Monday, 17 December 2012

A little bit of sport can go a long way

In this season of indulgence, I am going to indulge myself with a monologue on sports, and the meaning it can hold.

Bradley Wiggins won the Sports Personality of the Year award last night. He was the first Briton to win the Tour de France, and followed it up 9 days later with a gentle peddle to win the Gold medal in the Olympic time trial. He was my hero, before the Olympics, and remained it afterwards. He beat Andy Murray, our first grand slam winner for a million odd years, and Jessica Ennis, who for years has lived under the cloud of expectation, that seemed to assert that as she is both hugely talented, and also has a nice smile, that it was destiny to win the heptathlon in London. Have a look at footage from the moment she crossed the line in the final race of the event: was that joy or relief that we saw flicker across her face?

Across several hours of saccharine, and late running reminiscence of the last year of sport, clear themes emerged: people are emerging from a dream-like state, and it was clear that many of these sports men and women are starting to wonder whether it happened at all. Pain, sacrifice and support all emerged as prevalent sentiments. I particularly enjoyed the phlegmatic Brownlee brothers talking about how they had gone running for a couple of hours that morning, not because they wanted to run for a particularly long time, but because they got lost in West London, and decided to carry on until they found somewhere that they recognised.

But perhaps what was most telling was how many people cried. Even Teflon Coe delivered his elegantly smooth speech with tears in his eyes. This stuff matters.

But why? It's just sport. But that's the point. It matters because it is defined as a personal test. Without distraction, sport is the arena in which you show yourself how far you can go, how hard you can push yourself, and how well you can handle the pressure. Those elite sports men and women we celebrated last night had laid themselves open to scrutiny, to the risk of failure, and won. I imagine they found out things about themselves that they never knew: they discovered limits, new heights, new resolve and performances that at times they must have doubted they had.

It is the purity of sport that makes it so engaging. At an amateur level, we compete and play because it is fun, because it keeps us fit, and because it allows us to vent our competitive spirits. At an elite level, they compete to win. And we watch them, because we want to see them win.

The concept of plucky British losers is a fiction. That is the explanation given after the event of people who lost because they did not prepare well enough.

And this I think is the legacy from this year of sporting triumph: preparing hard does not guarantee you will win, but without it, you are unlikely to shine. Winning is not everything, but giving a good account of yourself means a huge amount. There is glory in winning, but more importantly, there is glory in giving yourself up to be as good as you can be, however far that takes you.

Tuesday, 11 December 2012

The shame of shame

Jacintha Saldanha is dead.  That much we know. I imagine that Mel Greig and Michael Christian, the radio DJs behind the prank, are also full of remorse. But that won't bring Jacintha back. The anguish of her family can only be compounded by the lingering sense of waste - that she felt her only option was to take her own life speaks volumes of the way she felt, or the way she was made to feel, about the mistake that she made. In fact, I still wonder whether the action of transferring a call to a colleague could actually be classed as a mistake at all. Judgement about that lies in details that I do not have.  

Life is full of unintended consequences. No one predicted that a hoax call to a hospital, made in the name of entertainment, would cause a woman to take her own life. And I don't imagine that the hospital predicted that this is what would happen. Who knows what kind of feedback and support Jacintha received - and no doubt people who spoke to her after the event are reflecting on what they said and did, and what they could have done differently.

Remorse and guilt are feelings we should all have experienced. They follow on from those moments one wishes they could do again - those times when shortcuts or risks that you took failed to come off. When looking back, the decision you took seemed crazy, but at the time it felt like the right thing to do.

In some walks of life, the price for failure can be high. In medicine, it seems that the fallout from getting things wrong is big. Often it is - it is people's lives and their health that we are dealing with. Fear of failure encourages doctors to be more aggressive in how they investigate and treat problems. The moral offset is that iatrogenesis is easier to come to terms with from the perspective of the practitioner, than fallout from inaction. Missing the diagnosis, or not doing 'everything' is considered worse that causing harm with the tests and treatments. This might sometimes be right. But it might sometimes be wrong. It really depends on the patient. And this is where Al Mulley's concept of 'preference misdiagnosis' comes in: we can only know what the right action to take is if we have spent time helping the patient to understand what it is that they want.

The communication involved in making the right preference diagnosis can be complex and time-consuming, and we don't do it well enough at the moment. Patient preference also gets confused sometimes with the preference of relatives, which often overlap with those of the patient, but not always.

But no matter how good we get at communicating risk and benefit to patients, there will always be occasions where treatments don't work, complications occur, or diagnoses are missed. And that's just the broad-brush stuff - along side all of these headline mishaps, are the day to day events that as doctors you wish you could have done better - the phrasing used, the brief snap of impatience, the wrong assumption made when describing a problem to someone. The list of potential pitfalls is endless, and yet we work in an environment, where people can display the belief that the inflexible demand for perfection makes perfection possible.

Men and women perform as well as the system allows. Issues that are often labelled as personal failings would perhaps never have happened if those individuals had been afforded better support, better back-up or more understanding from the people that they work with or for.

We will always get things wrong. I think we should aim high. But I am also convinced that nervousness about making mistakes makes mistakes more likely. People perform better when they are relaxed, happy and supported. It is only possible to be relaxed and happy if the support really kicks in when bad things happen.

I don't know whether someone put their arm around Jacintha and told her that it was OK, or whether she got a telling off. I don't know whether it would have made a difference, but it would be comforting to know that she was given support and encouragement, and that perhaps her despair came from somewhere else.

Being supportive is not about forgiving idleness or carelessness, but does perhaps rely on making the assumption that people in general, are trying their best, and that they do not want to get things wrong.