The Blame Game: How we let ourselves off the hook at the patient’s expense

Today’s post is a bit more philosophical.

Being a doctor is hard. It’s even harder when things go wrong. Most of the time, the things that go wrong aren’t our fault. They usually aren’t the patient’s fault, either, even if they are a direct result of the patient’s actions. How is that possible, you ask? If a patient comes in to the hospital in labor, with no prenatal care, is it really her fault? It’s easy to say yes. It’s easy to say that she doesn’t care about her baby enough to prioritize her prenatal care. You shouldn’t have to think about that for more than a few seconds to realize how ridiculous it is. It’s nearly impossible to just not care about your own child. What is possible, likely, and common, is for patients to have to make tough choices about how to use their limited resources. Choices that few physicians have ever been faced with. When you have $20 in your pocket and 3 kids at home, are you going to buy prenatal vitamins, or food? When you have no one to watch your kids and you can’t bring them with you to the doctor, would you consider skipping a prenatal visit or two as long as you feel fine and have no complaints? It’s easy to judge, hard to empathize.

Here’s a situation I want you to consider:

Technical version for the OB/GYNs in the room: A patient is getting antenatal testing because she is diabetic. She has 3 other kids at home. Her NST has been nonreactive every week, so every week (sometimes twice a week) she gets sent to L&D for a biophysical profile. She has to find someone to watch her other kids for 2 hours, and her BPP is always 8/8. At 39 weeks, she has another non-reactive NST. No decels, just non-reactive. She can’t find anyone to watch her kids, and the baby is moving well, so she decides not to go to triage this time. She comes to triage three days later with complaints of leakage of fluid and is found to have a fetal demise.

For the non-medical folks in the audience: We put this particular patient’s baby on the monitor every week for the last two months of her pregnancy because she is diabetic. Her baby never does all of the things that we want to see it do on the monitor, so we always send her to the hospital for a more advanced test. Getting to the hospital, getting checked in, getting the test, and waiting for the results takes about 2 hours. She has to find someone to watch her kids every time, and the baby always passes this second test with flying colors. Less than a week before her repeat c-section was scheduled, we put her baby on the monitor in the clinic, and as usual, the kid didn’t do everything we wanted to see. So we told her to go to the hospital for the more advanced test. She couldn’t find someone to watch her kids, so she decided not to come to the hospital for the test. After all, she had been through this so many times already, and everything was always fine! Her kids needed her. Three days later she thought her water broke so she came to triage. Her baby was dead inside her.

For everyone: When she came in, labor and delivery started to buzz. It was all people could talk about. The focus of the conversation? “If she had come in when we told her to, her baby would be alive.” Think about that for a minute. This woman was just told that her baby is dead. She sat through who knows how many tests, visits, and ultrasounds for this baby. And now this baby is dead, and all the nurses (and some of the doctors) can say is that it’s her fault for not coming in before. When they tell other healthcare providers about this patient, they say “She is a diabetic who had a non-reactive NST and didn’t go to the hospital for a BPP and then her baby died.”

What a horribly cruel thing to say, even if only to each other! What a cruel thing to think! If you mention that to the people criticizing this patient, the immediate response is that they would never consider saying that to the patient. They think that as long as they don’t say anything directly to the patient, it’s ok. It’s hard to imagine, though, that this attitude doesn’t come across at all in their communications with the patient, or in their degree of patience and gentleness in caring for her.

When I describe this patient’s story to a medical student, I say “She had a 39-week fetal demise, and she is coping as best she can.”  If they bring up the fact that she didn’t come in for the second test, all I can say is that she will be judging herself for that for the rest of her life. She doesn’t need me to judge her, too. She needs me to support her through the worst experience of her life.

Maybe it helps that I took care of her in the clinic, that I knew her before this happened. I knew her as a dedicated mother who was struggling to take care of her own health while nurturing her kids. Once, she brought her other kids to her appointment because she couldn’t find a babysitter. She patiently corrected them when they started getting stir-crazy in the exam room. She didn’t yell or hit, but she didn’t tolerate bad behavior, either. She was a hardworking mom, doing her best, and now her world has been shattered.

So, for my New Year’s resolution, I encourage you not to blame your patients when something goes wrong. Even (and maybe especially) when it is a result of the patient’s actions. She didn’t do what she did thinking her baby would die, and she doesn’t deserve our scorn.

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