. Healthcare is not an impersonal ‘system’. The mere hint of a mistake has the power to convulse a doctor’s world

. ‘“Would someone else in your shoes have made a different diagnosis based on the same presentation?” Perhaps. How could I know?’ 

 

Every few years, a letter arrives that has the power to send a cold shiver down my spine. Its wording is typically discreet, but it provokes apprehension, followed by powerlessness, shock and occasionally resentment. These letters inform me, the doctor, that a patient who came into hospital under my watch has filed a complaint to which my earliest response is required.

 

For doctors like me, who are non-procedural specialists, the complaints fall under two broad categories: insufficient care and inadequate communication. Some complaints are either vexatious or could have been addressed earlier with attentive listening from a variety of people. Some are settled out of court in the interest of efficiency and cost. All of them feel enormously threatening at the time. I remember my very first letter. The plaintiff was upset by my failure to diagnose a condition she said had occurred under my care. The details were not so straightforward as that, but it hardly mattered. “If you spend your entire career without being sued, you’re not a good doctor”, the lawyer whose counsel I sought practically cooed at me. I shuddered.

 

“And most of these cases don’t go to a jury”, she added reassuringly, as I tamed my horror at imagining myself in a witness box. I told the lawyer that I had met the plaintiff only briefly, a long time ago. We dissected the case and she meticulously cross-examined me. Hundreds of discharge summaries have gone out over the years bearing my name as the consultant. This one took on an ominous significance as we keenly scrutinised each line.

 

The lawyer went through her familiar routine, exhorting me to recollect that one patient seen one afternoon along with 30 others. Were there any red flags? Not that I noted, no. Did I consider other diagnoses? Yes, then I ruled them out as best I could with the information at hand.

 

“How can you be sure?” the lawyer asked. At some point, you have to back your experience, instinct and clinical judgement, I replied. Otherwise you could keep investigating forever. “Would someone else in your shoes have made a different diagnosis based on the same presentation?” Perhaps. How could I know?

 

The plaintiff’s lawyer had a second opinion from a specialist who had reviewed the notes but not the patient, and thought that things could have been done differently. I broke into a sweat. The lawyer shrugged. “That’s easy to say with the benefit of hindsight. But everyone knows that nothing replaces the actual clinical encounter with the patient.”

 

Our time passed in groaning slow motion. The lawyer didn’t see the big deal; I felt criminal with each passing minute. As my colleagues with similar experiences observed, you didn’t need a court verdict when the mere hint that somebody thought you did something wrong had the power to convulse your world. They were right – the hours I spent poring over the plaintiff’s presentation and the decisions I made caused me great heartache and self-reproach. I realised that although the lawyer called her a plaintiff, she was still my patient and a person who had felt harmed by me. But the lawyer was also right. The “incredibly routine stuff” sorted itself out; the patient was unharmed, along with my reputation. My fevered imaginings remained just that.

 

In subsequent years there have been complaints, thankfully very scattered, but each flooded me with anxiety and dread at their potential significance. A woman refuses point blank to take her mother home, insisting on a second CT scan for muscular back pain. After days of circular arguments, I refuse the unnecessary test, thus incurring her wrath for denial of care.

 

A furious husband complains that a conversation his dying wife asked to have about her prognosis was out of line. A man contests that he won’t place his demented father in a nursing home “because it’s my inheritance money” and then threatens to sue for inappropriate care. It is both wrong and impossible to feel complacent about complaints, but the more vexatious ones do test a doctor’s patience and erode goodwill.

 

It is a telling sign that whenever healthcare is mentioned, crisis is not far away. In a recent Ipsos poll, voters in Victoria nominated healthcare as their chief concern. Ever-looming strikes, plaintive patients, dissatisfied bureaucrats, stressed doctors, unhappy nurses, disgruntled paramedics, overworked clerks – mix them up and we are portrayed as one large, dysfunctional apparatus.

 

There is a relentless squeeze on doctors, spilling onto others, to improve the metrics that are most relevant to politicians, like emergency department waiting times, elective surgery lists and length of stay figures. But those working at the frontlines know all too well that the single-minded pursuit of such metrics can detract from appropriate patient care.

 

No wonder then that morale suffers and many doctors openly advise their offspring to pursue a career other than medicine. Add to this the depressingly familiar statistics about the high rates of alcohol and drug abuse, depression and self-harm in doctors in particular, and you might wonder why anyone chooses to stay in a profession that grows more imperfect by the day.

 

So it was with some weariness – along with habitual trepidation – that I opened the most recent letter forwarded to me by the hospital executive. What did I do wrong now? My eyes widened a little as I read the letter. And they kept widening. My correspondent was an elderly man who had written directly to the hospital’s CEO on a plain sheet of paper. His small, curly letters traced out long sentences in black ink on the unlined page, crawling and colliding with each other like tiny ants. The language faltered at times, befitting a migrant who had never had the benefit of a formal education – but the sentiment was palpable.

 

I knew exactly what he was talking about because he was and is my patient. First he graciously thanked the busy CEO for taking the time to read his letter of “heartfelt appreciation and kindness”. He went on to discuss the kind of care he had received under my team for many years.

 

He paid us some genuinely nice compliments but the more I read his letter, the more one sentiment stood out. It was his unaffected claim that at 77 years of age, with various illnesses contributing to his fair share of hospitalisation, he felt safe. Safe in our hands and optimistic about his future, once clouded by cancer. “I am now convinced that I will be around for a long time yet…” he concluded.

 

I kept thinking for a long time afterwards that of all the things healthcare professionals strive for, making patients feel safe was the loftiest of our goals. How wonderful that someone actually thought we had achieved it. In a supposedly behemoth system, labyrinthine in setup and typically portrayed as a production line, an old man had the confidence to pen a handwritten letter to the CEO.

 

I found something very heartening about his belief that he could approach a seemingly impersonal organisation in this way. It was a reminder that although we get it wrong at times, we can still connect with our patients and our patients want to connect with us.

 

The dominant healthcare stories of the day are about hospital stuff ups and the misdemeanours of doctors. The system is blamed, repeatedly and ardently. Yet it is this very healthcare system that routinely ranks at the top of global ratings in practically any measure of health and welfare you can think of: infant mortality, childhood immunisation, infection control, adult life expectancy, cancer survival, cigarette plain packaging. The list goes on, although the parlous state of Indigenous health is an admittedly shameful postscript.

 

Does it not stand to reason then that the many thousands of individual doctors, nurses and others driving and influencing these results must by and large be capable, competent and invested in what they do? Yet, general society regards healthcare with a continuous low-level irritation. No wonder so many of us start to feel a bit like the child who can never quite make his parents proud no matter what it does.

 

No system should rest on its laurels which is why feedback, constructive criticism, and when needed, the force of the law, are needed to make us aim higher. The various complaints that filter in keep us all on our toes. Although sometimes, instead of more accountability, what society ends up getting is a more defensive, but ultimately more harmful, style of medicine – at an increased cost.

 

A letter from a grateful patient, on the other hand, is one of medicine’s genuine privileges. It dispels cynicism and is a wellspring of enormous goodwill from the level of the CEO to the individual worker, each hassled in our own way about how to honour our obligations to society. You could call it a cheap but cost effective thrill. 

 

Complaints can make us feel helpless, like we are cogs in a system, prompting us to find ways of disowning personal responsibility. Letters of gratitude from patients on the other hand, are our most cherished and effective reminders that the healthcare system is not some inanimate entity but our collective selves, and our deliberate actions to try to change the lives of those we serve. 

 

Ranjana Srivastava

TheGuardian