Reflections on medical culture and the Bawa Garba case

For a background to the case – see this excellent BBC report by Dr Deborah Cohen

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 practiced 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 where patients and their families feel more confident, 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.

Dr 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 did not help her think through what had happened in a place and at a time suited for reflective thinking. He made her write a list of everything that she had done wrong in a hospital canteen. He then made her upload the list as a ‘reflection’ in her educational eportfolio. This is not medical education as I or any other medical educator would practice it, but too many doctors’ experience of ‘reflection’ in medical education is shallow, critical, unsupportive and frankly, unreflective. If anyone in this case was ‘truly, exceptionally bad’ it was this doctor, Dr Stephen O’Riordan.

To make matters even worse, the media is a menace – fanning the flames of fear, pitting doctors and families against one-another 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. Doctors and patients learn that justice is rarely achieved.

Consequently, many doctors grow cynical, hateful of the GMC and the tabloid media and suspicious of patients. And a growing number of patients are losing trust in medical professionals.

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. Both have good reason to think that the system is unjust. 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’. 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 JulianTudor Hart has argued, ‘Accountability must require that doctors insist that they have time to do their work properly’.

Relationship centred care Dr Jonathon Tomlinson blog

Defining Patient Centred care New England Journal of Medicine

A New Kind of Doctor: Professional Accountability. Dr Julian Tudor Hart

Managing the threat to reflective writing. Dr John Launer

2 responses to “Reflections on medical culture and the Bawa Garba case

  1. Suzanen Loveridge

    Sadly after 36 years in nursing I left the NHS Trust I had sent 25 years at- the reason , the strategic protection of a group of staff who were responsible through medical procedures I witnessed, for the injuries to my Granddaughter by Midwives Doctors and Nurses. The injuries then blamed on my son and hIs girlfriend. The NHS trust worked with Social Services to block the necessary actions required to prove the Hospital staff had been responsible and my Grand daughter adopted. The betrayal of trust in those I had spent years working with. The trust makes a huge thing about Transparency and Duty of Candour, but in this and at least one other incident, they failed and the fall out of their actions resulted of the loss of a child and the destruction of a family. I no longer trust the actions of medical professionals for members of my family and the trust lost can never be regained.The doctors midwives and nurses involved are a disgrace to their profession.

  2. It is time to realise that all hospital staff, medical, clerical or ancillary – are HUMAN.

    It is time for all concerned – whether professional or patient – to acknowledge that we all human, and as such – we make mistakes. , No one is infallible, so when a mistake is revealed, it must be acknowledged and rectified if society is to benefit. It is all a matter of courage.

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