From the humanisation of medicine to the dehumanisation of professionals

Gustavo Tolchinsky

The well-being of doctors is an issue that has a direct impact on the quality and quantity of care that healthcare systems can deliver to society. You only need review several of the entries of recent months and certain articles that even quantify the cost and waste that burnout implies for healthcare organisations. As has been shown in these articles, organisational factors, workloads, alienation from the values of organisations and professionals, the autonomy of professionals to manage their work, and even the type of clinical information management programs and their usability affect professional well-being.

In various forums for patients and professionals, there is agreement on the need to promote an experience that does not dehumanise the patient in his or her interaction with a health system that tends towards the industrialisation of care processes. It is known that to increase the efficiency and reliability of healthcare processes, a part of them, approximately a third, can and should be industrialised as far as possible, and that this would benefit patients and the system, and also professionals.

But even the most competent, caring and resilient professional can fail in an infallible system.

The emotional reaction after making a medical error can be very varied. It depends on the impact of the mistake and, above all, any legal proceedings following the event that can also condition professional practice. A recent article reviews all the spheres of involvement of professionals regarding clinical judicial syndrome, described by Dr Hurtado-Hoyo, with the purpose of highlighting the need to organise psychological care for doctors who have experienced the ‘bench penalty’. The consequences are varied, as described in the article by Dr Arimany et al., which highlighted that 80% of the professionals evaluated after a lawsuit present a significant emotional reaction in some situations. In extreme cases, the impact can lead to the suicide of the affected professional. Those who have read Paul Kalanithi's When Breath Becomes Air will remember the surgery resident, Paul’s colleague, who ends up committing suicide after failing to overcome the impact of the death of a patient from a medical error. Some papers collect this variety of reactions, among them the famous defensive medicine, which established in many of the things we do for no clinical reason, as Dr Vallejo recently hihglighted in his post. A search for "malpractice and defensive medicine" yields 2,450 articles in Scholar Google from only 2018 to the present, and in some of them, it explains how the practice of defensive medicine slips into teaching.

Recently, the BMJ published an editorial, Abandon the term "second victim", which has generated controversy regarding the advisability of using ‘second victim’ to describe professionals involved in a malpractice case in which the patient has been the primary victim. Some of the co-authors belong to organisations such as Mothers against Medical Errors or Citizens for Patient Safety. The arguments they cite relate to the system's or the professionals' lack of accountability when an error has been made. The exculpation occurs because the fault is of the system, thus diluting the responsibility of those directly involved in the process/procedure. Furthermore, it is argued that professionals, by calling themselves the second victim, appropriate the suffering that belongs the patient and the people close to him or her.

The responses to this article, which can be reviewed, are varied. It has to be noted that denying the doctor's right to an emotional reaction, both to the negative consequence of the patient intervention and the fear of the consequences derived from his or her professional practice, supposes an act of dehumanisation of the professional by society. And, for the system, changes in the behaviour of a professional, turning predictably towards defensive medicine, mean moving away from good professional practice. From the Praxis Area of the Barcelona College of Physicians, Dr Gómez Durán also responded to this article and BMJ has published her response. The term second victim may be more or less appealing, but it has brought to light the impact of a situation so complex that it involves obtaining the opposite result to that desired with medical intervention, and has created an awareness of the need to address it. Additionally, despite the appearance of the term second victim, initiatives aimed at improving patient safety have continued to grow and, therefore, this has not been a reason for relaxing the safety policies of health institutions.

Thus, while considering the ongoing debate, we ought to have a sound psychological support system in place for those professionals who may be involved in legal proceedings that may negatively impact their professional practice, the quality of their interventions or even interrupt their professional activity. And it is the case that the suffering of patients as victims is not exclusive to them, nor should it preclude that the professional also suffers. However, I think it is even more relevant to combat both the defensive medicine we practice, because of this fear of litigation, and the things we do for no reason. Lastly, I believe it is fair to assert that the humanisation of clinical care is bidirectional between its two protagonists, based on trust and on an understanding of uncertainty and fallibility, without ceasing to demand safer work environments and processes that minimise the possibility of error.