The GMC’s choice to appeal the Medical Practitioner’s Tribunal decision regarding Dr Bawa-Garba demonstrates a deep lack of understanding of human beings, human failings, the NHS, mistakes in the NHS and the fact that a fear-based, protectionist, condemnatory and punishing approach to medical regulation does not protect the public but leads to greater harm both for patients and doctors.
The Dr Bawa-Garba case has sparked intense debate on the News, twitter, Facebook and in medical forums and coffee rooms across the country. There is a divide between those who celebrate and agree with the GMC’s approach to appeal the MPT decision of suspension to seek erasure of Dr Bawa-Garba from the medical register and those who completely disagree with it and fear for its long-term consequences on the medical profession’s ability to be open, transparent and able to learn from its mistakes without fear of GMC retribution. The latter are predominantly, but not exclusively, in the medical profession and who speak with a deep understanding of the issues at hand and a genuine desire to provide high quality patient care.
This is not a case of the medical profession seeking to protect its own.
We can recognise when genuine malicious harm with intent has been committed and in those cases, there is no twitter storm of protest or rallying cries of a miscarriage of justice.
THIS IS DIFFERENT
Most, if not all, doctors who have spent any significant time in front line NHS work, know that another day, another time, another patient – this could have been any one of us; our clinical errors, our reflections being used against us, our name in the tabloids, our name struck off the register generating a bitcoin public key. Not because all doctors are incompetent and deserve to be in jail or struck off – but because all doctors make mistakes, it is part and parcel of the inexact art and science that is medicine. “To err is human” – and doctors are, believe it or not, very human and just as capable of making mistakes as anyone else – the difference is our mistakes can cost lives.
But as many have pointed out, those mistakes do not occur in isolation but are often part of a sequence of events and circumstances that come together resulting in the unwanted outcome and in this case, there was a long list of such factors identified by the trust itself which significantly contributed to the death of Jack Adcock. Expert witnesses make pronouncements on whether Jack would have died had his management been different – but no-one really knows, given how sick he was, if he would have survived with different management. Sadly, sometimes children do die despite all that medicine offers.
It is completely fallacious to just look at this case in fragments, looking only at one person’s role, without taking into consideration the whole sphere of activity that was occurring or not occurring on that day. It is also fallacious to compare the reality of the NHS today with what is an idealised approach to healthcare that does not exist. It’s as if there is an assumption or expectation that this was the only patient that Dr Bawa-Garba was responsible for and therefore everything should be done instantly – in an ideal world yes, but we do not live in an ideal world. Three hours to review an Xray in the NHS is probably common, maybe it shouldn’t be, but it likely is, particularly in busy units with multiple admissions and patients to see and attend to, especially when compounded by a lack of adequate junior and senior support.
Indeed, many questions remain unanswered in this case – regarding the lack of consultant accountability, the role of the unprescribed anti-hypertensive and its administration without medical checks, and why key evidence was seemingly blocked by the prosecutors from the original trial?
Would the court have held the same finding of gross negligence manslaughter had they been privy to all the information and not, as I’ve read, had the submission of the systemic failings blocked by the prosecution? How is it possible for a jury or a court to come to a fair decision if they have been denied access to pertinent information and mitigating circumstances?
More worringly, I have heard it said from a legal source that short staffing, short resources, excessive workloads etc. are unlikely to be accepted as mitigating circumstances in a court of law – and this case seems to affirm that to be so.
But that does not make it right or true.
Is this process just about having someone to hang, a scalp to hold up and say ….see, we have found a perpetrator, someone to blame – should it not be about developing true understanding of exactly what circumstances, events, actions, communications, etc. were involved so that they can actually be rectified and not repeated, doctors remediated as needed and restored to work, not hung out to dry? Is the GMC seeking to genuinely improve the quality of healthcare or is it just seeking the scalp – flexing its muscle to preserve its own reputation irrespective of the effect on doctors or the profession as a whole?
Despite the judge noting and agreeing with the MPT that it is right that the maintenance of public confidence and standards do not mean that “it is necessary to sacrifice the career of an otherwise competent and useful doctor who presents as no danger to the public in order to satisfy a demand for blame and punishment” – this is exactly what has happened!
The emphasis on protecting the reputation of the medical profession over and above any individual doctor irrespective of the circumstances is sickening – the medical profession is made up of people, not machines who can be programmed to function with the flick of a switch like some factory machine that never goes wrong – but even the best of machines can break down.
We are people, caring people, with feelings and emotions, we can have all the messiness of life issues like everyone else, we can have good days and bad days just like everyone else, we can make mistakes, big mistakes, that cause harm and can lose lives, and we hurt and cry, often suffer in silence or a bottle or two of wine, or try to bury it away…. but sooner or later it raises its head again one way or another.
Work long enough and every Dr’s heart will have its scars, its wounds….no matter how many we get right, get better, restore to health, the ones we remember most are the ones that went wrong, didn’t get better, where we made a mistake and the patient suffered or even lost their life.
And so it shall be until we learn that there might just be another way….a way based on true understanding, love, compassion, acceptance and deep care for all.
What if the best way for the GMC to improve the standing and reputation of the profession, as well as the quality of care for patients, is to actually genuinely care for doctors; to understand that probably most of those who end up in front of the regulator are already hurting and harmed themselves and in need of even more care and support?
Naming, shaming and blaming – do not work, it does not improve the quality of patient care, nor does it remediate the doctor in any way. Indeed, it could be said that GMC fitness to practise proceedings render a doctor more unfit to practise than they were before, such is the toll on the individual of the draconian, condemning, punishing nature of such proceedings as highlighted by the significant number of suicides in those undergoing GMC FTP investigations.
Whilst there is definitely cause to seek a complete review of the fairness of the original judgement – the MPT obviously had to work with the court’s decision and at least they took into consideration all the information available, the systemic failings, Dr Bawa-Garba’s track record both before and after the event and her remediation and insight in order to not erase her but to suspend her. Sadly, the GMC do not seem to have the same understanding of the multiplicity of factors that contribute to medical error and that in most cases there are significant systemic failings, otherwise why would they have gone to so much trouble to get erasure? Even for other medical issues that come in front of the GMC there seems to be very little understanding that often someone who has harmed has often themselves been harmed in some way, leading to the erroneous behaviour, such that they too are in need of understanding, support and compassion – not the GMC guillotine.
Erasing a doctor who otherwise had an unblemished record before and after this event does not protect the public as the GMC seems to think. Today there is much less acceptance generally both within the public and the profession for any form of error. Medical students and doctors already have perfectionist traits that are unhealthy and the exceedingly high expectations of no error allowed only compound this further. It does more harm by increasing anxiety which is already pretty high, more defensive medicine, and reversion to a more closed culture and lack of transparency regarding medical errors. It results in harm to patients and harm to doctors – a lose-lose situation.
Whilst any such tragedy is difficult and heart-breaking for the family who has lost a loved one, who cannot be replaced by any form of compensation or legal ruling, there is a toll taken on the hearts and minds of the doctors involved as well. We are not immune to such events. This seems to be overlooked and not fully appreciated by many and certainly not by the GMC – sleepless nights, anxiety, depression, suicidal ideation, stress, alcohol/drug addiction, over-eating, angry outbursts, obsessive traits, burnout, domineering and super controlling tendancies, restricting one’s sphere of work and more can all be a consequence of the toll of making mistakes – the secondary trauma that does not get effectively addressed or dealt with.
It can be heart wrenching, absolutely crushing to make mistakes especially when significant complications or even death occurs, leading us to question our own ability and judgement, to doubt our skills and knowledge, and even our role in the profession. Over a lifetime such incidences can weigh heavy on the heart and mind, lead to illness and disease, addiction and in some cases suicide.
Whilst we aim to help and not harm others, we can end up being harmed ourselves by the work that we do. Surely something is amiss if the helpers are significantly harmed in the process of helping in a profession that is supposed to be caring for all? And herein lies one of the problems – for the medical profession has traditionally not been caring of its own – yet the quality of care we can provide very much depends on our ability to care for ourselves and each other, not just our patients.
The quality and safety of healthcare will never be improved as long as the GMC continue with their naming, shaming, blaming, condemning and punishing approach for medical error – whilst there will be a few individuals who need to be erased for heinous crimes committed, the vast majority of doctors are caring people, who seek to do a good job, to provide high quality care and who are increasingly constrained and restrained from doing so as a consequence of government policies, resulting in rota gaps, excessive workloads, unsafe working conditions and who themselves are harmed before they harm.
Instead there needs to be a system of regulation that is founded upon the true understanding of the human being, how mistakes occur, the systemic factors at play, the fallibility of the human condition and the inexact world of medicine, a system that seeks to support and protect not just the patient but the doctor, such that the latter can learn, evolve and grow and return to medicine as a more healthy, caring, compassionate doctor – who also knows and understands the need for acceptance and compassion for oneself.
Such experiences are humbling and knock the wind out of the sails of most – one of the most pressing challenges in the medical profession today is finding a way to help staff stay healthy when mistakes occur, such is their toll on the wellbeing of the healthcare professional; to be accountable and take responsibility as needed, but to have the capacity to hold that there is always a bigger picture than the one we see with our eyes, more going on in the cycle of life and death than we tend to acknowledge, one that is always seeking to heal and bring understanding and love to all, void of condemnation, denigration and blame.
What if when all is said and done, and suicides aside, the timing of our death is not an accident or a mistake, but in the hands of the One who gave us life? And even if that is not your understanding, it is perhaps still worth considering that there just might be more to it than what we see, believe or think…..
Clearly the GMC needs to re-think its approach to these cases and perhaps one day it will care not just for patients, but the doctors who care for patients, and at times are patients themselves. To see our humanity, to know we are not and never will be perfect, to know that medical error is rarely an isolated event but can involve a multiplicity of systemic, technical and human factors and that it can never be completely eradicated; to know that those that have harmed are often harmed themselves, by the work that they do and other life events, as well as whatever current tragedy has occurred – to be able to bring a deeper level of understanding, compassion, care and support to remediate instead of blame, to guide instead of punish, to heal instead of harm further, to restore to a healthy state and work as a doctor instead of erasing; to value the doctor as a living, breathing, sensitive human being who cares deeply and wants the best outcome for their patients in the vast majority of cases.
Feel free to share your thoughts and comments on the above case or anything that this post has raised for you.