Reflections on medical culture and the Bawa Garba case
For background to the case – see this excellent BBC report by Dr Deborah Cohen
Originally posted at https://abetternhs.net/2018/08/13/reflections-on-medical-culture-and-the-bawa-garba-case/
I have been a doctor for over 20 years, 5 in hospital and 15 in general practice. I have been on the receiving end of medical errors and have made complaints about my own care, and the care of family members, who are not doctors and have lacked the confidence to complain, even when complaints are clearly justified. I have also been on the receiving end of serious complaints from patients, I have been successfully sued and had cases against me investigated by the Parliamentary Health Ombudsman.
Any doctor who has practised more than a few years will know that the vast majority of medical errors are not noticed, ignored or covered up – and though the majority of these don’t cause any serious harm, a minority do. Any doctor who has practised as long as I have, will, like me, have personally contributed to a patient’s death. Doctors are aware that most patients and their families do not complain even when they are aware that there has been an error and when they have had very reasonable grounds to complain. I have had to make complaints on my patients’ behalf because they were afraid or insufficiently literate/articulate to do so themselves. I know that most of the time, complaints are dismissed. When patients do complain, clinicians know that the majority of complaints are not about issues involving patient harm or clinical decisions, but about problems that they feel confident in their criticism, for example; lost dentures or professional attitudes, cancelled clinics, lost results or other organisational issues. Doctors know that the worst of their colleagues seem to be immune to the complaints they deserve, while the most conscientious are prone to the most vexatious.
Bawa Garba was forced, under stress to write down everything she could think of that she personally had done wrong. The person who forced her to do this wasn’t a prosecuting lawyer, but her clinical supervisor, the consultant who should have been supporting her on the day that Jack Adcock died. He then made her upload this as a ‘reflection’ in her eportfolio. Too many doctors’ experience of ‘reflection’ in medical education is shallow, critical and frankly, unreflective. Finally, the media is a menace – fanning the flames of fear and baying for vengeance and then moving on to the next story before the dust has settled.
In very little time at all doctors learn from experience that complaints are no measure of a doctor’s moral character or clinical competence.
Consequently, many doctors grow cynical, hateful of the GMC and the tabloid media and suspicious of patients.
These are problems of culture and psychology far more than they are technical and legal.
The solution must therefore involve an honest acknowledgement of the cultural milieu that doctors and patients inhabit. Doctors live in fear of patients discovering the mistakes they make and patients live in fear of being harmed. The solution must bring patients and clinicians together to have honest conversations that bring about what Richard Lehman has described as the ‘shared understanding of medicine’((Richard Lehman, University of Birmingham - ResearchGate)). It must include much greater transparency including shared medical records, patient safety reports, transparency about organisational pressures and what the NHS can afford. Patients and clinicians do need safe spaces where they can learn from mistakes apart from one another, but this should not and need not reduce the requirement to have shared learning as well. Only by making alliances with patients (contra pharma/commercial healthcare) and by treating patients as expert partners in care (and part of the solution) rather than a burden / problem, can we change. Medical educators and supervisors must take reflection seriously and learn how to use it as a force to challenge and change medical culture for the better. Finally – as Dr Julian Tudor Hart has argued, ‘Accountability must require that doctors insist that they have time to do their work properly’.
Links
Relationship-centred care - Jonathon Tomlinson, abetternhs.net
Defining "Patient-Centred Medicine" - Charles L. Bardes, The New England Journal of Medicine
A New Kind of Doctor: Accountability For and To Individuals - Julian Tudor Hart, Socialist Health Association
Managing the threat to reflective writing - John Launer, BMJ Postgraduate Medical Journal
At CHPI we aim to provide a platform for healthcare workers and academics to provide fresh perspectives and debate on key issues in health and social care policy.
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