These days, medical school selection processes place great emphasis on candidate’s interpersonal skills. Future doctors are chosen on the basis of their communication skills, caring ability and social and cultural awareness. But one essential quality seems to be neglected – and that is courage. In the current climate of political unrest against politicians and the snare of rules and regulations that bind us, courage is becoming frowned upon, is branded as ‘militant’ and risks our professional lives.
To go against a guideline risks litigation and the prospect of our notes being judged by an ‘expert who has the luxury of time on their hands. Doctors are not allowed to let people die anymore without filling in DNR forms. We cannot turn off life-support machines without lengthy court processes. Anyone brave enough to go against these procedures and use their heart or gut-feeling to do what they think is best for the patient risks litigation from angry families, the GMC and the prowling, hyena-like press. He or she who has been courageous risks a spell in the stocks as a fool.
Yet to be a good doctor demands great courage. Surgeons have to be brave to know when to cut and to be wise enough to know when to stay up. GPs need courage to live with clinical uncertainty or to deliver bad news. More than ever, doctors need the courage to say no when we believe something to not be in patient’s interests or when it takes us away from the real work we are meant to do.
An event from many years ago sticks in my mind. I was leading resuscitation on a young woman who was 26 weeks pregnant on the ward. Although there were paediatricians, anaesthetists and obstetricians present, somehow everyone had their consultant present except me. I was 30 at the time and not that experienced; I had been a medical registrar for less than a year. I tried to make the decisions to be something that we owned as a team, going on until there was unanimous agreement to cease but ultimately it was up to me. I wonder now, could I still be that courageous to make that final decision or would I have doggedly kept going until my own consultant could be found.
But experience and regulation have made me less courageous with age. Recently I visited an elderly woman with chest pain. I walked into her house and immediatly saw the shell of a former person, shrunken, one hand clinging to the rails of the bed in the living room; the skin like tissue paper, ready to break down. Frailty and vascular disease had eaten their way into the soul of this person, leaving a twig-like figure, unaware yet half sitting up and staring into space.
Twenty years ago, it would have been easier to be kind. I would have made a brief assessment and concluded that, whether or not this person had cardiac chest pain, there was nothing more to be done as long as she seemed comfortable in bed.
Now there are complaints and regulation to contend with. Unable to get hold of the family, I became confused about what to do. Perhaps in hospital, a senior nurse would have been matronly and given me a nudge in the right direction. But instead, I felt the creep of the carer's own anxiety hanging around my neck. I sensed we were both thinking, ‘what if this 96 year old dying woman dies and then someone complains.’
People who create regulation think that making more and more rules makes things better; that it forces us to be safer. In reality, this is a snare. Over-regulation somehow presumes that we’re all inherently evil or careless and that more forms and procedures and investigations will somehow force us to care. But at times, it disables us. It can mean weak decisions that aim to cover our own backs. Ultimately that means the decision is about protecting us, not the best interests of the patient.
In the end, with the elderly patient, I did nothing and left her comfortable in her home. But I didn’t feel kind or courageous or professional. I was left feeling worried what could happen to me.