05:35, March 05 99 0 theguardian.com

2018-03-05 05:35:11
Views from the NHS frontline  
 If Hadiza Bawa-Garba worked in the US she would still be a doctor

When I moved to Philadelphia for training in radiology, three things struck me about the US – the numerous types of bagels, defensive medicine, and the amount of support for trainee doctors. American medicine, though famously litigious, protects its residents (trainees), who work as hard as their British counterparts, and often make critical decisions, sometimes unsupervised, but rarely unsupported.

I’ve trained in both systems, as a surgical senior house officer in Britain and a radiology resident in the US, and the difference between the two systems for trainees is stark. In the US residents must gradually earn their independence; in Britain independence isn’t earned but assumed. I was on call overnight, unsupervised in a busy A&E in London 18 months after qualifying from medical school, with no consultant or registrar on site. This would be unthinkable in the US. I never complained because I enjoyed the independence and felt supported by the nurses. In hindsight, I feel goosebumps knowing that I was only one catastrophic error from facing the same fate as Hadiza Bawa-Garba, the paediatric registrar convicted for manslaughter for missing sepsis.

In the US, training programs are monitored by the Accreditation Council of Graduate Medical Education (ACGME). If several residents complain that they are shortchanged by a training program – ie they are not taught well or are unsupported – the ACGME disqualifies the program and the hospital loses residents.

As a resident I had protected time to attend lectures. I was amazed by how invested the attendings (consultants) were in my education – they took my knowledge, or lack of it, personally. A big difference between the US and Britain is that residents usually stay in the same hospital in the US and know the system and its idiosyncrasies and the consultants monitor their progress.

Sometimes I found the degree of supervision intrusive, having worked so independently in the NHS. Now that I’m an educator, I understand. I have one major educational responsibility: making sure radiology residents don’t miss emergencies of the vascular system – some potentially fatal ones – while on call overnight. When residents detect them and save patients’ lives, credit goes to them. However, if they miss them and the patient experiences an adverse outcome because of the miss, the blame falls on me. I’m aware of this asymmetry, but I think it’s only fair – the resident works when I sleep. Also, it motivates me to put in that extra effort making sure they’re competent in dealing with emergencies.

When I tell American physicians the plight of Bawa-Garba, they’re incredulous that she was unsupported by her consultant. The US medical system has many faults, but it does not throw the trainee under the bus. Dr Riordan, Bawa-Garba’s consultant, must share some blame when Jack Adcock tragically died from sepsis.

Had Jack died from delayed diagnosis of sepsis in the US, it is likely that the hospital would have been sued, but Bawa-Garba would have been dropped from the lawsuit. The lawsuit would probably not have gone to jury trial because the hospital would have settled, potentially for millions of dollars. The fiscal punishment would have forced the hospital to make systemic changes and use resources so that another child didn’t die from sepsis.

A year after Jack’s death, Rory Staunton, a 12-year-old boy, was seen in the emergency department of New York University (NYU) hospital complaining of vomiting and fever, a day after scraping his arm playing basketball. His doctors sent him home with paracetamol and fluids, thinking he had flu. His condition deteriorated and he returned to the hospital, and three days later he died from septic shock in the intensive care unit.

No one went to jail for Rory’s death. NYU was found negligent for systemic errors – notably that a blood test for white blood cells, cells that fight infection, which are not normally raised in a flu but were raised in Rory’s blood, was obtained but never reviewed.

Rory’s parents lit a sweeping fire of awareness. The mainstream media publicised Rory’s death. The media did not blame incompetent doctors, but inadequate systems, for his death. A private charity in Rory’s name raises awareness of sepsis.

Realising that sepsis is a deadly deceiver that can easily be missed, after Rory’s death American hospitals developed protocols for potential sepsis. At my institution, anyone with suspected sepsis must have a chest x-ray to look for pneumonia, and the x-ray must be reported by a radiologist within 30 minutes. It took 90 minutes to perform Jack Adcock’s chest x-ray but it was never read by a radiologist.

When we see pneumonia on a chest x-ray, we call the physician straight away. Had Bawa-Garba worked in a hospital in the US, she would have been alerted by a radiologist within 30 minutes of the x-ray being done that Jack had pneumonia. Jack would have received his antibiotics sooner. I don’t blame British radiologists – there aren’t enough of them to read chest x-rays, let alone read them in 30 minutes.

It is ironic that in the deeply individualistic US, medical errors are blamed on systems but in the collectivist NHS, individuals are blamed for errors. Rory Staunton’s death saved thousands of lives as hospitals learned from NYU’s systemic errors and became safer. Bawa-Garba’s conviction for manslaughter, and erasure from the medical register, will not make the NHS any safer.

Saurabh Jha, a British-trained medic, is an associate professor of radiology at University of Pennsylvania, Philadelphia

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