WHY DO WE PLAY THE BLAME GAME?

Dr. Geeta Sundar

Patient is wheeled in. Chronic alcoholism, big belly of ascites, with complaints of hematemesis, rectal bleed, jaundiced eyes, all signs of liver failure prominent.

I stand there in the casualty area, on duty, on edge; it’s on the other half of the day and my patience is waning thin. I am hungry, frustrated, dehydrated and sleepy. It’s been a rough couple of days and any other resident would stand testimony to that.

I mean, I see this patient from the corner of my eye and I know, somewhere in the parts of my brain still functioning that this guy is for “medicine” consult, not “surgery”. So, I don’t pay much heed to him and focus on the trauma cases to tick off my list whilst I assume the medicine resident would check him out.

Ten minutes later, the emergency nurse gets in my face, annoyed as hell, screaming at me that no one has seen this patient. Trust me now when I say this, my frustration is at a weak threshold, and I can almost see the cogs turning where I scream back at her, stating my obvious need to intervene on the trauma cases, rather than this possible chronic, stable cirrhotic patient.

But I take a deep breath and calmly explain to her that it’s not “my” case. But she doesn’t budge. She states that he has “acute abdominal pain” and “rectal bleed” and that makes it “my” case and also that the medicine resident is busy in the ward intubating some patient who crashed and I needed to tend to this patient.

Relenting, despite all the annoyance in me, and building that restraint to avoid rebelling, I check out the patient.

My clinical examination revelation stands as such –

Stable vitals – check

Signs of pallor, jaundice and liver cell failure – check

Abdominal examination – ascites +, minimal tenderness around the umbilicus

DRE – no active bleed, stools noted on gloved finger, no bleed

Imagine my surprise, folks! NO “acute abdominal pain”, NO “rectal bleed” presently.

I’m miffed, to say the least. I document my findings, and state in it that he requires medical consultation and am about to leave to get some water, when the same nurse stops me. Now she’s got another order – admit the patient and medicine will “take-over” tomorrow. The medicine resident is really busy, he can’t come, so he calls and tells the nurse that “surgery” needs to admit the patient, for observation in case the “acute abdominal pain” increases or “rectal bleed” worsens and after discussion with his senior/consultant tomorrow, he will “take-over” the patient for further care as required.

Given the circumstances of local political and logistic issues, I ended up admitting the patient into our “surgery” care, facing the wrath of my senior resident as to why I admitted a “medicine” case, to documentation and constant follow-ups with that medicine resident to finally “take-over” the case, and explaining to that patient and bystanders why their doctors were being changed within a day.

I’ll bow out here from the story before we lose the take home message.

I’ve been a perpetrator and a victim of this “inter-departmental” conflict. It’s as common as the air we breathe or the vitals we measure. It’s an inbuilt mechanism, learnt from years of observing the seniors. It’s a defence mechanism to be able to only handle the “right” cases, and shun away with the ones that “don’t” matter. Of course, I’m not being coarse or lowering the value of the human life but that’s just the way it is – someone from a specialized field is better to handle that respective care, than someone who is not.

But the thing is, even if we ordered a side of French Fries (the French fries here, representing, say a field of medicine), the patient (let’s try to say they represent a menu) don’t come only with the French Fries, they come with a whole appetizer, dessert all included and only choosing the French Fries then becomes an issue.

Pardon the silly metaphor, but the conflict of a simple admission of such a varied abled patient is just the tip of the iceberg. On top of the tug and war of “who” admits the patient, comes the decision making process that varies from doctor to doctor, and across specialties with overlap of diagnosis among the fields – each respectable, sensible doctor has his/her own choices and understanding of the basic sciences that they choose the medications, the doses, the intervention on their knowledge and experience; and the worst part beyond that is who takes the blame for the downfall of such a patient if the care was transferred in the middle.

And therein lies the problem. We play the “blame game”. We don’t put out our chest, accept with humility, endorse our teamwork and admit to the problems that we were part of or the problems we have in the system. Red tape, logistics and so many other influential aspects of our medical system will always play a role, but it’s up to us professionals, as human beings, as strong role-models in the world to embrace a mistake when we make it. Otherwise what are we teaching the next generation? That it’s okay to make mistakes and absolve them by brushing it under the rug?

We say, oh, that doctor (insert name), yeah he does that, his mistake are well known. Or, this doctor, sure her choices and diagnosis is always wrong, don’t go back to her. And we demean and insult our own colleagues in the profession, not understanding often that the situation may have demanded it, or that it’s probable that the circumstances spoke of urgency, or that the doctor may have taken such a decision because he had learned from past experiences. Yes, I do agree there are always a few bad apples in the lot, but not each should be branded as bad. In this manner of ridicule, we create an impression on the society that encourages to pit one doctor against another and belittle their knowledge, their efforts and their esteem. Given that the doctor-patient relation is so fragile and built on trust, such interventions only speak of how indifferent we are towards the other professionals in our field and indicates to the community that they can demolish our entire medical journey in seconds of backlash!

So why do we do it then?

You know I’ve pondered over it since many months and each time I think I am closer to an answer, the void just gets bigger and tells me it’s multifactorial and a huge component is with the upbringing, the principles we were taught, and the kind of exposure we had during our foundation years at intern and residency training. It maybe parts insecurity, parts ‘hate begets hate’, defence mechanisms, competition for fame and money, personality issues or just a combination of all that is disharmonious.

It takes a lot to break the cycle. But it can be done. Just needs one person to stand up and change and transform those around him. After all, this kind of revolution is in our blood!

Images – Google Images