This week, even in Australia, there has been discussion (on two ABC radio programs: Saturday Extra and The Health Report) about the Bawa Garba case which has stimulated so much discussion in the UK. I won’t summarise it except to say a paediatric trainee was ultimately struck off by the GMC after being convicted of manslaughter when a young patient died in 2011. There has been much angst on Twitter and articles in the BMJ and lengthy discussion about workload, understaffing, whistle-blowing, the role of supervisors, the use of reflective journals in training and so forth. I could illustrate this blog post with any number of Tweets. There has subsequently been a justification of their position by the GMC on their blog (links below). You can read the details yourself but the issues I feel it raises for educators are those of patient safety and a “safe” learning environment for learners.
For any educators responsible for work-based training it is important to consider what sort of learning environment is provided by the work environment. The GMC claim a strong emphasis on patient safety as do all health systems and training programs. Their explanatory document maintains that clinical supervisors are required to adhere to high standards. The impressively titled document Promoting excellence: standards for medical education and training repeatedly notes that patient safety is the first priority but notes that Patient safety is inseparable from a good learning environment and culture that values and supports learners and educators. I don’t work in the NHS but I am well acquainted with documents about training standards. In the Twittersphere many in the NHS are commenting on their current work load, even as they head in to a shift, and asking on Twitter, in effect, should I work today when it is not safe? The GMC advises they should work and follow their algorithm for making complaints but other tweets make comments that this algorithm does not work in the real world. Policies, standards, statutory regulations and accreditations seem only able to delegate accountability rather than to ensure the quality of the system.
The other recent popular response is to focus on producing “resilience” in doctors – yet again focussing on the individual for the solution, rather than on the system for some responsibility.
Discussion has progressed about strategies for maximising patient safety in various health system contexts. Professionals are trained within a health system which also provides the learning environment and this is a complex situation. How can the safety (for patients and learners) of this training environment be ensured and whose responsibility is it when issues occur? Can you always be a good or safe doctor in an unsafe environment? A further question might be whether we can rely on increasing rules and regulations (and increasing delegation) to really ensure quality and if not, what does? When is it the responsibility of the medical educator or supervisor to not only comply and tick the relevant boxes but also to speak up when the system is not functioning to facilitate the safety of the learner or the patient? It is probably not enough to introduce a module on resilience in the hope that learners in future can cope with a dysfunctional system should it arise. I am sure the debate will continue.
- A very interesting account of what happened clinically by concerned UK consultant paediatricians.
- This BMJ comment looks at the supervisor’s role http://www.bmj.com/content/359/bmj.j5534
- This is an interesting point by a cardiologist
- The link for the GMC blog explanation is on
- A SMH article summarised some of the issues that might apply to Australia http://www.smh.com.au/national/australian-doctors-disturbed-by-manslaughter-conviction-against-dr-hadiza-bawagarba-20180201-h0rrat.html
- This is a letter written to the GMC by UK journalist and broadcaster Nick Ross http://www.bmj.com/content/360/bmj.k481/rr-1