Some musings

Children don’t die. Not in this country, not in this day and age. Or so we’d like to think. So when, tragically, a six year old does die, society is unsettled and needs to be reassured. Blame must be apportioned and those responsible must be punished and removed in order that the public’s misplaced confidence that nothing bad will ever happen can be restored.

Being a professional is to deal with uncertainty, to apply knowledge and wisdom in complex, never before experienced situations, to do what seems best in less than ideal circumstances. And that’s hard – mistakes will sometimes be made – bad things will sometimes happen. To need professionals is to acknowledge the uncomfortable truth that life, and death, is uncertain. And so there are those who would like to see the end of professionals, to have them replaced by an ever increasing barrage of rules and regulations, protocols and proformas, in the misguided belief that certainty exists, that what needs to be done is always clear, that a good outcome can be guaranteed for all.

Much has been written recently regarding the Hadiza Bawa-Garba case and not all of it has been sensitively handled. In all of our reflections on what has taken place we must not forget that at the very centre of all this are parents grieving a much loved son. Regardless of how uncomfortable we may feel about how a doctor has been treated we mustn’t forget who has lost most. Though I’m sure such is never intended, none of the battles we rightly feel compelled to fight should suggest in any way that the blame for doctors having problems lies with patients who are inconsiderate enough to become ill. Patients are not the enemy – we must not forget to show compassion to those who are hurting the most.

The response of some to recent events is that if doctors are to survive in what many perceive to be an increasingly hostile professional world, one in which doctors feel unsupported by the likes of the GMC, then they have no option other than to practise defensive medicine, that is ‘medical intervention without clinical indication to safeguard the doctors interests’. Recently I have read of those who openly admit to having admitted patients they wouldn’t have previously, just in case, for fear of some comeback on themselves were something to go wrong.

But to assert that practising defensive medicine is the answer is, I believe, a mistake. Such practise is bad for patients, bad for the NHS and bad for the medical profession as a whole.

Defensive medicine is bad for patients since, as well as being frequently inconvenient and often financially costly, it exposes them to unnecessary investigations which are themselves not without risk. Furthermore, defensive medicine burdens patients with unnecessary anxiety since, out of a doctor’s unwillingness to carry any anxiety his or herself, he or she is reluctant to give patients the appropriate reassurance they need.

Defensive medicine is bad for an NHS which can ill afford the expense of inappropriate referrals both in financial terms but also in respect to an already overstretched workforce. Ironically, to practise defensively and admit patients ‘just in case’ serves only to stretch still further our hospital colleagues with whom we say we sympathise and thereby add to the very set of circumstances that increase the likelihood of the errors that brought about in the first place the tragic circumstances that we were all recently debating. Never mind “#IamHadiza”, practise defensive medicine and we might as well tweet “#NotmyproblemHadiza”.

And defensive medicine is bad for the medical profession itself since to practise so is to practise unprofessionally. Being a doctor isn’t easy. To be clear, we all need to acknowledge our uncertainties and make decisions accordingly. We need to be conscious of how confident we feel at work and how the level of that confidence can fluctuate over time. When we are feeling confident and imagine we have finally mastered being a doctor, we need to be careful that we aren’t overly cavalier with our patients’ well being. And when we are feeling less confident and imagine we will never be able to convince anyone that we are really a doctor at all, we need to acknowledge that we may sometimes investigate, refer or admit patients more that we might have otherwise. Furthermore we need to accept that this is part of being a doctor, part of what it takes to remain in practice for 30 years rather than burning out with the stress of it all within six months. So of course there will be times when, because of our own limitations, we investigate, refer and admit that which in time it emerges we need not have. But that is not practising defensively – rather that is practising responsibly, something we should all be doing. Practising defensively is different to that in that its primary concern is the doctors welfare – it is the ultimate in being doctor centred. Like it or not, part of what it means to be professional is to be patient centred, to put our patients welfare before our own.

Thinking only of ourselves and not being willing to make a professional judgment, not being willing to do what’s best for our patients, not being willing to do what seems wise based on our years of training and experience, reduces us to the likes of the 111 protocols we so often delight to criticise and thus only serves to suggest that we are surplus to requirements.. Practising defensive medicine dehumanises us and plays into the very hands of those who would undermine the need for professionals at all.

In short, practising defensive medicine is dangerous.

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