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Patient Harm and Medical Error As Threats to the Doctor Identity - a New Lens for Improving Patient Safety?

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Patient Harm and Medical Error As Threats to the Doctor Identity - a New Lens for Improving Patient Safety? Patient harm and medical error as threats to the Doctor Identity - a new lens for improving patient safety? A thesis submitted for the degree of Doctor of Philosophy of the Australian National University © Fiona Tito Wheatland 2017 Student statement This thesis is my own original work. According to the Procedure: Higher degree by research – submission and examination of theses, the word count of the thesis is 99,500 words. ii Preliminary Pages Acknowledgements The research for and production of a thesis requires the support of many people. I acknowledge the support of my principal supervisor, Professor Peter Cane over the many years of my work, and for the patience he has repeatedly shown as my life interrupted my work. I also thank my Panel Members, some of whom came and went over the 13 years of my efforts. Thanks especially to those who finished the journey with me. My Panel has included: Professor Valerie Braithwaite, Dr Sophie Hill, Dr Bill Runciman and Professor James Reason. I acknowledge the love, patience and fortitude of my husband, Clyde Wheatland – we married at the beginning of this journey and I am sure he is looking forward to having more non-thesis time with his wife. I also am grateful to my children, Anna Tito and Patrick Tito, who have grown from young people to wonderful adults over the period of growth of my thesis. You inspire me always. Their respective partners, Jim Curlewis and Sascha Bagrianova, have also shown great forbearance in inheriting a mother-in-law whose mind was often elsewhere and in loving me and my children just the way we are. I also wish to acknowledge the contribution of my child Mathew Stewart, who gave me a deep understanding of the profound effects of trauma as I loved and cared for him, and who is now growing into a fine young man. My family provided sustenance for my body, heart and soul as I worked. They gave me a deep understanding both that my work was important and that they were as well. I acknowledge my late mother, Jean Smyth. I cared for her as she became ill and as she died, while I was on the thesis journey. Her living and dying were rich sources of inspiration and love for my work. She was a wonderful teacher right up to the end. I wish to acknowledge all my friends in the health consumer and health regulatory arenas, who told me that I had to finish, because it was important work. In particular, I would like to thank Janne Graham, Kate Moore, Darlene Cox, Judith Briscoe, Russell McGowan, Theanne Walters and my colleagues in the Australian Medical Council, Ros Lawson, Catherine Settle and the late Dr Christopher Newell. There are many other health consumers to whom I am grateful. They told me of their experiences, sought my advice and kept me grounded in the reality of the patient and regulatory experience. I wish to also acknowledge the medical and health care colleagues who also told me the work was important. They provided generously of their time to talk to me about their lives and the issues I was thinking about. In particular, I would like to thank Dr Elizabeth O’Leary, Professor Christine Phillips, Professor Katrina Anderson and my colleagues on the Canberra Region Medical Education Council, Dr Peter Loa, Professor Paul Dugdale and my colleagues from the seminars in the ANU Centre for Health Stewardship. I thank all my friends and university colleagues, who have been through the tears and joys, the trials and successes – patiently enduring long delays in contact and conversation. In particular, I acknowledge the practical support, love and transport provided by Mary Ivec; the love and friendship of Penny Gregory; endless food and fellowship from Elizabeth and Michael Croft; the inspiration of my two mates, Dr Joyce Wilkie and Dr Dell Horey; the life-long guidance, love and mentoring of Professor Marcia Neave; the singing and support iii Preliminary Pages from my neighbour, Kate O’Neil and the Once Voice Community Choir; dreaming of and working towards a better world with my Anabaptist friends, my friends in CAPAD and other community organisations; Lorraine Gatehouse and Merryl Bollard, from the Gathering Place in Dickson, who gave me shelter to write over a long period at the early stages of my work; Darryl Bounty for being part of a dream team of support; and Sue and Mark Mannion, Lorraine and David Pring, and Caz and Glenn Ensor, for holding us up, when tragedy struck our family, and for keeping me, keeping on. I’ll be onto you all soon for that long awaited meal, meeting or movie, without me being distracted by my thesis! I also wish to thank the inspiring Dr Inger Mewburn and Victoria Firth-Smith, and the rest of the team of the Research Training Unit. We met through the Surviving the PhD MOOC (Massive Open On-line Course), which was pivotal in my completion of the PhD. I also acknowledge the amazing community that has grown around the PhD OWLs Facebook group, which I started to provide support for older wise learners/PhD students, following the MOOC. In particular, I am grateful for the support and love of Helen McGowan, Tracey Griffiths, Caroline Compton, Zibah Nwako, Regina Nava, Michael Nycyk, Paulette Del Rosso, Steph Burton, the dedicated members of virtual Shut up and Write and all of the others who continue to contribute to that fine community. I also acknowledge the great assistance and support from the ANU Thesis Bootcamp folk, the BC Veteran’s Days and the Social Media course group, especially Danny Kenny. You have all been the wind beneath my “owl-y” wings. I also especially thank my employers at the Australian National University and the members of the ACT Law Reform Advisory Council, especially Professors Simon Rice and Tony Foley – who gave me encouragement on the journey and cheered as I got there. I acknowledge the financial assistance of an ANU Graduate Miscellaneous Scholarship between 2004-2012, most of which was paid as a part-time scholarship. iv Preliminary Pages Abstract Preventable patient harm and medical error occur frequently in health care. Despite the apparent widespread commitment to the “First do no harm” aphorism in medicine, it has proved difficult to get prompt, effective and sustained action to detect and prevent these. The existence of preventable patient harm and medical error has been well established over the past 50 years and its high frequency has been confirmed in many international studies over the past two decades. The thesis used a secondary source research methodology across a wide range of disciplines that have looked at medical error, preventable harm and doctor behaviour to explore possible explanations for these phenomena. The thesis concludes that there is an alternative plausible explanation for why action on identification and action on these issues by doctors, as leaders in health care, have been so slow and inconsistent. The thesis provides evidence in support of three hypotheses that form part of this explanation: • the occurrence of patient harm and medical error can be perceived psychologically by a doctor as a fundamental threat to his or her identity; • a serious threat to identity causes a range of psychological defences, often rooted in the biological responses of the brain to threats to existence, and these defences can make it hard for a doctor to recognise, identify or accept the risk of patient harm; • elements of the Doctor Identity deny ordinary human psychological responses and physical limitations, and thus promote unrealistic self or group perceptions. This creates risks to both doctors and patients. Many of these risks may be avoidable through modifying these perceptions and developing more realistic self-and professional schemas. The thesis concludes that these hypotheses provide potential new ways to address the issues, and reduce harm caused to both patients and doctors. v Preliminary Pages Table of Contents Title page and copyright ........................................................................................................ i Student Statement ................................................................................................................ ii Acknowledgements ............................................................................................................. iii Abstract .................................................................................................................................. v Table of Contents ................................................................................................................. vi INTRODUCTION ................................................................................................................ 1 A. THE GENESIS OF THIS THESIS ...................................................................................... 1 1. The Professional Indemnity Review 1991-1995 .......................................................... 1 2. The Quality in Australian Health Care Study and beyond ......................................... 4 3. The Australian Council, then Commission, for Safety and Quality in Health Care ... 8 4. The 2001-2002 Medical Indemnity Crisis ................................................................. 11 B. THE POSITION OF THIS THESIS .................................................................................. 16 C. THESIS METHODOLOGY ............................................................................................. 17 D. AN OUTLINE OF THIS THESIS .................................................................................... 20 Chapter 1: Preventable
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