Blame Culture

Today we woke up to the news that the GMC has won its appeal to the High Court, and has struck off Dr Bawa-Garba.

Imagine, if you can, returning to your job after a prolonged leave of absence (maternity leave in this case), beginning your role afresh in a new environment with which you are not familiar, and being told that your colleague couldn’t be in today, and could you please do their work too? Additionally you find out that your boss is uncontactable, the other members of your team all started 2 weeks ago and are just finding their feet, and the IT systems are down. Someone else, in a different team, makes a mistake for which you are punished, and at the end of a gruelling workday you make an entirely avoidable mistake, which leads to catastrophic consequences. Are you no longer qualified to do your job? Do you lack the qualities and experience necessary to carry out your day to day duties? Or are these exceptional circumstances, and an entirely understandable lapse in judgement?

This is what happened to Dr Bawa-Garba. She made a mistake, on the back of incredibly hard working conditions over the course of a 13 hour shift, and a 6 year old boy died. Initial investigations into the case found that her mistake may not have influenced the end result of the resuscitation effort – the outcome may well have been the same. As so often happens in medicine, the SUI team found multiple contributory factors leading to this horrific outcome, and ruled that no specific person was at fault. However, Dr Bawa-Garba was convicted of manslaughter, suspended from the GMC register for a year, and has now been completely struck off.

We hold clinicians to a higher standard than most. It is understandable – our mistakes carry higher stakes. There are horrendous consequences to our failings. However, can we blame individual doctors for an outcome that has occurred in a working environment that no sane person would find acceptable?

We, as doctors, often work shifts where you go 13 hours without eating, drinking, weeing, or sitting down. I have often joked, whilst on call, that I am treating a patient for hypoglycaemia or acute kidney injury, but that my blood tests may well be worse than theirs. We prioritise the need of our patients consistently above our own basic, human needs. We work in conditions that you would be sued for trying to impose on any other profession. And the worst thing is, we impose those conditions on ourselves. We consistently state that our working arrangements are unsafe, no one in their right mind would think that staffing a 500 bed hospital overnight with a medical team of 3 people is a good idea. Wards of 30 beds go from a team of 3-5 doctors during the day, to sharing the 3 on call doctors with the other 470 patients in the hospital. Even on days when the rota is fully staffed and all the systems are working, it is a disaster waiting to happen. Medical ward cover consists of running from one fire to the next, never feeling like you are winning. How are you supposed to prioritise your need to eat when a succession of patients are, literally, trying to die on you?

But hungry, exhausted, overstretched doctors make mistakes. It should not be news that we aren’t at our best when our last meal was 12 hours ago. I remember clearly finishing one day on call on the maternity ward, and passing out on the walk to my car. On reflection, I hadn’t had a meal since dinner the previous night. I was concerned about my ability to drive, and called a cab home. 45 minutes previously I had been responsible for resuscitating a patient, solo.

During my time as an intensive care doctor, I frequently covered a ward of 14 critically unwell patients, with no Consultant cover on site. I started the job, on a night shift, with no induction to the computer-based notes system, no idea how to review medications or change doses. No understanding of how the filtration machines or ventilators worked. The fact that both I, and the patients, survived those on calls is testament to the incredible standard of nursing care. The nurses on that unit saved me more times than I can recall. But it should not be the responsibility of the nurse to educate the doctor. By that logic, there is no point in me being there. I reflect on that unit, and the fact that nobody died as a direct result of my lack of training or experience is frankly baffling.

The GMC has gone on nothing short of a witch-hunt. Bowing to tragically bereaved parents, making an example of someone who did nothing more wrong than any one of us has done on countless occasions, but got away with due to circumstance. The CEO of the GMC released a statement following the outcome:  “We are totally committed to engendering a speak-up culture”.

How do you expect to foster a culture of speaking out, when you victimise people attempting to reflect on, and learn from, their mistakes? Doctors are human. We will all make errors in our careers. I have personally made management decisions that have contributed to a patient’s death. We are a cohort of professionals that go into medicine in order to improve people’s health and lives. Nobody can make us feel worse about our failings than we already do. Nobody can berate us more than we berate ourselves. We worry about doctors’ mental health. We worry about a culture where no one wants to accept responsibility or blame. And then we have a doctor, with an exemplary record, who reflected on a difficult case, gave evidence to an investigation panel, and then had her reflective evidence used to bring a court case against her.

We are all Dr Bawa-Garba. I don’t need to know the case specifics to know that similar situations are happening across the NHS on a startling scale. That the people responsible for safe staffing and rostering are not the people living with the effects of shortages on the frontline. That the people who have made a scapegoat out of this doctor get to go home at 5pm each day, and never have to hold a person’s life in their hands while trying to remember the last time they had something to eat.

It’s okay not to be okay.

I am British to a fault.

I have been ruminating on aspects of our character that we may be unaware of. My other half is an Aussie, and when we first got together we had numerous arguments based around the different connotations of the word “fine”. Myself, a Brit, would tell her that something was fine, and expect her to infer that it was anything but. She, in typical Aussie fashion, took everything at face value and then was unable to understand why I was miffed (another classic British understatement).

When she moved over here she commented on our typical British greetings “Hiya, you alright?” and how there was no acceptable response to that other than “Yeah fine thanks, you?” We are not asking after the other person’s well-being, and if someone were to deviate from the script it would be awkward to say the least.

These discrepancies can be amusing, but our idiosyncrasies sometimes inhibit our ability to let other people in. This can have devastating consequences, particularly in Medicine. In addition to the British avoidance of talking about feelings, people in Medicine are also reticent to admit what they perceive as weakness, and emotional responses and feelings often get bundled away and taken home, not aired and explored in a positive atmosphere. Mental Health is still not addressed as it should be, and we continue to perceive the demonstration of emotion as a sign of fragility.

When you work it every day, it is easy to forget how emotionally taxing our job is. We see people at their worst, both physically and emotionally, and the range of conditions we have to deal with on a daily basis can often be a complete mind-fuck. You go from treating 4-day-old babies with sepsis, to trauma calling a teenager who tried to commit suicide, to dealing with the aftermath of a neglect case. There is often no time to think about it, no time to dissect your feelings about a case, and definitely no time to deal with the emotions that either of those actions would inevitably stir. You have to develop a way of coping that allows you to move on to the next patient, the next parent, and the next disaster. It is a fine balance. We traditionally shut off the parts of ourselves that struggle to process the things that we see, and we notice ourselves become less affected by our daily exposures. But this is not healthy, and it only takes a small thing to tip the balance.

Between 10-20% of doctors become clinically depressed at some point in their careers, and there is a higher rate of suicide than in the general population; particularly in the acute specialties, where there is a “stiff upper lip” attitude and a tendency to push forward in the face of signs that we are perhaps not as okay as we seem.

This has repercussions not just for us as physicians, but also for the way that we treat our patients. Up to 50% of Emergency Medicine trainees resign prior to completion of their training. As a specialty we are seeing the highest rates of burnout in the history of the healthcare system. EDs are becoming like warzones, and our already fragile mental health is about to snap. The higher rates of burnout correlate with self-reported depression rates of up to 40%, with associated lack of empathy and altruism, and increased rates of errors. Over the last few months, I have actively felt myself becoming more cynical, and less motivated to help people. A parent books in with their sick child and I am annoyed that they are there. The very reason that I trained to do this job has become a source of irritation.

This façade spills over into our home lives too. I am so used to shutting off my feelings about things that happen at work, that I attempt to do the same with things that happen at home. Over recent months I have been endeavouring to insulate myself from my feelings about both issues at home and difficult cases at work. And my mind simply doesn’t have the capacity.

I have recently considered going to a counsellor to help me unpack all the emotions I carry around with me, both from my personal and professional life. It has taken an almost daily struggle to keep those emotions under the surface to illustrate to me how important it is to deal with your responses to situations instead of packing them away, and using the traditional dark humour to cover them up. I have been less than keen to address these issues, due to both an inbuilt, British avoidance of talking about “feelings”, coupled with a desire not to seem nauseatingly American by attending therapy; but also due to the inescapable concern that it makes me a weaker person. That other people are managing, and by my admission I am not. That this somehow makes me a lesser doctor, a lesser person.

Acknowledging emotions is not a sign of weakness. Unpacking your response to a patient, or a situation, or your relationship, is the healthy way to deal with it and move forward. We need to stop prioritising relentless, emotionless work ethic above the ability to be normal, functional, people. We need to allow ourselves to be human.

Some of this needs to stem from a revision of NHS culture, for the establishment to recognise that lack of debrief, lack of NHS counselling, lack of self-care for our emotional selves is damaging to our productivity as a workforce, but most of it can stem from us, as individuals. If we are affected by something, take the time to feel it. Discuss it, dissect it, and get different perspectives on situations. Maybe not at the time, but we should prioritise debrief, prioritise acknowledgement of an emotional response. Allow ourselves to care.

We need to recognise, as individuals, that we are not built to carry all our stresses around with us. That showing compassion towards our patients begins with showing compassion towards ourselves, that when you are saturated by stress and emotional baggage you lack the capacity to truly help the patients that put their trust in you. We need to understand that overexertion and dependence on 3 coffees to get through the day is something to be avoided, not romanticised. That working hard doesn’t have to mean running yourself into the ground, and that taking care of our mental health is paramount to being empathetic, successful physicians.