Residents…mmm, tasty!

November 25, 2010 at 7:11 am | Posted in Uncategorized | Leave a comment

There are several topics that have been floating around in my head for the last few weeks, but none of them has coalesced into a post.

Probably the most appropriate to the season is the topic of forgiveness.  The capacity to forgive is a gift that benefits both parties, and it’s also essential to a stable society.  But it’s much easier to behave as though you’ve forgiven someone, than actually to do so.  And while society requires only the behavior, its gift of redemption is reserved for the genuine article.

One current cultural shift within medicine is in its response to errors.  I see this, in a way, as a rebellion against the tyranny of the lawyers.  In the past, when an error occurred, it was always considered an individual error, and the person responsible must be found and punished.   Then, possibly in defense against sophisticated arguments designed to assign the hospital (and its far deeper pockets) a portion of responsibility, systematic contributions to human error became a target of improvement.  Possibly that was not the reason, but I’ve seen enough of hospital management to know that in the end, it’s a business like any other.

Risk management is also behind the other major shift in dealing with errors, which is to approach the victims with candor and compassion rather than stonewalling.  Human beings want a human response.  They want what everyone wants from someone to whom they’ve entrusted their life: honesty, transparency and empathy.  Just as in any relationship, you know when any of them are missing.  You may not be able to identify exactly what it is, but you know that something’s not right, and that you’re not getting the whole story.  Most people don’t get mad when the mistake is made, no matter how awful the results.  They get mad when they see the wagons starting to circle, to deny fault or shift blame or whatever the lawyers are recommending as a legal defense.  All that most people really want is to know that you did your best, or that if an error was made, that you feel awful about it and want to keep it from happening to anyone else.

Supposedly there are people out there who are looking for a quick buck, and see your mistake as an opportunity to take you to the cleaners financially.  But I’ve worked in health care for around 25 years now (I started before I was in high school.  Not kidding.), and I’ve never met anyone who wanted anything more than compensatory free service.  Which I think is the least that you owe someone who’s been harmed while under your care.

At this point, these practices are fairly well-established with respect to patient care.  What’s disappointing is that those who advocate this approach in clinical medicine don’t seem able to make the connection to other aspects of their lives.   For example, education.  Residency is still very much about ascribing error to individuals rather than examining the process of teaching and learning.  To some extent, this has value in that one of things we must learn is to avoid mistakes, and to take responsibility, examine and remediate our weaknesses.  But so much of the time, we’re only doing what we’ve seen others do without rebuke or remediation, yet the program chooses one particular resident to castigate for it.  It might be you.  Or it might be a colleague who’s under some kind of unusual stress outside of residency, or perhaps comes to residency insufficiently prepared in some way by their medical school.  The program never has to defend that choice, because the only real record of the action is the fact that it was disciplined, or perhaps a report of it by someone with a malicious agenda, so it looks to any outside inquiry that only one resident was guilty of it.  When those of us on the inside, if we’re being honest, know that this is not the case.  How can the resident ever obtain justice?  And how can they ever find forgiveness, even if only for their own mental health, for the program and the people who treated them so?

I’ve been thinking about this lately with respect to Tulane.  I am still angry about what happened with my OB/GYN rotation, and I’m angry because people there behave as if they know they’ve done something wrong, but no one will admit it, and no one will apologize.  They made me sign a statement absolving them of blame before they would send the records the state board requires for my application for licensure.  Apparently they don’t know what duress means, or its significance with regard to any statement made under it.  They offered to send me my records, and then reneged when I took them up on the offer, saying that the board needed them directly.   Which makes me think there’s something in them that they’re afraid of me seeing, and they were betting that the offer would suffice to gain my trust.  I wasn’t looking for reasons to sue, but now I wonder what they’re hiding that’s so damning.  I would prefer to like and trust the school that granted my medical degree, and be proud to be an alumna, but they’re making it difficult.

And so I wonder: does forgiveness have to come first, for transparency to follow?  Or will it simply feed the monster?