Tom Ronan

Originally submitted for the BMA Writing Competition 2020. The theme for entries was the word ‘sorry’

A new poster has sprung up in the dense thicket of the nurses’ noticeboard. Nestled somewhere amongst invitations to bygone Christmas parties, it proudly proclaims the title of yet another quality improvement drive. I don’t retain much information from the poster, nor do I look up the campaign, but the title sticks in my head.

Harm Free Care.

Is such a thing possible?

It’s something I mull over when I meet Laura, a few months down the line on my psychiatry rotation.

Laura is in crisis, and her crosshatched forearms speak of countless trips to this same unhappy state. She took a handful of pills in the early hours of the morning and has been seen by a long succession of professionals before ending up with me.

During my clerking I get to spend a fair while talking to her, and the word sorry crops up on a few occasions.

Laura’s problems started in a childhood marred by unspeakable cruelty. She was raised in care after suffering repeated abuse at the hands of her father, now serving a lengthy prison sentence. His incarceration provides her with some assurance of physical protection, but the ongoing psychological toll is profound and seemingly inescapable.

Her voice is shaking and tears start to trickle.

“I’m so sorry this has happened to you,” I offer.

The words feel hollow in my mouth. They feel rote, reflexive, and insincere. But, beyond tissues and a listening ear, they’re all I can offer her in that moment.

We eventually draw things to a close and I write up my plan. I prescribe the long list of medications she takes in the community, knowing with a heavy heart that neither the medications nor the admission will provide any meaningful fix for her particular condition. For her, admission means risk containment, not cure.

Laura carries a diagnosis of Emotionally Unstable Personality Disorder. She is the woman doctors euphemistically call “complex”.

I want to tell her that I am sorry. I am sorry that there is no simple salve for her sickness, and I am sorry that we, as a healthcare service, can sometimes make things worse.

Medical harm can take obvious forms – a surgical complication, a hospital-acquired infection. In Laura’s case, my mind jumps to the benzodiazepines she uses to get to sleep, first prescribed with perfectly good intentions, but now spiralling her into a pattern of tolerance and withdrawal.

Iatrogenic harm can also be more subtle. In a moment of desperation Laura takes a box of tablets and calls the Crisis Team. Blue flashing lights arrive at her door, and she gets whisked into a world of concerned professionals who provide the unerring unconditional care absent from her childhood. It is a co-dependent relationship: the victim is soothed and I, as rescuer, get the warm glow of having helped. The sick role is a safe bosom and, when discharge looms, Laura is that child once again, being abandoned by a slew of inconsistent caregivers. The world flips and I become persecutor; Laura stays victim, and is left reaching out for a new rescuer. This revolving drama – an analogy of her tumultuous childhood – plays out across all aspects of her life. Sometimes the cycle of self-harm escalates. The outcome can be fatal.

Laura is only in her early twenties. The direction of her life rests, in part, on the way the health service reacts to her distress. There are difficult conversations ahead. ‘Sorry’ isn’t just a word for recognising past errors; it can appear when making difficult decisions about the future.

“I’m sorry,” we might say, “but I do not think an admission would help you on this occasion.”

“Sorry, but starting you on those tablets would do more harm than good.”

Interventions and investigations give the impression of care and, as doctors, our instinct is often to escalate care, even when this risks escalating harm.

Harm Free Care – three words on a poster that manage to capture all the tensions and paradoxes of medical ethics. Laura’s life has been an ebb and flow of harm and care. All I can hope is that, with time, the tide starts to turn in her favour.