3Rs in medical eRRoR

For all the scares about prosecution, and talk of candour, what really happens when mistakes by senior medics seriously harm people?

To answer, we should first consider how doctors are seen and like to be seen.

Doctors are widely trusted in society. To uphold this, the General Medical Council (GMC) signals them to act with virtue.

And the Hippocratic imperative “First, do no harm” advertises that safety is doctors’ first concern.

But doctors are bred for cleverness, not virtue. So medics’ claims to greater virtue may, at best, be wishful thinking. Why do we foster this?

The value of virtue

Well, there are psychological benefits. We like to trust those we depend on. Granted we don’t trust our bus drivers or food makers in quite the same way as doctors. But medicine can be very personal; and there may be no choice but to trust our given doctor.

Doctors too need to feel trusted; to explain the potential diagnoses and treatments; for those to be considered and received in good faith by their patients.

There are financial benefits too. A doctor’s reputation has long been bankable. Earning in both public and private sector, doctors can cash in on personal recommendations. These are particularly important when, as is often the case, outcome measures fail to distinguish one doctor from another.

So the preservation of medical virtue has value to the public, and to doctors. How then is it maintained, if doctors are as human as the rest, and if they work in an error-strewn industry?

It might be thought that the General Medical Council keeps doctors in line, having them protect their virtue for the reputation of the profession as a whole.

That, I think, has some truth, but only once we clarify terms.

Doctors do tend to guard their individual virtue very closely; but in ways that can seem to favour looking blameless over being blameless. How can this be achieved, even after serious medical error?

This brings us to the 3Rs.

The first way is repression, both psychological and institutional.

It protects doctors’ sense of their virtuous selves and shields the organisation’s reputation. Good doctors end up hiding what went wrong – in order to remain “good”. They block out their trauma. Notes get altered or destroyed. Reports are redacted so errors are repeated. Litigation is drawn out to get the patient or family to settle. Confidentiality clauses save face at the cost of learning.

If repression is insufficient or challenged, the next way is recrimination. It’s vital once the cat is out of the bag.

It’s seen in the scapegoating of juniors like Dr Bawa Garba, which enables senior doctors to maintain their virtue.

It’s seen in the removal of whistleblowers, like Dr Chris Day or in the denigration of relatives like Dr Sara Ryan, when their questions puncture medical virtue, and endanger a whole system of earning.

Much later, if campaigners persist (e.g. the hyponatraemia inquiry), the recrimination may come to focus on those actually responsible. But by this time, they may have retired or disappeared.

The final way is reform.

Reports and action plans are common, but reform is rare. In part, this is because repression and recrimination are so effective.

This is why progress is so slow. Safer care could save many more lives than research in e.g. genetics or neuroimaging. But a challenge to unsafe care does not sit well with tales of medical virtue.

To make progress, we have to break the pedestal from which medicine directs the show. But that involves a conversation far beyond medical colleges; one that engages the public with a profession of easy virtue.