There but for the grace of God . . .
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k485 (Published 01 February 2018) Cite this as: BMJ 2018;360:k485
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
There but for the grace of God . . . Fiona Godlee’s Sanctified Common Sense [FGSCS] Re: http://www.bmj.com/content/360/bmj.k485
BMJ Editor-in-Chief Dr Fiona Godlee writes (Feb 1 2018), quoting another editorial doi:10.1136/bmj.k479: “It is tragic that a child has died. But no one is served when one doctor is blamed for the failings of an overstretched and understaffed system. We must channel the sadness at Jack Adcock’s death, and the anger at Bawa-Garba’s fate, into positive change for safer patient care.” [1 2]
If this is not sanctified common sense I don’t know what is. But why is that “sanctified?” asks someone.
ANSWER: What other adjective can I use, pray, in this sad case to qualify Dr Hugh Mann’s admirable definition of Common Sense? [3].
Competing Interest: None Declared
felix@konotey-ahulu.com Twitter@profkonoteyahul
Felix I D Konotey-Ahulu FGA MB BS MD(Lond) DSc(UCC) FRCP(Lond) FRCP(Glasg) DTMH(L’pool) FGCP FWACP FTWAS ORDER OF THE VOLTA (OFFICER) Kwegyir Aggrey Distinguished Professor of Human Genetics University of Cape Coast, Ghana; Former Consultant Physician Genetic Counsellor in Sickle Cell and Other Haemoglobinopathies Korle Bu Teaching Hospital & Director Ghana Institute of Clinical Genetics, and 9 Harley Street, Phoenix Hospital Group, London W1G 9AL. Website: www.sicklecell.md
1. Godlee Fiona. There but for the grace of God … BMJ 2018;360:k485 BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k485
http://www.bmj.com/content/360/bmj.k485 February 1 2018.
2. Ladher Navjovt, Godlee Fiona. Criminalising doctors: What must we learn from Jack Adcock’s death? BMJ 2018; 360: k479 https://doi.org/10.1136/bmj.k479
3. Mann Hugh. What is Common Sense? www.bmj.com/content/360/bmj.k485/rr Re: There but for the grace of God … Fiona Godlee BMJ 2018; 360: k485
Competing interests: No competing interests
When one doctor's diagnosis or treatment with hindsight is found to be incorrect or inappropriate, s/he is penalised, even loses licence. Wisdom by hindsight is easier and cannot be compared with the decisions doctors have to make at a particular point in time.
There are many court cases where the verdict of a case is reversed by the next level court on appeal or review. In both courts, the same evidence is evaluated but leads to the opposite interpretation and outcome. Sometimes the judgement of the first court has led to the conviction and imprisonment for years before the verdict is nullified by the higher court and the accused is freed. Is the judge of the lower court then punished, asked to resign, suspended or is the licence cancelled? Why should such treatment be meted out to doctors alone who in all sincerity are trying to help the patient?
I have taken the example of judges but the same applies to almost all professions and situations.
Competing interests: No competing interests
Consultants are in-charge of their team and have responsibility to make sure that team members are right in number and skill mix. This is more important on the days when the consultant is off site or on leave. The same applies to change-over days, when consultanst need to make sure that they are physically around to help juniors in the ward. Other non-ward commitments must be cancelled to create time for the ward.
Otherwise there is always trouble, which cannot be regarded as unexpected
Competing interests: No competing interests
Doctors harming their patients in any form against ethics is wrong.
Doctors harming patients medically, physically and surgically is wrong. Doctor neglect in the form of undiagnosed disease, under-diagnosis and over-diagnosis also harm patients and their families. Doctors who are not treating disease or are under treating and over treating their patients are also against medical ethics. So harming patients knowingly or unknowingly in any form against ethics is wrong.
Competing interests: No competing interests
Some doctors can be brutally frank on actions of commission and omission during the course of performance of clinical duties, usually remaining confined to the unit when they are working in a team. In solo practice the responsibility and the risk stand added and multiplied. Usually the classification in ascending order is - error, mistake and blunder.
Some misdiagnosis and errors of judgment are detected at CPCs. Most important is to learn from them, never repeat; supervise, warn and pre-empt as you become senior in position. A feeling of guilt and remorse is natural and reflects your moral and ethical perspective. System defects can vary widely from minimal to abysmal, but doctors in several areas of the globe working and employed in underfinanced or overcrowded situations should never refuse for the simple reason that they may be depriving the patients of very basic care needed.
Dr ME Yeolekar
Mumbai
Competing interests: No competing interests
Governance for the individual: a route to revalidation
The erasure of Barwa-Garba from the GMC register of medical practitioners and endorsed by the High Court has brought about the unprecedented self referral to the GMC by Peter Wilmhurst challenging his own “fitness to practise” (FTP), despite repeated revalidations, has raised serious doubts about the very revalidation scheme itself.
This gives the profession and Parliament another golden opportunity to question the validity of revalidation on the basis of five successful appraisals with little or no attempt to measure outcomes of an individual’s practice.
Revalidation is defined in the Medical Act 1983 as an ‘evaluation of the medical practitioners’ fitness to practice. The GMC Consultation Paper of 2000 was emphatic that appraisal would be a formative process. Dame Janet Smith insisted that the information obtained for FTP should be amenable to audit. Prof. Pringle, then chairman of RCGP, said that the revalidation as proposed by the GMC would ‘create an illusion’ of protection in the eyes of the public.
The GMC has conducted multiple reviews of revalidation including the Keith Pearson Report and the UMbRELLA (UK Medical Revalidation Evaluation coLLAboration) Review with Dr. Julian Archer as the principal investigator made no attempt to address the issue of objective assessment of FTP. Which is not surprising since this was not in their remit.
If the GMC is to convince the British public it has to heed the warning given loud and clear by Wilmhurst and by others but ignored by the GMC. Revalidation is best based on an objectively evaluated measure of performance and outcomes: the measure of outcomes reflecting the ability of the individual' a sine qua non to demonstrate the individual’s fitness to practice’. Appraisals do not demonstrate fitness to practise as required by the Medical Act 1983. It is also clear that the GMC has adamantly turned away from an objective assessment of FTP. Commenting on appraisals, Dame Janet Smith concluded ‘that in my view [they are] quite incapable of providing a basis for an evaluation of fitness to practice’.
May I have the audacity to present a scheme for revalidation based on the hallowed Clinical governance modified by me for the individual and published in the Hospital Doctor (July 29 2013):
A framework in which an individual is required to comply rigorously with guidelines for good medical practice, assessed through objective measures of performance and outcome for the delivery of high quality health care and provide evidence of continuing professional development.
It incorporates three distinct components to satisfy the fundamental requirement for revalidation:
Requirement to comply with guidelines for good medical practice as provided by the GMC, Royal Colleges and other organizations and hardly requires further amplification.
– Assessed through objective measures of performance and outcomes.
This I submit as the major innovation and the value of the new version of clinical governance providing a more logical and robust approach on which to base revalidation compared to revalidation through appraisals. Performance and outcome measures reflect ability skill and the knowledge to perform the required task. Performance and outcome measures would thus establish objectively an individual practitioner’s fitness-to-practice (FTP). Publication of the cardiac surgical and other surgical mortality figures pioneered by Sir Bruce Keogh have led the way and demonstrated the feasibility of this approach. It would be interesting to see if Mr. Wilmhurst’s morbidity and mortality figures were included in the analysis. Establishing FTP is demanded in law and should form the basis for revalidation.
To complete the requirements of revalidation it is essential to relate the performance to assessments of the delivery of high quality healthcare through patient satisfaction, 360 degree appraisals and other recognised criteria as included in the appraisals.
– Evidence for continuing professional development. This too requires little clarification.
It is my assertion that together; the three components would provide evidence for revalidation of a doctor through establishing being up-to-date and fit-to-practice, thus fulfilling the legal requirements.
This approach to revalidation was not unacceptable to my responsible officer and I was refused revalidation and retired on my eightieth birthday.
Will the GMC have a re-think, or are there none as blind as those who will not see?
Competing interests: No competing interests
Any medic who knows the details about Hadiza Bawa-Garba's recent erasure from the medical register can't help but feel "There but for for the Grace of God go I..."; as titles this week's BMJ editorial and is stated by numerous other medical writers, both in print and online. Sadly, there are still many doctors who don't know the details, never mind other NHS professions and the wider public. We can get angry and upset, feel demoralised, stop recording our mistakes in frank personal reflections and practice increasingly defensively; but none of that will change the system that has scapegoated and destroyed one of us, and could as easily be ourselves next.
Why is this not being reported on the mainstream media? Why is the BMA PR department not stirring up sympathy for her? There are so many facets to the unfortunate circumstances that led to the tragic death of Jack Adcock - but there appears no censure for the hospital management, the medical director, the unit's consultants, the nursing managers, Hazida & her juniors' educational supervisors or training programme directors, the rota managers of medical and nursing staff, the IT department and the IT systems' company; nor for the politicians who have systematically underfunded the NHS to the point of catastrophe like this.
The BBC news website reports again today on the gender pay gap for professional women... but no one seems to push awareness that Hadiza having no post-maternity leave induction surely amounts to sexual discrimination, for a start? And what if a railway operator expected & forced a driver to drive 2 trains simultaneously for 12 hours without a break? Who would the public blame when the inevitable crash occurred - the driver???? These are the kinds of points and analogies that should be explained to the general public if we are to engender any kind of political will to change the use of individual criminal penalty for multi-system failures in healthcare.
Crowdfunding her appeal is a fantastic gesture; but it doesn't raise the profile of the injustice of the case that much, if no one reports on it outside of medical media. I am flabbergasted how many of my medic colleagues have still never even heard of Hazida, and no one I know who's not a doctor has heard of her case either.
Here's a practical suggestion for someone at the BMA, or for any individual who feels compelled to stand up for our collective profession's protection: why not produce & sell "#IAmHazida" badges & tshirts? Profits could go to support her appeal. Announce a specific day when everyone (medic or otherwise) who feels she was treated unfairly wears either to work. Hospitals, GP surgeries and community clinics full of people all wearing them as protest would surely ignite more media interest? We can't win against politics by keeping the injustices within our own sphere.
#IAmHadiza
Competing interests: No competing interests
Human beings will always make mistakes, but some are of greater significance than others. As doctors we are responsible for our actions and should apologise when things go wrong; if serous mistakes happen or our behaviour is not up to an acceptable standard, we are duty-bound to accept the consequences.
Competing interests: No competing interests
Neither ‘Working with doctors’, nor ‘Working for patients’.
Competing interests: No competing interests
Re: There but for the grace of God . . .
Human beings are the most advanced creatures of this world. We have the ability to think, memorize, communicate, analyse and God has blessed us with attributes of creativity, innovation and invention. Doctors can be defined as skilled human beings in their field. They are meant for the amelioration of human suffering. By and large, doctors exploit their expertise for the welfare of Humankind.
But I wonder whether we have conquered all diseases affecting the human population. Certainly not: In fact research scientists are working day and night to get more insight into diseases and their therapeutics. We have to learn many more things.
Our society expects 100% results, which is not possible. In India, tertiary centers are overloaded with patients. We have to entertain around 500 patients in our Outdoor patient clinics.
If doctors can make the right decisions then there is a fair possibility of making some errors. These errors can be inbuilt errors, mistakes due to time constraints and sometimes the right things don't click at that point of time.
The authorities must understand whether there is negligence, reflexive errors of doctors or systemic errors. Taking tough decisions against an individual doctor without taking into account the complete scenario discourages thewhole medical fraternity.
Society is dependent on medical service providers for their ill health. It is the responsibility of all the concerned institutions to provide a very congenial and conducive atmosphere for doctors so they can provide the best possible health services to society.
Competing interests: No competing interests