s underwhelmed expression, “Look, either I do this procedure or it’s another five hour wait…what will it be?” As the authors conclude,

It does, however, offer a useful way of approximating this ideal in light of the constraints imposed by the reality of medical practice.

I don’t think there is a way of truly resolving the Kantian conflict unless our patients accept that it is not possible to always see the most qualified person in the institution. But the deal must be reciprocated by trainees – they must ensure that every single clinical interaction is approached not from the point of view of ‘polishing their resume’ (as the Dallas News article put it), but from the point of view of the patient. The trainee may well be on the cusp, there may be a theoretically increased risk, but if the skills are embedded, if the trainers have given their blessing, if they feel ready on that particular day or night…no more can be asked.

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The needle and the damage done: circumspection

needle

Scrolling through my timeline on Twitter the other day, I saw that a junior doctor had suffered a ‘blood splash’, presumably in the face. This is when a patient’s blood is sprayed or flicked into your mouth or eyes…carrying with it the risk of infection from a blood borne virus such as hepatitis C or HIV (medical staff are immunised to hepatitis B). It made me think back on a similar experience as a junior doctor…a needle stick injury from a patient infected with hepatitis C. I’ll describe what happened in a minute, not because I enjoy telling unpleasant personal stories, but because I think the impact that these ‘avoidable but let’s face it they’re going to happen now again’ accidents have on doctors and nurses should be understood and emphasised. When I looked into the subject I discovered that research had been published on the subject this year, the results of which I will go on to summarise. It seems that the psychological impact of these accidents can be very grave indeed.

*

As soon as I felt the deep sting of the needle as it entered my finger I knew what it meant – potential disaster. I was cutting a space between the ribs of a patient on intensive care, making room for the insertion of a large chest drain. The tissues were tough, and I had to tear at the fibres with my fingers deep under the skin. But the patient was not sedated, and she was feeling it despite the local anaesthetic injection I had administered beforehand. So I did something stupid. I kept one finger in the cut, so as not to lose the track I had struggled to form, and with my other hand I carefully inserted the anaesthetic needle alongside it. In this way I hoped to numb the deeper tissues. I jabbed my own fingertip – ouch…a shock, but not really painful. It was the knowledge that hepatitis C viruses in my patient’s blood could now be running up the veins of my arm and into my bloodstream that caused me to freeze in fear. I withdrew my finger, looked down at my hand, tore off the glove, and squeezed the fingertip until droplets came out. The nurse who had been helping me recognised what had happened, but had nothing to say. I walked over to a sink, washed the blood off, wrapped a waterproof dressing around the tiny wound and went back to the patient. She still needed a chest drain after all. Soon the job was done, and the rest of the nightshift passed without incident. But throughout the small hours I could think only of myself: were there any viruses in the needle? How many would it take to cause a permanent infection? Would I need anti-viral treatment, would it work, could I continue to be a doctor while receiving the famously toxic combination of interferon and ribavirin? Might it fail, would I develop cirrhosis, would I end up in this very hospital, waiting for a transplant? Oh God.

I was distracted by anxiety for weeks, not to a disabling degree…not so as anyone would notice. At six weeks I had a blood test to see if there were detectable levels of virus in me. A week later I attended the occupational health department to get the result. The nurse had not read a Hep C result before, it seemed to me. She looked quizzically at the small piece of paper in front of her, and tilted her head slightly.

‘Err…you have…err…Hepatitis C.’

I nearly fainted. I looked at the report closely, upside-down, and lunged forward,

‘Let me see that!’

I turned the report round and saw that she had misread a < for a >. I had < 50 virus particles per millilitreof blood, not > 50! I was negative! She accepted my interpretation, and was embarrassed. I left the room and walked back to my ward. My skin was cold and wet. I felt fifteen years older.

There were antibody tests at three and six months, and they were negative too. I was not infected. In fact, looking back, knowing more now about the absolute risks, and the cleaning action that plastic gloves perform as a needle passes through them, it was never very likely. But the experience changed me.

*

Professor Ben Green and Emily Griffiths (University of Chester) recently published a paper called ‘Psychiatric consequences of needle stick injury‘ in Occupational Medicine. They administered a depression questionnaire to 17 needle stick injury (NSI) recipients who had been badly affected enough to be referred to a psychiatric clinic. None were actually infected. They compared these results with 125 non-NSI recipients who had been referred for other forms of psychological trauma. The authors hypothesised that NSI caused shorter or less intense periods of psychological morbidity. Their findings included a description that I recognised immediately,

Four of the cases (24%) described an initial period of up to 2 days of acute anxiety, disbelief, tremor and profound sleeplessness consistent with an acute stress reaction.’

Within the (admittedly highly selected) group of 17,

‘Thirteen (76%)…had a diagnosis of adjustment disorder (AD). Four (24%) met the guidelines for post traumatic stress disorder according to ICD-10 diagnoses.’

Other observations included,

‘NSI patients with AD repeatedly said that although accident and emergency staff or occupational health staff had reassured them that the chances of seroconversion were small they focused on the fact that there was still a ‘possibility’ of seroconversion and thus did not feel reassured.

They concluded, among other things, that

‘psychiatric disorders in NSI patients were similar to other trauma-related psychiatric illness in severity, but while they last for 9 months on average, this was not as long as other psychiatric trauma patients. Psychiatric illness following NSIs had major impacts on work attendance, family relationships and sexual health.’

*

These individuals were at the worse end of the spectrum, and the conclusions reached in this paper do not apply to all NSI recipients. I wonder if there is a more subtle effect on those who do not end up being seen by a psychiatrist – a heightened, and more general, sense of self-preservation. My own experience brought it home to me that while my career would involve seeing hundreds or thousands of patients who might carry serious or incurable infections, there was only one of me. I resolved to do everything I could to protect myself…not to a paranoid degree, but by applying a greater sense of caution. So, instead of plunging into the next cardiac arrest situation without a care for the bodily fluids that were leaking onto the patient’s chest or bed, I held back until my gloves were safely on. I know that’s what you’re supposed to do anyway, but in real life people don’t. They rush to save the patient. When I saw a woman collapse during a night out in Soho I ran up to her, checked for a pulse, but did not contemplate performing mouth-to-mouth resuscitation without a mask. I felt selfish, but I could not face the prospect of waiting for more blood test results. (Mouth to mouth is out of fashion now anyway – and fortunately, she was breathing.) Beyond the arena of infection, I became less inclined to make sacrifices that might affect my health or put me at risk of making mistakes; swapping into crazy sequences of night and day shifts as a favour for colleagues, covering extra clinics when dog-tired…sensible behaviour, in no way abnormal, but a change. The damage done.

The Needle and the Damage Done is a song by Neil Young (Harvest, 1972)

[an adapted version of this article appeared in The Guardian online]

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Hazard in context: the psychology of medical continuity

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Continuity of care in hospital is a hot topic. It is well recognised that reductions in the hours worked by junior doctors have resulted in a fracturing of the traditional team structure and more frequent handovers between staff as they come off shorter shifts. The Royal College of Physicians published a survey on the subject in February 2012, their press release saying,

‘…over a quarter (28%) of consultant physicians surveyed rate their hospital’s ability to deliver continuity of care as poor or very poor. In addition, over a quarter (27%) believe that their hospital is poor or very poor at delivering stable medical teams for patient care and education.’

Althought improved safety on the wards was a driver for change, a document published by the Royal College of Surgeons, ‘Do reduced doctors’ working hours create better safety for patients? – assessing the evidence’, challenged the assumption that working to the European Working Time Directive (48 rather than 56) led to greater alertness and fewer mistakes. The author Matthew Worral wrote,

‘There is a much greater evidence base to suggest the full-shift system being brought in increases patient harm through greater handovers and stratification of hospital staff. The potential for important information to be missed and inability to access senior expertise at key times are a greater problem for patients.’

Accompanying the move from long on-call periods to shifts has been a reconfiguration of the way patients are assigned to teams. In a soon to be published book ‘The Changing Role of Doctors’ (Radcliffe Health, May 2013), the main strength of the ‘old way’ is neatly described;

‘This firm structure, with the associated working pattern, meant there was a high level of understanding of one another’s strengths, weaknesses, training needs and personality. When this medical team was working at its best, all members of staff felt supported and there was a genuine sense of camaraderie and team spirit.’

and,

Continuity of patient care was of a very high level. Most patients were clerked in by a member of a firm (usually the most junior doctor) and then remained under the same team of doctors for the duration of the stay, regardless of where the available beds were.’

 

This contrasts with the new ‘ward based’ model, where,

‘…the junior doctor and consultant who first admit a patient will usually pass over the responsibility of care for the patient to another team as soon as the patient moves to an inpatient ward.’

 

The ward based model has significant strengths, not the least of which is that patients are directed to teams with expertise in their particular disease, rather than remaining with the ‘random’ team who happened to be on-call on the day they were admitted. Another strength is that work intensity remains constant, rather than fluctuating with the ebb and flow of admissions either side of an on-call day. A major downside is that whenever the patient moves within the hospital (into a side room because of infective diarrheoa, for example), her or she becomes the responsibility of another team. That team will have to review all that has gone before, check the results, get up to speed, and carry on delivering appropriate care seamlessly. The process of developing a full understanding of the patient’s needs and goals must be repeated. Rapport must be rebuilt. Subtleties may be lost. Errors can be made.

What is at the heart of these errors? System failures, ‘dropped batons’, poor communication…all are likely contributors. Professor Roy Pounder, contemplating the effects of reduced working hours, highlighted these factors in advance of the EWTD changes:

“Seeing a patient once or twice before handing over to the next doctor, who then does the same after a short period, means it is difficult to detect a subtle deterioration in a patient’s condition.”

But I wonder if there is a deeper issue, related to the way doctors understand their patients. The psychology of discontinuity. This needs to be adressed from the point of view of both patients and doctors.

Patient experience: anchorage

A 2002 BMJ paper, ‘Continuity of hospital care: beyond the question of personal contact’ offered some good insights into patient experience, using the following quotes;

“They keep asking the same questions…”

“My file was not present and new doctors were not informed of my situation”

“You always get different orders from new doctors”

“Too many doctors! A second opinion is OK, but the sixth and seventh are quite frustrating…”

These are the more obvious symptoms of discontinuity, but they do not describe fully the sense of vulnerability and frustration that I have sometimes detected. When I see a patient in the emergency department or acute admissions ward, a common question is,

“Are you going to be my doctor now?”

or,

“Will you be coming back to see me again? Will I see you tomorrow?”

I interpret such questions as an appeal for permanence or anchorage in the huge, complex system into which they have been delivered. Patients, it seems to me, are desperate to make a connection that can be relied on. If I know that the patient will come to my ward, I can answer ‘Yes, I’ll be along to see you tomorrow…’ and there may be a visible relaxation in their anxious expression. But if not, I have no choice but to explain, ‘No, it won’t be me who sees you from now on…but one of the other teams, lung specialists…’ Sometimes, if I have spent a good deal of time speaking with them, digging down in important medical or social details, I will add, ’But we will make sure they know all about you…about everything we have discussed…’ If it is a crucial fact I will make a point of telling the new team, but more often than not such hand-over of information will occur on paper, in the notes. This requires a clear handwritten entry, a transparent narrative. It is not uncommon for me to see what has been written by the junior doctor accompanying me only to realise that they have not interpreted the patient’s words in the same way I have. The emphasis is not quite right. So I re-write it, and leave the ward hoping and expecting that whoever receives that patient will see my note and make sense of it. This is an attempt to maintain the chain of continuity.

I wonder if the psychological distress that derives from uncertainty, not knowing if someone in the machine ‘owns’ you, if someone is personally invested in your wellbeing, may be sufficient to undo the benefit of technically correct, well timed medical interventions.

Fast track empathy

How do lack of continuity and the diminished feeling of ownership that follows, influence doctors in a way that jeopardises safety? It may hinge on empathy.

Serious illness requires the application of powerful medical interventions. These bring with them the potential for hazard. Recent debate about ‘zero harm’ culture has crystallised the notion that medicine and its tools can do as much harm as good. To avoid harm staff must be vigilant; they need to keep an eye on the details, spot irregularities, check the blood tests, double check the drug charts, maintain the ‘housekeeping’ (as it is sometimes called), and anticipate complications. These duties should be automatic, but they are done better if the doctor knows the full story. If they have gained a full appreciation of the patient and their background they will understand better the true impact of those potential harms. Risks and harms can appear abstract, but when they are imagined in the context of the whole person they become tangible, transforming from theoretical ‘adverse events’ to personal tragedies. A better understanding of those risks may motivate doctors to work harder in ensuring that each job is done properly. Otherwise they will not be letting down, ‘…the lady in bed 25, acute kidney injury…’, but ‘Mrs Jones…she was hoping to get out in time to attend her grand-daughter’s wedding this weekend…’ Continuity encourages personalisation, personalisation permits the exercise of empathy, and empathy gives our actions relevance.

The challenge for doctors working to shift patterns and caring for patients who arrive to their ward areas on a daily basis, is to learn the practise of empathy in compressed timeframes. This requires active listening, generous emotional investment…energy. But to ensure that connections between patients and doctors are made within the restrictions of the modern hospital environment this has to happen. Otherwise patients will flow through wards without knowing if anyone really ‘owned’ them, or who that person was. And doctors will float from patient to patient without understanding quite how much trust was being put in them.