Exploring the ‘blame culture’ in modern medicine
Patients occasionally point the finger when things don’t go as smoothly as expected, but how does this affect doctors?
By Dr Jessica Garner, graduate of Barts and the London School of Medicine and FY1 at Southend Hospital.
Blame culture. It’s a phrase that is batted about a lot nowadays, but what does it actually mean? According to the free online dictionary, one definition of ‘blame’ is “the state of being responsible for a fault or error”. The concept of this is horrible – who wants to be responsible for when things going wrong? The answer to that is no-one. The connotations from this are almost always negative, and the point of blame culture is that, normally, one entity takes the rap for everything. This is usually one individual, and in medicine, this one individual is usually the doctor. The idea goes that since one doctor will care for a patient, if something were to go wrong, or not as planned, then the blame for this supposed error can be pinned entirely on that said doctor.
However, I think it is difficult to pinpoint the blame all on one thing; as with most things in life, adverse events are usually a result of a combination of factors and the different ways these interact to form an outcome – doctors are just one cog in the NHS wheel after all. Of course there are exceptions to every rule, but it seems unfair for one person to be blamed for the whole event where they may only be one part of the puzzle.
In medicine, this kind of negative attitude of blaming can lead to a number of issues. One being that this system of naming, shaming, and disciplining can actually lead to less errors being reported, with the consequent effects on patient safety. Professionals are scared to report events due to the showcased consequences, so they just continue as they were, when it would probably be more beneficial to review the problem so that similar errors do not occur in the future, and safety nets can be put in place.
Are doctors in danger?
Doctors being sued by patients is another aspect of this argument. The patient is blaming a specific doctor for their maltreatment or negative result. Sometimes, this may very well be the case, but in others it may be more of a system failure or a team effort, and one individual should not bear the brunt of this. I remember in my first year of med school, in the tedious three hour long ethics lectures, learning about being sued. We were told in detail all the ways outside of a hospital we could accidentally become responsible for people’s care and as a result be sued if things then went wrong for them. For example, if we were called upon to treat a sick person on a plane or in the street. I remember a lot of students at the time being worried to help people in a case they were sued, which surely defeats the object of being a doctor?
No one wants to be accused of negligence, it goes against the very being of what you aim to achieve.There are lots of ethical loopholes that you could fall into; debates about capacity, doctrine of best interest, the list goes on. These are all issues that can be a grey area clinically and ethically, and sometimes there may not even be a right or wrong answer. But they are also issues that can provoke strong views and subsequent litigation. On a more selfish note, being sued probably doesn’t do very much for your career aspects either.
Is this the same abroad?
Having spent a short amount of time in New Zealand, the system there for patients suing due to poor medical management is different to that of the UK. ACC is the Accident Compensation Corporation, and from my preliminary discussions with doctors in NZ, if patients obtain an injury from medical treatment, they are able to fill out an ACC form and get compensation. With this, the patient sues the system, and not a specific doctor, so no individual is blamed. Is this a better system? Although blame is negative, I wonder if this encourages no responsibility being taken for the error by anyone; errors must occur for a reason, so genuine errors that could be prevented should be investigated and corrected in the interests of patient care. The lack of individual blaming though I believe is a good thing, and probably makes things more transparent and open to discussion as no one feels that they will be persecuted for speaking out, hence these things can be approached with an educational viewpoint.
In addition, specific ‘blaming’ only reinforces the concept of defensive medicine, which Catino (2009) defines as “when healthcare personnel order unnecessary treatments (positive defensive medicine) or avoid high risk procedures or patients (negative defensive medicine) with the principle aim of reducing their exposure to damage claims.” This practice has increased with the increasing numbers of medical litigation over recent years. This is obviously not the way to practice medicine as it may expose the patient to unnecessary risks, and it also raises costs of healthcare significantly. It is also suggested that a lot of doctors establish a defensive strategy in order to protect their careers; many fear litigation and negative publicity.
As previously alluded to, the culture of blaming and punishing one person for an adverse event can lead to poor organisational aspects being overlooked. Khatri, Brown and Hicks (2009) provide evidence in their review that errors due to non-technical organisational aspects of medicine actually outweigh the technical errors, suggesting that advances in organising healthcare provision may be just as important as advances in science and clinical work to patient care. They also suggest that organisational bodies believe (wrongly) that they have little input in the decisions that caregivers make, and that these bodies act in isolation, or concentrate on certain aspects, rather than utilising coordination and communication in order to maximise organisation of patient care.
So – blame culture. The culture of unwillingness to take risks or take responsibility due to fear of criticism. People blame each other so as not to be blamed themselves, and errors are not reported so no individual gets reprimanded. No new ideas are discussed as no one want to be wrong. It’s a rather unhealthy professional system to be in. How does this change? Probably from the top down; it needs to come from management as these organisational bodies are generally rule orientated, and if compliance is not met, then blame needs to be placed. Re-structuring and promotion of an open environment to discuss issues and beliefs without fear of punishment would go some way to better communication and ideas for improvements in patient care.