Medicine is a noble profession and doctors are at times looked upon as deities. They are men and women with above average intelligence, who have spent their lives striving for excellence, achieving excellence and being rewarded for excellence. It almost makes it impossible to imagine that a good doctor could make a mistake. Certainly a bad doctor could make one. An evil monster or a con artist perhaps, but not a good doctor.
Dr Fiona Tito Wheatland calls this elevation of the profession the ‘Doctor Identity’, hypothesising that the belief that doctors are too smart to make a mistake creates a barrier for preventative measures for those who inevitably err.
“It’s a bit like workplace health and safety, if you think everything is safe you won’t put a guard up. So if you believe doctors are infallible you won’t put check processes in place,” she said.
“People who go into medicine often come from a particular subset of our society. They’re already much more perfection-focussed and often come from families of practitioners. But as well as that there’s a whole lot of mythology within our society that supports that notion as well.”
At the end of February Dr Tito Wheatland, flanked by her husband Clyde and some of her fellow Higher Degree Research students, walked her thesis Patient harm and medical error as threats to the Doctor Identity – a new lens for improving patient safety, to the examinations for submission. Completing it had been a long and at times arduous process – 13 years in all – but worth it to answer a question that had nagged her for many years.
“I headed the Professional Indemnity Review for the Commonwealth government in the 1990s and part of it revealed about 15 per cent of people were harmed by the healthcare treatment process,” she said.
“We released the research and people first of all resisted the data, the government put a lot of money into trying to disprove the figures but in the end it was accepted and now it’s become part of the World Health Organisation’s understanding of why there is such a high incidence of harm during treatment throughout the world.”
Despite WHO’s acceptance of the research there was continued resistance to the idea that doctor-error should be accounted for in harm prevention projects.
“Because the moral motivation of doctors is first do no harm, I couldn’t work out why it was so hard to get sustained change in relation to healthcare,” she said.
“We’d work with doctors to implement change but as soon as you moved on and stopped monitoring them it would go back to the way it was.
“It was a question that continued to nag me throughout my career so that’s why I started doing the PhD.”
Are lawsuits to blame?
The obvious answer was fear of litigation. Doctors and hospitals were trying avoid lawsuits by underreporting incidents. That was what Dr Tito Wheatland expected to find. However, it wasn’t that simple.
“I spent the first 12 months of my PhD accidentally disproving that,” she said.
“I analysed the various jurisdictions who had done studies like ours but had very different compensation systems in place. It became clear that it didn’t matter what the litigation system was, there was something else underlying that actually led to that same reticence and the same outcomes for patients.
“The conclusion I’ve ended up coming to is that the education and training process creates a ‘Doctor Identity’ which is common throughout the profession. Part of that is a notion of perfect performance – and that’s embedded in who they are as professionals as well.”
A well-known example of this professional denial is evident in the expectation upon doctors to do double and triple shifts.
“We wouldn’t find it acceptable for truck drivers or pilots to work the kinds of hours that doctors work,” she said.
“There’s a culture that says if you’re a doctor you can work like that. It’s true, some people need less sleep than others, but we don’t pick people for medical school on the basis of their ability to stay awake and nor should we.
“What you have to do is actually recognise that hey, I’m human and that means I get tired, I get emotional.”
Vulnerability of doctors
The consequences of Doctor Identity aren’t just felt by patients. Dr Tito Wheatland’s PhD also examines the mental wellbeing and suicide rates for doctors.
“I remember one doctor in a book who described his visits on lonely nights to the graveyard in his brain, remembering all of the people who he’d lost, as he wandered alone there,” Dr Tito Wheatland said.
“The level of mental ill health is partly caused by the failure of the system to support people. You can’t provide support if you can’t even acknowledge it’s an issue.
“My supervisor sees it as also being relevant to lawyers and academics because it’s people whose professional identity is wrapped up in knowledge so I’m hoping that it will not only be relevant to doctors but to others as well.”
Lessons learned from personal experience
Two major events that occurred since she began the research both delayed and informed her thesis, reminding her of the very human desire to hide or deny mistakes.
The first came after welcoming a foster son into her family. She began to familiarise herself with the emerging research around brain plasticity in order to understand his behaviour and meet his needs. But as any parent can appreciate, her patience was tested.
“It one stage I got into trouble because I’d smacked him,” she said.
“I can remember sitting at the interview with the case manager where I thought I was going to be offered help. Instead, the worker told me it was an allegation of abuse, even though I had come forward, told them and asked for help. Cognitive dissonance kicked in – my identity said I was not a bad mum. I couldn’t stop my reaction - I was almost sitting outside of myself watching as I minimised it, saying ‘I didn’t smack him very hard’, ‘any parent would have done it’ and all of a sudden I realised this must be what happens to doctors in this situation.
“It was then that I moved from a position of perhaps judgment to empathy.”
In the last year of her mother’s life that empathy was tried when she spent time observing hospital staff not as subjects of her research but as the people caring for a loved one.
“I did a lot of interaction with a hospital and its nursing staff as well as a nursing home when my mum was dying and I saw how the hospital system treats older people, particularly older people who are dying,” she said.
At one stage Dr Tito Wheatland noticed staff at the nursing home were applying inconsistent procedures to her mother’s medication doses. When she pointed out the problem and the affect it was having on her mother, staff welcomed her feedback.
“This compared to when I made suggestions in the hospital. In that system, there was great resistance and I felt that their response was ‘what would you know you’re just a patient’s carer’,” she said.
“That fear that I had that I would be seen as a troublemaker and that her care would suffer was quite palpable for me and I started to consider the psychological impact when you as a patient feel vulnerable and how that might change your behaviour.”