Sue Ieraci: Blame and shame

MY previous article in MJA InSight about risk aversion and overinvestigation hit a nerve with many readers concerned about this trend in health care.

If we want to do something about this culture, we need to accept an important cause — blame and shame.

Although Australian doctors generally do consider the risk of litigation by patients when ordering tests, my observation is that the tendency to overinvestigate often occurs because of the fear of being blamed and exposed for having “missed something” by our colleagues.

In this dysfunctional culture, where it’s not acceptable to ever be “wrong” (even without the benefit of hindsight), it’s tempting to think that doing every test means we will always get it “right”. But that’s the problem — doing inappropriate tests is not right, especially if we have failed to listen to the patient.
    
No matter how much technology we invoke, it is our human interaction with the patient, and the use of our cognitive skills, that characterise our professionalism.

The potential harm of overinvestigation for fear of missing something is no less important than the harm that can be caused by the further investigation and treatment when a patient test comes back with a false-positive result.

Many doctors have a tendency to chase a diagnosis for every symptom — the ‘’tyranny of diagnosis’’. Yet, sometimes it is more realistic — and logically preferable — to admit that we don’t know the precise pathophysiological cause, provided we can exclude conditions that need urgent treatment. Not every symptom requires immediate management.

The desire for a label for every symptom is not solely the preserve of doctors.  It can also reflect a patient’s need for security and certainty. Witness the popularity of many “alternative” therapies, where a pronouncement of a “subluxation” or “deficiency” is made with confidence, therapies are recommended, and the accuracy of the diagnosis doesn’t even enter the discussion. What is the error rate of iridology, or live blood analysis? We don’t even know, because it is the therapists’ confidence that reassures the patient, not their diagnostic accuracy.

Why, then, in medicine, do we hold ourselves and our colleagues to such a high standard of accuracy, even to the point where an asymptomatic person has a diagnosis? Have we created such an expectation for perfection that we are hoist by our own petard? Are we displacing our own anxiety about error onto each other, thankful that it wasn’t us who “missed the diagnosis”?

Philosophical tradition says that wisdom means you neither know nor think that you know. Perhaps it also means knowing what you can and can’t achieve, and being honest about it — to yourself and to others.

Ultimately, the purpose of medical practice is to help others. That requires an acute understanding of human nature, including needs, desires and motivations.

We must apply the same understanding to ourselves and our colleagues, not just our patients, and behave in a humane way towards each other. No more blame and shame.
 

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.