Damned If You Do, Damned If You Don’t

Emergency Room Entrance

Ever made a mistake at work?

Mistakes, they say, do happen. But some are bigger than others. Forgetting to put the milk back in the fridge might get you some dirty looks, but what if your actions (or inaction) result in harm to – or even the death of – a patient?

For the public, the solution to medical mistakes seems simple: Find those responsible and hang ‘em high.

In some cases, the masses have a point. Psychopaths like Harold Shipman, Jane Toppan and Michael Swango – these so called ‘angels of death’ – could certainly have used a dose of their own medicine. But acts of genuine malice are, thankfully, a rarity. The truth on the ground when a case of medical negligence, incompetence, or accidental blunder raises its head is often much different.

Picture a dangerously understaffed A&E on a Friday night; an overwhelmed locum left without an on-site consultant due to staff sickness. This doctor is on the second round of a double shift, again due to staff shortages. Imagine they’ve just been threatened, yelled at, or thrown up on for the umpteenth time – and here comes their thirty-fifth patient of the evening.

This patient is an infant, presenting with a mild fever and hovered over by anxious first-time parents. The child is responsive but seems tired and irritable. Meanwhile, the next patient waiting has a deep gash in their forehead and is dripping blood all over the floor.

Who is it most important to help first?

To be on the safe side, the doctor asks a colleague for a second opinion – but then a code alarm beeps and that other doctor rushes off. One of the child’s parents admits they’re probably over-reacting. The doctor agrees that the baby has a slight temperature, and puts them in for a round of fluids. After an hour with no signs of deterioration, the small family is sent home.

Since you can probably already tell the tone of this article, you’ll know what’s going to happen next: Early the next morning, the same child is rushed in by ambulance – feverish, unresponsive and critically ill. It’s suspected meningitis.

Of course, this is a simplified series of events, and doesn’t take into account the multitude of tests that would likely take place. It would be foolish to assume that every case like this ends up the same way. Yet, running through the scenario after the fact is much like watching a YouTube video of road rage incidents and driving fails – you might think the drivers are willingly putting themselves into a dangerous situation, and decry their poor decision-making from your informed perspective. The truth at the moment of the recording, however, is that these people are not intentionally courting harm or disaster – they simply don’t know what is about to happen.

Crude analogy aside, let’s head back and follow our imaginary A&E doctor. A tribunal is called to determine what mistakes were made. The distraught parents are unwilling to engage with the hospital, and instead, they take their story to the media. The ensuing report goes viral, and someone has to be held publicly accountable.

Who will bear the brunt of the blame? Will it be the tired, overworked and under-supported doctor who made a genuine mistake? Or will it be the system that allowed a human being to work two consecutive shifts in an underfunded, understaffed and unsafe work environment?

I think we both know the immediate answer to that one – and this is the reality for doctors across the world. As I write this, there are several high-profile cases in the UK and US where medical professionals are being struck off, sued, and even accused of manslaughter – leading to the prospect of time in prison.

Possibly the most high-profile case of this type right now is that of Dr. Hadiza Bawa-Garba, whose story reads like a step-by-step walkthrough of a What Not To Do manuscript, designed to prevent catastrophic institutional failure. Neurosurgeon Dolin Bhagawati does a swell job of exploring the harsh and reactionary behaviour of the NHS and GMC in his article for The Guardian, here.

As Bhagawati explains – and given the forced back-tracking the GMC has had to take following Bawa-Garba’s appeal trial – responses of this kind, where ruling bodies distance themselves from those they’ve failed and directly contribute to the vilification of individuals and destruction of careers, do not provide the groundwork for an environment in which medical practitioners can feel supported or safe.

When you’re raked over coals, paraded in the public square, and fed into a mincer due to making a mistake – or even for simply being accused of making a mistake – the natural result is a toxic environment where everyone covers their own ass, points fingers at everyone else, and refuses to get involved in matters for fear of being singled out next.

And unless systemic changes are made, to the degree that doctors feel offered the benefit of the doubt and the support of their employers until the facts of any case have been straightened out, this will continue. Why? Because humans make mistakes. We always have, and we always will. Even the best training and depth of experience in the world won’t eliminate the possibility of a simple – but potentially serious – slip-up occurring at some point.

At least, not until medical technology catches up with Star Trek and we can wave a little device at patients and immediately know what’s wrong with them. But damn it, Jim, I’m a doctor, not a futurist.

One thing of which I’m sure is that we cannot remain in the status quo. When lives are on the line, medical decisions cannot be feared. Paralysis of indecision and the overriding desire to protect oneself – knowing full well that you could be the next Bawa-Garba if your decision is incorrect – is a dangerous state. It weighs heavily on the minds of practitioners who already know full well the severity of their responsibility; it offers a fast-track to burnout, and puts patient health at risk. Are we supposed to work together to grow, learn, and overcome… or batten our own hatches and shun those who slip up?

Right now, you’d think it was the latter – as whistleblowers are hung out to dry, zero lessons are learnt from doctors’ strikes, and the tennis game of rhetoric continues with no institutional change in sight.

Primula non nocere are the watch words, but every doctor will make a mistake at some point, and actual harm may be the result. With every sympathy and concern offered to the victims of those mistakes, it’s also how the mistake is acknowledged, learnt from, and how practice is adapted that matters too. We’ve seen doctors damned if they do (making a mistake, whether the blame rests entirely on their shoulders, or on a surrounding set of circumstances for which they shouldn’t solely be held accountable), and also damned if they don’t (the mere accusation of wrongdoing that is found to be false – but not before reputations are ruined and careers left virtually unsalvageable). And once the fires have died down, nothing new appears as testament to acknowledgement or learning.

Trial by media with emphasis on grieving relatives will never result in improvements in medicine. It will result in nervous doctors, frightened away from the profession by virtual lynch mobs and the knowledge that a majority of colleagues and those at the top of the ladder will not take a stance of solidarity in the firing line. It’s past time to talk openly about mistakes in the medical profession. How can an industry possibly get better when those who accept they made mistakes are thrown to the wolves and exiled to the wastes? What kind of environment is allowed to thrive when a single accusation can go viral and completely level a career?

Incompetence is one thing. Mistakes are another. The two do not necessarily go hand in hand – and until those in governance are able to make a sober distinction we will continue to see devastatingly high rates of physician burnout, disillusionment, and abandonment of the profession.