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.

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