Fear and loathing in patient safety?


I have a confession: I’ve never seen the film, and never read the book.

From what I gather it’s a surreal and strange world: that’s how I’ve felt about my place in patient safety recently.

More worryingly, it’s a phrase that’s resonated through my head a lot more over recent weeks (If you’ve read this blog before, that’s what happens: phrases circulate in my head, and I over-think them…)
It’s taken me a while to work out what’s so strange, and why “fear and loathing” resonated with me so much.


I went to a conference: that’s not strange, I do that quite a bit.
But this wasn’t just any conference:  this was the FMLM annual conference in Edinburgh.
Great line-up;
fantastic participants;
and really important themes of changing culture in the NHS, and managing risk.
Things I’m interested in; that I care about. Or so I thought.
Now, I accept, I usually get a bit cross at conferences, but I also get enthusiastic.  FMLM had me feeling just dispirited.  I thought I was tired, and generally fed-up, so I’ve taken a while to think about it.


 I’ve had…
and watched two episodes of GBBO
(not all at the same time; although there was chocolate with the GBBO), and things are no better.
The conference followed a Twitter conversation I had with the inspirational Dr Umesh Prabhu (@DrUmeshPrabhu).  He pointed out that BME doctors won’t speak out on patient safety because they’re too scared.  He’s one of the few people who acknowledges just how important fear is in preventing doctors from speaking out.
What really made me think about this exchange was this: I believed that the problem was junior doctors standing up in the NHS hierarchy.  (To be honest, I’d always assumed that I was being a bit cowardly about the whole thing, and it’s always been easier to use the “but I’m just a junior” excuse…)  Dr Prabhu highlights the issues that BME doctors face in the NHS: fear is a huge part of that.   That’s an issue for thousands of professionals in the NHS; it’s also a massive issue for patient safety.
Then I had another look through my Twitter feed: it’s full of professionals and patients in the NHS who are scared for other reasons.  People with mental health diagnoses facing stigma, and talking about the bravery needed to be honest about a clinical diagnosis (@LisaSaysThis is a brilliant example of sharing experiences).  There are female doctors facing discrimination and sexual harassment who don’t want to report it in case it affects their careers and references; doctors on career breaks; working LTFT; who’ve failed exams or had complaints (and if neither of these applies to you, then you are incredibly lucky)…
FMLM was great;12018921-emoticon-with-adhesive-bandages-over-his-lips
it was full of inspiring speakers and champions for patient safety;
we talked about culture change;
we agreed we had to make patient safety a priority…
We didn’t talk about the fear that stops us speaking out.

Is there a link between patient safety and fear?  The tabloid press would see it as easy: patients terrified of entering the NHS, disasters on every corner.

Then there’s the other side: the fear that whistleblowers overcome; the bravery that is every small daily challenge that makes patients safer.  We know about the “big” cases of whistle blowing, the dramatic ones.  We don’t talk about professionals overcoming their fears every day to make patient care a little better.  We don’t acknowledge how much courage it takes to go against the convention of a group, and to question.

If you think I’m being over-dramatic about this, then just think about the terminology we use about people who do raise their concerns:

“raising their head above the parapet”
(“Whistleblowers” – I have no idea where the term comes from, but it makes me think of referees, calling time on people that aren’t playing the game.  Except that this isn’t a game.  This is the NHS, and people’s lives and wellbeing.)
Incident forms are completed “against” someone; their completion apologised for.
Rather than seeing this reports as a chance to work together to find good solutions, we function defensively.   It’s hard to see critical incidents as learning experiences and opportunities to make things better, when the fear of standing out limits us.
And that’s what made me so dispirited.  I came out from the FMLM conference thinking that I have to speak up; I have to keep sticking my head above the parapet; I have to be brave, and be awkward.
And what makes me so furious is that I shouldn’t have to be brave.
Making changes; raising concerns; shouldn’t be an issue for anyone in healthcare.  This shouldn’t be something that we’re struggling to do, that we’re seen as different for doing.  This should be a basic part of our job as professionals, as carers.
And this is where the self-loathing comes in.  Staying scared goes against everything that I believe in as a healthcare professional.  It goes against what my colleagues feel as doctors, nurses, cleaners, porters; as parents, children, partners; as human beings.  Protecting others; caring for others; trying to make things better is a basic component of our motivations and inspirations to work.  It’s part of being human.  And yet we work in an atmosphere where we are too scared to undertake such an essential part of that work.
No wonder we’re burnt-out, disillusioned, and habituated to the environments we work in.
We’re constantly working against our preferences in this situation; against our inclination and need to make things better; And fear is what underpins that.
Solutions are complex, but in the meantime, I can’t keep working against my inclination.
And that means that in order to do my job, I have to continue to be awkward…
And to be awkward I have to overcome my fears.
But if I can get help from anywhere, I’m taking it.  Hopefully, to use my courage wisely…

Although, I may need a little of the anger…

Just to see me through…

Just a little, teeny, tiny bit of fury….