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Perfection in an imperfect world

Dr Shaba Nabi

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One of the mantras adopted by educators within our GP training programme is being ‘good enough’. It is a challenging concept to convey because good enough isn’t in the DNA of someone who has achieved A* grades, breezed through medical school and is training in one of the most competitive parts of the country.

Yet even for the academically gifted, arriving at the doorstep of general practice is like being parachuted into a foreign country where no one speaks your language and there are no interpreters. Trainees try to counter this amorphous uncertainty by staying later and later, poring over results, writing copious notes and documenting safety netting.

And who can blame them? There are myriad ways for people to complain about us: anonymous posts on NHS Choices, vindictive comments on Facebook and the more career-changing GMC and medicolegal routes. So acceptance of complaints and adverse events is a crucial part of learning – the alternative is lifelong anxiety.

Of course, in core general practice we don’t clock off when our shift ends. We can only leave when the work is done, no matter how exhausted we are. Having a triage screen of 20 patients to call back, and six more in the waiting room is no defence in the eyes of the law. No allowances are made for the day a GP is off sick when another two are on leave, and you are left managing an outbreak of measles. The impossibility of our day is never a factor when we perform less than perfectly; the tunnel vision with which each patient contact is viewed ignores all peripheral activity.

Despite the flaws of the creaking NHS around us, the pursuit of perfection is still our goal

It is this relentless expectation that is leading GPs and trainees to burn out and causing mental health issues, although support is finally filtering through in the form of the GP Health Service. The pressure also obviously extends to our nursing and paramedic colleagues in general practice.

A good friend of mine recently told me of the suicide of her colleague – a nurse with an impeccable career. She’d been badly affected by the death of a young patient she’d seen a day earlier. The nurse left behind three small children. I was struck by the similarities between this tragedy and recent experiences of my own, and experienced acute survivor’s guilt. Rationally, I knew that although lessons can be learned, some deaths are unavoidable. Yet emotionally, I felt the all-consuming responsibility many healthcare professionals endure when faced with an adverse event.

Sadly, case law has not helped. Bolam’s test, which was established in 1957 and holds that a health professional is not negligent if acting in line with accepted practice, has been undermined by the 2015 Montgomery case, meaning the action another reasonable doctor would have taken in your place is immaterial. But other countries, such as New Zealand, have taken steps to protect doctors by adopting a no-fault compensation scheme.

So, despite the flaws of the creaking NHS around us, the pursuit of perfection is still our goal. If the GMC was serious about reducing clinician suicide, it would be advocating a no-blame culture for us to work in.

Dr Shaba Nabi is a GP trainer in Bristol

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Readers' comments (15)

  • What if, God forbid, the GMC was political? :(

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  • Well said Shaba, we all can see what happens when corporate failings cause harm, gross negligence manslaughter charges await the poor individual, with the ‘support’ of a vindictive regulator. Enough said as the trainees may be listening.......

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  • Don't forget all the following are avenues to complain and each one will require further time to answer and appologise irrespective of if you have done the right thing or not:

    Local complaints procedure in surgery
    CCG
    NHS England
    Health watch
    Ombudsman
    GMC
    CQC
    Lawyers
    Press

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  • Great article. A healthy sugar of reality let's also not forget the recent Bawa Garba case. The population and our commisars want risk free medicine. They may get what they wished for.

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  • Good article Shaba.
    The Daily Mail (and possibly it’s readers and others inc GMC) want ‘risk free medical care’ as mentioned by BAP above (and usually want it free, as they have ‘already paid their taxes’).
    However, that such an attitude and philosophy has come to pervade the Great British Public is surely a reflection of failure by the medical profession to instill realistic expectations.
    And yes, sometimes the medical profession should take the blame for systemic failures (inc. it’s own inability to behave as something other than a ‘bag of autistic deaf cats’).

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  • The public have NO CONCEPTION of how demoralising a simple complaint can be. Our employers and those involved in the complaints system run a manifestly biased show where the patient can choose to ramp up the pressure even when it has been shown to be a complaint without merit. The BMA and RCGP and the GMC need to make it fairer and it should involve patients being made to apologise when they make unfair accusations. Only then will it seem more fair.

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  • Decorum - However, that such an attitude and philosophy has come to pervade the Great British Public is surely a reflection of failure by the medical profession to instil realistic expectations. - No only the free market can do that. It's what is the rational outcome of taking direct financial responsibility for healthcare from people (ie socialist policies). And Jonathan, APOLOGISE? no, unfair accusations, or even malicious complaints, should be justifiable grounds to counter-sue, if it has resulted in a legal case, for libel, compensation, etc. At the very least, successful defences of malicious complaints should have their legal costs covered, but even that's not the case at the moment.

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  • If only we had a union that would fight against these issues for us. Has anyone heard of one?

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  • Ummmmm.

    Contrast the first paragraph of the article with the last-on the one hand trainers espouse being "good enough" and then in the last it is stated that the pursuit of perfection is the goal.It cannot be both.

    Christopher Ho and his reflexive raising of the prism of free-market capitalism to his eye to survey all problems through makes me chuckle, but he is right about unrealistic expectations but not solely due to the explanation he gives. In part we as doctors have over-empowered clueless patients about the merit of their own evaluations through exploring their expectations thereby adding to the notion they have of their own importance, in tandem with the "efforts" of social media. We have also devalued ourselves in the patients eyes ("If I knew WTF was wrong with me I wouldn't be coming to see you!") to the point where AI or an app will soon have us applying for ESA, and this is before you consider the paucity of GP hands to deal with the workload.

    When everybody is right, why shouldn't they complain? This is how our beloved patients see it, and we have reached a sorry nexus of interweaving factors where we must expect complaints and no consideration of how we are affected. Bacause we get paid loads, our well-being is prostituted to the wage in the eyes of many.

    Consider the following - you have just completed your only 6 month medical job post and are then expected to carry the hospital registrars bleep. Or it could be O+G, or paeds or any other discipline you care to choose which forms part of the GPs work. You are expected to evaluate whatever is presented to you accurately. Using Shabas example, the foreign language school is ones secondary care experience where "the lingo" is heard before being parachuted into primary care.Only by getting sufficient experience of the appropriate quality in secondary care can some of the primary care demons be properly slayed. As I see it, this is far from the case at present.

    Perfection is not a human attribute, and good enough means different things to different people.It is a case of having a sufficiently robust foundation which can be built on to produce work of a thorough nature, which can withstand scrutiny. Because this scrutiny is here to stay for the foreseeable future.





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  • Lol Idgaf - I'm glad I tickle your funny bone. But I've never insisted that the free market will solve ALL problems, but a lot of them. Or that the UN-free market system is the sole cause of the problems either. I'm not against scrutiny too, which is exactly what I'm doing. Now, how do you define 'unrealistic' expectations? If I paid £10k for cryotherapy of a wart instead of £100, would I then be realistically expecting greater efficacy, post-therapy care or even warranty, etc. The free market (as opposed to state intervention), is the 'best' system we have of 1. reflecting the cost (i.e. nobody is going to pay £10k for a wart cryo), 2. modifying the expectation in line with the cost. I would trust free market forces over state bureaucracy any day of the week, and so should you.

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