Real failures of Dr Hazida Bawa case: Five issues to ponder-why doctors suffer?


 The case of  Dr Hazida Bawa  is of importance worldwide in many ways, an opportunity  for learning some hard and truthful lessons, as it touched upon various crucial aspects involved in medical treatment, especially in difficult situations. Every one has sympathy for the deceased, but  to blame a human factor, doctors should not be presented as sacrificial lambs.

       The current verdict is nearer to reality and away from a feeling of revenge and harsher penalties. It  gives a hope  that now there will be  acknowledgement of the difficult circumstances and limitations of medical system in health care environment.  To make doctor scapegoat for the  system limitations, poor prognosis or severe disease may be satisfying for some but not sensible. In this case doctors lodged their protest, collected money for lawsuit and the decision was re-looked legally. But every  doctor may not be  lucky enough and may have to suffer  in silence.

 Real failure in this case will be ignoring the factors that actually cause huge suffering for doctors-

  1. Presumptive failure by retrospective analysis: Retrospective analysis of any treatment will always show few things at hindsight that could have been done and would have proved life saving.  One may presume that omission or commission  of certain actions during treatment would have saved the  life,   but one can’t be sure whether these additional presumed treatment would really have benefited the patient.  Therefore a  perception-reality gap is created and with  negative perception towards doctors, it is interpreted as a  failure of doctor merely on presumptive basis and hence declared as negligence.  The doctors who deal with life and death know that it is not correct interpretation, and no one can ever be sure of what the real outcome would be. They just do what they think will be most effective for the patient, and it may not eventually turn out to be the best ever.
  2. Variable interpretation: Same evidence, incidence and circumstances are interpreted and  judged differently by people and  even courts. Some will say it is negligence and other will say it is not. Some will bay for doctor’s blood and other will not. This variation in perception is not only in minds of lay men but also in the learned courts, who  decide  differently.  At the time of death of patient, a constant and  universal last link is only the doctor, that is visible. He is an unfortunate victim, a human factor   and blamed for  the harm done because of variable thought process.

 

  1. Medical knowledge vs wisdom: People who do not treat patients, may be very wise and may acquire medical knowledge by various sources. But medical wisdom comes  only after years of medical practice,  by observing varied situations and spectrum of diseases. An understanding of what can happen in given circumstances comes only by treating such   emergencies.         For non doctors, it is very difficult to  comprehend the medical complexities and real time scenarios. Even doctors, who do not treat regularly emergency patients, can attribute the harm as doctor’s  mistake.

 

  1. Feeling of revenge:  in case of an  adverse event, negative thoughts prevail all over. In present scenario with legal powers with the sufferer and common sentiments against doctors, it is easier to identify and blame some human factors.   Adverse outcome is frequently covered by media to create a sensation among masses.  Real circumstances can only be felt by doctors  but that remains unheard. Harm to patient, media cry and negative sentiments against the service providers creates a sense of revenge in mind of people.

 

  1. Doctor’s negligence vs system inadequacy; This visibility of doctor at the time of  declaration of death  or while treating the patient on his bedside, makes him vulnerable to all kinds of accusations. By application of an average wisdom, all deaths can be easily attributed or linked to fault of the doctor. Subtle presentations of severe disease, rapid deterioration, multi organ complexities, under staffing and sub optimal systems, inadequate equipment and  other innumerable shortcomings of the whole system may not be visible or not given consideration in the  haze, as compared to  publicity and attention  given to only doctor’s faults.

 

Dr Hazida Bawa-Garba case: sacrificial lambs “The doctors” and not health administrators? Dangerous precedence for doctors worldwide


Dr Hazida Bawa case is of importance worldwide in many ways, an (lost)opportunity  for learning some hard and truthful lessons, as it touched upon various crucial aspects involved in treatment, especially in difficult situations , for doctors.  At the time of death of patient, a constant and  universal last link is only the doctor, that is visible. This visibility of doctor at the time of  declaration of death  or while treating the patient on his bedside, makes him vulnerable to all kinds of accusations. By application of an average wisdom,  all deaths can be easily attributed or linked to fault of the doctor. Subtle presentations of severe disease, rapid deterioration, multi organ complexities, under staffing and sub optimal systems, equipment and  other innumerable shortcomings of the whole system may not be visible or not given consideration in the  haze, as compared to  publicity and attention  given to only doctor’s faults. This is specially so when the wisdom is applied retrospectively, with knowledge  of hindsight,  and by the people who have never treated emergencies or have never been in such difficult situations  themselves.

Analogy to  Dr Hazida Bawa case

        Imagine a situation where during a bad sea storm, large number of people are trapped and are in mortal danger. The coast guard on the duty tries his best in the emergency situation with his limited resources and saves a large number of people. There were only a few coast guards present, equipment were inadequate and sub optimal.  However the guards manage to salvage the situation by doing the best possible in the circumstances. There were instances, where they decide, act, communicate and document events simultaneously, in an instant.  Those who could not be saved were exposed to risk of death as resources allocated by authorities were limited.  The near and dear ones of those who died were unhappy and revengeful with the services. Inquiry is done to find out the cause of failure in preventing those deaths. Rather than appreciating the facts that greater proportion of victims were saved in those difficult circumstances, the guards are blamed for those who could not be saved. Guards who are already apologetic for not been able to save the few, are blamed for doing their duty shabbily after careful fault finding analysis of the event. The administrators  who are responsible for allocating the inadequate number of guards and equipment, who actually failed in their duty, also participate in pointing fingers at the guards.

  The saddest part was that courts also were  unwilling to apply wisdom to look beyond the guard faults and  reach beyond the fog in present hazy circumstances. Systems and administrative lapses and inadequacy of number of coast guards was not raised as a concern. The responsibility of the deaths is thus fixed on the persons who struggled to save the lives of many. Every one has great sympathies for the deceased, but there is another angle for doctors in such  difficult situations.

This is an analogy to Dr Hazida Bawa case, but similar unfortunate incidents are happening to medical professionals worldwide, more so in developing countries. The new regulated system of medicine has an aberrant evolution and   chooses to hang their own wounded soldier for not putting up the best fight, rather than accepting the limitations of medical science or errors in the supporting systems.  Was  she an easy scapegoat for some obviously non- admissible reasons prevalent?

Why is it always necessary to punish a doctor, and  conveniently overlook errors of the sub optimal  system in cases of unfavorable prognosis, especially in sick patients. Why a sub optimal system or unsafe working conditions  like  all other registrars were on leave simultaneously, or only one registrar in place of three and that too a trainee. There was no consultant or registrar covering her?   Why is a single doctor stuck in a difficult situation  not  treated as  just another human being in an emergency situation, especially in cases of very sick patients? Why administrators or managers are not punishable for putting doctor and patients at risk and unsafe condition ?

If a doctor is supposed to raise concern (may be at cost of his career), then what is the role of managers, management and administration?  Are they inefficient or incompetent  to anticipate the situation? A new doctor coming on duty can not anticipate the deficiency of system. He will not have time to assess the managerial deficiencies. Therefore raising a concern by doctor on duty is something, which is expected but at the same time not feasible always, in true sense.  This expectation to raise  a concern  may be  used to later implicate the doctor as to why he or she did not raise a concern.  At the same time it takes responsibility off, from the  administrators whose  duty was to raise concerns.

NHS is looked upon in the world as one of the better organized health care organization in terms of uniformity. If such an organization has to sacrifice its working hands in the form of scapegoats to prove its quality, deliberately overlooking its system errors, then it is a sad state for doctors all over the world. This would set a precedence for governments and health administrators, world over to be  fearless in  putting errors of sub optimal system under the carpet by punishing the doctors instead. Since there will always be a doctor in the end who will declare the death, is the last and common link in all deaths. Other circumstantial issues would be overlooked  because of sheer unwillingness to do so.

Irony of the situation is that generally people who have been invested with the power to decide on these issues of medical negligence  may  have  never faced  such situations themselves.  They may be the people in administrative positions who have never treated a single patient, leave aside emergencies.  They do not even  know, what it takes to deal with emergencies of life and death, that too multiple ones, with limited resources. The court takes years to decide on these issues discussed retrospectively with wisdom of hindsight, on issues which the doctor had to decide in a jiffy.  A person who perhaps can only imagine such a situation, or  never handle it himself, even in his wildest dreams is the one who decides what went wrong merely based on how the situation is placed and presented before him.

         If there is unsaid immunity to governments and administrators for providing a suboptimal systems, then the doctor should be the first person to get this immunity. But unfortunately nobody seems  to be willing to find out who is responsible for putting  the doctor  in such  a difficult situation, making everything error prone.

       If in such system a doctor is punished, then the administrator, manager or trust should be an automatic accomplice to the doctor’s punishment. Firstly   for providing an unsafe and  suboptimal system, and secondly for not raising a concern as management . Thirdly for putting it’s doctor in difficult circumstances. If it was an understaffed system, then disaster was bound to  happen sooner or later. This is a perfect example how management lapses contribute to death but doctors are the only ones who are entirely blamed and punished in isolation.

  Another sad part is the unwillingness of judiciary system to look at the larger picture and the fault in the system, which has led to mass demoralization of the doctors. The doctors are denied the true justice in many such cases.  They are being used as sacrificial lambs. Health administrators are obviously at an advantage enjoying the invisible immunity and perks, at the cost of medical professionals.  By crucification of the doctors, vengeance of the society is fulfilled and everyone feels  satisfied  with false sense of justice.  But does this give any advantage to the society? Definitely not. In fact  the society is thus raising a  demoralized force to be their care providers, who under duress, will definitely not perform to their very best.  If this is quality of justice for saviours, this demoralized force may also not be available in future.

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