Adverse events from the doctors' perspective. Episode 54

Monika Rachtan
Hi, Monika Rachtan. I would like to welcome you very warmly to another episode of the programme "Po Pierwsze Patient". Recently, in our programme with the Patient Ombudsman, we talked about adverse events. I would like to come back to this topic and show you a little bit of the doctors' perspective, a little bit of the patients' perspective and maybe give you some instructions on what we should fix. And with me, Sebastian Goncerz, I welcome you very warmly.

Sebastian Goncerz
Good morning.

Monika Rachtan
Sebastian is president of the Residents' Agreement, but above all he is very active when it comes to adverse events. He sends appeals to the ministry. What should be done so that the patient is better protected, but also so that doctors simply work more safely? Sebastian, I would like to start by asking you how you would explain to us in human terms what adverse events are, so that every one of our audiences, patient or non-patient, understands the concept.

Sebastian Goncerz
Well, as we discussed earlier, the subject of adverse events is hugely complex, so I will try to make it as clear as possible. The thing is that medicine is progressing all the time and the procedures that we perform in the course of patient care are becoming more and more complex. If, for example, we perform 20 procedures or 100 procedures on one patient on a given day, there is a huge chance that one of them will go wrong.

Monika Rachtan
What is a procedure, explain. Is the procedure a blood draw? Is it a medical appointment?

Sebastian Goncerz
Everything, i.e. both the drawing of the blood, the discharge of the medicines, the administration of these medicines, the changing of the dressings, the entire surgical procedure and all the individual things performed during it. And now I always start this conversation with the question: is the chance of one procedure going wrong of one per cent a lot or a little? And now everyone can answer internally. To give you an idea of the scale of what is happening, in intensive care there are between 100 and 200 procedures per patient per day.

Monika Rachtan
So from what you're saying, one or two will probably go wrong.

Sebastian Goncerz
Yes, one or two can go wrong.

Monika Rachtan
That is, one day one or two will go wrong, but you don't lie in intensive care for 1-2 days, but rather 10, 15 or 30.

Sebastian Goncerz
Exactly. This shows the scale of the problem we face. It also illustrates the fact that if you each set yourself 20 tasks each day, there is also a chance that you will forget one of them, or it will go against the plan. Something will be delayed, something will be rescheduled and so on. The foundation of understanding adverse events is accepting our own frailty as human beings.

Monika Rachtan
But wait. After all, doctors are not people, they are doctors. Can they be flawed?

Sebastian Goncerz
Well, that is exactly right. And here is the hugely important thing to understand is that the doctor is a human being.
Monika Rachtan
No, this is impossible. But I emphasise many times, of course, in this programme, I'm talking not only in the context of mistakes, but also that, for example, you need rest, you need to drink water, you need to eat, that 24 hours without food, it's not like that at all for you, because you're doctors, it's that you're human. And just like you have to eat, drink, you can sometimes make a mistake or even not make a mistake, just something can happen, there can be a sequence of events that, for example, you're doing something, a nurse lady comes into the office, Mrs Kasia, knocks you out just like any other office worker can be knocked out by Mrs Kasia the secretary. And you won't look at the sheet of paper you were looking at before, you'll just look at the other one, because it will seem like you've come to see her after all, and you'll read the name of those tablets, and you'll reach into the cupboard and hand them out. And as if, well, you didn't do it on purpose.

Sebastian Goncerz
Exactly, in the sense it illustrates exactly. So I'll emphasise again the fact that the doctor is human and people are not perfect and they make mistakes. And it's kind of fundamental to understanding adverse events that it's written into the recommendations of the Council of Europe. This is a document that was written in 2006. Therefore, a perspective on how much time has passed? It will soon be 20 years since that moment where it is just written that you have to accept that people make mistakes and equipment and systems sometimes fail.

Monika Rachtan
Is this common knowledge for the common man? What are you talking about? Well, because if there's a European Union document, I understand that it's a document that's publicly available that any of us can read, but I ask you, how do you observe the public? Are people at all aware that a doctor or a procedure can go wrong?

Sebastian Goncerz
It seems to me that the knowledge is there, I mean some kind of understanding of this, only that here we enter the second problem, that the moment it affects us or our loved ones, emotion enters and some damage to health, some damage to something enters. And here, when these emotions enter, it is very, very difficult to confront this fact that people have the right to make mistakes.

Monika Rachtan
To someone yes, but not to me.

Sebastian Goncerz
If this is some sort of maxim hanging in the air in a sense, I think almost everyone would agree that people will make mistakes and no matter how perfect a system we make, those mistakes somewhere will always be there and those mistakes will always be there. But the moment it affects us, it's hard to be understood. And I'm not saying that critically, I'm even saying it with full understanding. I think that without understanding that it will always be emotions and there will always be this feeling that someone might have hurt me, then we won't really solve this subject.

Monika Rachtan
At this point, can we say that there are some factors, can we list some factors? What can these adverse events arise from? Can we qualify it for ourselves somehow, can we separate it out somehow?

Sebastian Goncerz
Yes, I would divide it into these two things. That is, firstly, those factors that are in a sense unchangeable, those that we cannot change, no matter how we try, or to a very limited extent we can change them. And here, for example, I see the complexity of medicine, it's going to grow and there will be more and more procedures, drugs, methods, possibilities and we can't avoid that. And the more complex the system, the greater the chance of something going wrong. But we have factors that are also modifiable in a way and here a huge factor is, for example, on the part of the staff, fatigue.
Monika Rachtan
Doctors today are very tired in hospitals?

Sebastian Goncerz
Yes, doctors are tired in hospitals, but I would also like to point out that, for example, in research studies it comes out that many more adverse events occur later in the day. Because in the morning a person is still rested and thinks efficiently and quickly and makes a decision. But at the end of the day, what happens is that you are on duty and especially on 24-hour duty, that is, on weekends and holidays. And afterwards, one is simply tired and can overlook something.

Monika Rachtan
What does a doctor do when he is on call for 24 hours? Because many patients think the doctor is sleeping. All night long. Does it happen that the doctor doesn't sleep for 24 hours?

Sebastian Goncerz
Yes, there are times when he doesn't sleep for 24 hours, a certain extreme. But I will certainly surprise you by saying that the doctor sleeps. And you, as patients, want the doctor to sleep, because the moment something happens.

Monika Rachtan
Then someone will wake him up. He will be rested and thinking logically.

Sebastian Goncerz
Exactly. But during the on-call period, the safety of all patients who are on the ward has to be taken care of. If anything happens during the night, when the staff occupancy is lower, there has to be someone to secure the patients. And it is, in a sense, the role of the on-call doctor to maintain continuity of services and continuity of patient care. So that there is no situation where there is no doctor.

Monika Rachtan
That is, the doctor on call is there to ensure safety. And he can sometimes go to sleep, because then he is a better doctor, he cares more about our health. People don't understand theoretically, in my opinion, the essence of hospitalisation. They think the doctor should see them every two hours, entertain them a little, inform them a little, come more often. They should see him more in the corridor, and so they think to themselves that this doctor is probably not there, because he sits there and writes something. But even when he is resting, the essence is that the doctor is not there to entertain the patient on the ward. He is there to keep him safe and of course we should talk to him, we should see him. This is very important, but making sure he is rested is also very important. And with that appeal to you to remember that this doctor is not the mascot of the ward, he is there to keep you safe, that is super important. But one more question, because you said that medicine is changing. And tell me, is there an appeal to older people here and a question from older people about whether what the doctor told me 20 years ago might not be true today?

Sebastian Goncerz
That's the way it is, it's a perfectly normal thing that our information changes and medicines update and our medical knowledge updates and certain disease entities change, because suddenly it turns out that one disease that we used to look at in a certain way is actually two that were similar or similar, but are treated in a different way. According to newer medicine. Therefore, it is as if medical knowledge is updating all the time, and there is also such an element here in terms of adverse events, which is also, if I may digress a little longer, I want to move on to these factors, how can we improve the situation? Well, it is, first of all, knowledge, because the most important thing is that if an adverse event has already happened and it has come to this place, that we notice this event, record it in a certain way, include it in some databases and be able to analyse it, learn from it and protect ourselves against it for the future. To see what we can change in the system, what we can change in our behaviour, what we can change in the criteria.

Sebastian Goncerz
In a sense, to add to this unpleasant event. To protect ourselves so that no one else in the future has to be affected by this event. And this is where the systems play a huge role, which, unfortunately, in our country are a bit stuck, because we do not really collect these adverse events in an efficient way and we certainly do not analyse them in such a nationwide and central way. And it seems to me that this is such a huge problem that we simply have a lot of these adverse events. It is estimated that 10% of all hospitalisations, 10% of all hospital stays end in an adverse event. Well that's something like 7 million hospitalisations a year. That is 700 000.

Monika Rachtan
These figures are huge.

Sebastian Goncerz
These numbers are huge. And now the question is if, from the perspective of such a science, if there are 700,000 of something, we can extract a huge amount of knowledge from that. Currently we are not doing that.

Monika Rachtan
Only, for example, in aviation, everything that goes wrong on board is recorded, written down, noted down, not by us, but by the plane's crew, so that the second time around, when we are better off, we can draw conclusions and it will be safer. And now let us ask ourselves whether we would like to fly in an aeroplane on which there is no such information, no such procedures. But are the doctors in Poland ready for some kind of information to appear in some kind of system that something went wrong and that he complained about himself or a colleague, Dr Jan Kowalski. Well, you know, it's like admitting a bit of a mistake and like we think, we, the public, that doctors are doctors, not people, they absolutely cannot make a mistake, they cannot have a worse day, they cannot be tired. Always on 100%, always everything super, the best. In the same way, the medical community is ready for such reports.

Sebastian Goncerz
I will say yes, there are a couple of things here, because first of all within the local facilities such reports are submitted to the system by an adverse event, they are reported, in many hospitals there are facilities, there are cells that analyse this locally and within an individual facility. In many places, of course, not everywhere, but in many places it works. That is, incidents are reported, they are analysed. The team is educated. And it's all nice, it's just that the problem is that it doesn't go higher. And that's the one issue, and the other issue is communication with the patient. Well, I think that this is the future, that my expectation, and I have said this from the very beginning when this quality law was being drafted, which was supposed to change all this, but we were critical of it, that I want a system that when either my team or I myself experience an adverse event as a result of our actions with a patient, that I can come to the patient and say to them please sir, please madam, unfortunately there was an adverse event.

Sebastian Goncerz
This procedure has gone wrong and not in the direction we would like. Consequently, this and the fact that I can then express my regrets, I can direct the patient further. What, therefore, can he do to improve his situation. Where can he, for example, pursue a claim, get some compensation? And in such a system, where I and the patient are partners together in the treatment of their illness and also the complications of treating that illness, I would expect something like that. Not that we are on two sides of the barricade, but that we fight it together and in this fight sometimes we don't go straight to victory, but sometimes we stumble. And those stumbles should, I think, be open and honest about. And just talk about them. And it's actually also if they listen to the medics, no, it's also in our interest. Because really, the biggest reason why patients file lawsuits is.

Monika Rachtan
That someone has hidden something from them.

Sebastian Goncerz
That there was no conversation. Or put another way, that there was a conversation but the patient did not get the information they wanted out of it. It is estimated that about 80% of lawsuits are due to poor communication.

Sebastian Goncerz
And it's also a burden of our work that unfortunately the job doesn't always allow us. But as I say, it's the most important thing, that when something happens, those few minutes have to be set aside to go to the patient and talk to them and give them as much time as they need. In an ideal world, as much as our work allows us too.

Monika Rachtan
You have said that the system needs to be changed so that doctors can talk to the patient, so that maybe they can be mobilised a little bit to have that conversation. But tell me, isn't it more a need to change society? Because I don't know if our society today is ready for that before I imagine the situation. I'm lying down, I know I'm going to leave the hospital, everything is fine. At least that's how it seems to me. I was in a bit of pain there after the procedure, but after all it's normal, it must have hurt. They gave me painkillers. And a nice young doctor comes to see me. You can see that he is open-minded. He communicates very well with patients and tells me, Monika, generally everything went ok, but here we had some complications because the procedure didn't go the way we expected. You will have to, let's assume, go to a physiotherapist and exercise twice as long as we expected, well, because there is an adverse reaction, an adverse event. And now 90% people, despite the fact that this doctor will be open, will still write a card there, where you have to go.

Monika Rachtan
He'll say he's called, he'll say he's warned me that everything is super settled. Most people I have a feeling will get up and shout and say how the doctor may have hurt me and done this procedure wrong in general. It is definitely the doctor's fault. Me thinks that people are not ready. Communication errors are responsible for 80% of lawsuits, but just as doctors often point out that no one teaches them how to communicate with a patient, I feel that on the other side, no one teaches us, the public, how to communicate with a doctor.

Sebastian Goncerz
This is why I see such a difficulty here, although I don't know if as many as 90% would react this way. I mean, it seems to me that the moment you sit down frankly with a lot of people and clarify certain issues, then, despite these emotions, despite the obvious damage to health, some kind of understanding will sink in there. And now what is important from the perspective of this communication, what is important from the perspective of the system, so that this is not the last time we talk about this event, because this is not the end of the road, it is in a sense the beginning. Then there is rehabilitation, there is some kind of assistance. Well, and the issue of this compensation, that it's important that the patient gets some form of compensation for what happened to them, and preferably it shouldn't be a lawsuit where only 5 of them percent, because it's like, I'm addressing you again, that the moment you file a lawsuit that there was a medical error, you have to prove fault. And the thing is, a lot of errors, a lot of adverse events don't come from the fault of a single person or fault as an assumption at all, just certain, consequences of certain things.

Sebastian Goncerz
There is a model that explains this and allows you to visualise it without drawing. But how would you imagine a few slices of such Swiss cheese with holes in them. And now these walls with the cheese in them should be imagined as certain systemic safeguards against the patient, i.e. that, for example, the blood that is drawn is repeatedly checked to see if it is definitely the blood type that should go to the patient at each stage, that first in the person where it is drawn, then whether it has been packed in the correct package, then when it goes two people have to check, and so on and so forth. And each wall of cheese is in a sense such a blockade and even if something goes through one hole, it hits another wall. It's just that sometimes it happens that, despite all these safeguards, it just so happens that it goes through all the holes. And this is the best picture of some 90% adverse events, when it is not even a fault. It is a defect and a failure of the security systems to work. That is, how many times do we have systems both human and non-human, computer systems, systems in the form of notes on medicines or appropriate nomenclature or signs, pictograms, that tell us all this.

Sebastian Goncerz
And an adverse event shouldn't really be looked at as an individual human error, but a failure of the safeguards that are always made in this system. And now what we can do, when a systemic adverse event happens to us, is to think about whether we can still add that security somewhere, because these holes will always be there. But the more holes we patch and the more of these slices of cheese we add, the less chance there is of something coming through.

Monika Rachtan
This is what knowledge is needed for. What is needed is reporting, What is needed is systemic change. Patients today have such a tool as a compensation fund. It was created quite recently, and they can get this compensation. I only hope that the programme we have prepared with the Ombudsman has reassured you and given you information on where to look for this help. You have learned that the Patient Ombudsman, the Office of the Patient Ombudsman is at your disposal. And here, as far as the Fund is concerned, you can get all the information, but it turns out that the Fund is there and we hope it works. On the other hand, it could have been a bit better, it could have been tweaked somewhere, and there were such and such assurances from the Ministry of Health that this fund would be constantly raised to a higher level, to a higher level, so that patients could get as much as possible, so that doctors would feel safer and so that there would be fewer cases in court. And now tell me, what stage are we at and what would you improve?

Sebastian Goncerz
I mean yes at the very beginning it is kind of good that this fund is in this form, in any form in a sense, because so far we have only had one method of redress. A court that takes 3 to 6 years to litigate the case and 5% ends up with any kind of verdict, and an even smaller percentage of that ends up getting compensation in this way.

Monika Rachtan
And let me ask one more thing. Excuse me, if there is a proceeding in court, does the doctor pay out of his own pocket such compensation?

Sebastian Goncerz
It depends. It depends on, in some cases it pays. To be honest, I'm not entirely sure. It seems to me that in some cases it pays. Maybe the facility pays with specific types of contracts, but in other cases the doctor pays, so it very much depends on what kind of contract the doctor is on with the facility and also what kind of incident didn't happen and whether it's prosecuted under criminal or civil law.

Monika Rachtan
Well, because I remember that it's a bit unfair if, for example, the doctor or the facility pays, and as we agreed often, the adverse event is due to these different elements that go somewhere in this system. And it is difficult to blame one person or one facility or one team. If there were multiple teams involved in the treatment of a patient, for example, it is so slightly unfair.

Sebastian Goncerz
That's jesr the whole problem of our outlook, that we look at it from the perspective of guilt and punishment all the time, that you have to find the guilty party, you have to punish them and the problem is solved. But no, I don't. We have this sort of our own, human sometimes, sense of satisfaction at some win. Because. Because that's what we have as human beings, but from such a systemic perspective, finding the guilty and punishing them is a very poor method in solving the problem. In the sense of taking into account not undesirable events, but crimes. After all, we have been punishing thieves for thousands of years. As if punishment alone here does not seem to protect us specifically against the existence of such a social phenomenon as theft, and as if punishing people, all the more so when it is not the person who broke the law, but the person who was somewhere in the net of all the elements, one of which went wrong, well that does not solve the problem, it only builds such a culture of fear and apprehension about it.

Monika Rachtan
That is to say, we are back to systemic solutions again, i.e. those slices that should appear in order not to punish and blame. But back to the compensation fund.

Sebastian Goncerz
So it's as if it should be a system of issuing compensation that is non-judicial, administrative, as we have here, but there are a lot of these asterisks in the law that introduced it, in a sense links.

Monika Rachtan
And it is there in those small letters that it says.

Sebastian Goncerz
That, for example, these adverse events relate to hospitalisation, not outpatient care.

Monika Rachtan
And when we come to an office, to a doctor who, for example, gives us some medicine in that office, can something go wrong too?

Sebastian Goncerz
Yes, yes exactly. I understand that this is then harder to track because care, hospital care has more systems, procedures and so on and so forth. But medical services are not only performed in the hospital system. The other thing is that in a situation where someone has signed an informed consent where they have given consent for a particular procedure a procedure and there are complications written in there, those complications are not eligible for the compensation fund.

Monika Rachtan
That is, if a doctor told me whether.

Sebastian Goncerz
There is informed consent signed.

Monika Rachtan
He told me, and then I signed, that after this operation, for example, there might be a problem with walking and that I might never walk again, that if I signed this, I could no longer apply to the compensation fund for any compensation.

Sebastian Goncerz
It seems to me that this will still be for the lawyers to assess.

Monika Rachtan
The reason I went zero-one is because our viewers don't know all these procedures we're talking about either. When they are asleep, they don't know what this doctor is doing to them.

Sebastian Goncerz
So in the sense I also point out that I'm not a lawyer, but as far as I read the Act, that's how I interpret it, that could be a problem. That is then up to the judgement of the lawyers who operate the system.

Monika Rachtan
That is, again, the cost to the patient.

Sebastian Goncerz
We are aware of the fact that we are not a patient, but in general, at the time when this bill was being processed, we reported that in our opinion, these receipt rules are very obstructive. I understand that you have to start somewhere in order to be able to develop this later. I only hope that this development will take place and that we will eventually extend these procedures which obtain, because we know that Poland is one of the last countries in the European Union which has introduced such a compensation system at all. In Denmark, such a system has been in place for 20 years, it is completely administrative and about a third of the people who make such an application obtain compensation in the end. And that, I believe, is quite a lot. Comparing it to lawsuits, it's a lot.

Monika Rachtan
Is this Danish model one that we should draw on when taking these next steps in our compensation fund.

Sebastian Goncerz
In my opinion, yes.

Monika Rachtan
We talked about the fact that today we want to look for the guilty party and punish the guilty party for adverse events. Or at least that's what it looks like, despite the fact that this compensation fund has been created. Tell me, how does this translate into your mental state, into the mental state of doctors? When in fact what you do, every single thing you do can end up in court proceedings.

Sebastian Goncerz
Well, that's too bad, to put it briefly, and to put it more broadly, it's a phenomenon I'm trying very hard to popularise, which is called the second victim syndrome.

Monika Rachtan
What does this phenomenon consist of?

Sebastian Goncerz
Generally, the situation is that there is an incident in our work and it is not necessarily an adverse event, although it usually involves them, but just some kind of grave event. A patient dies who we have been taking care of for a month. And of course the first victim is that patient, his family, his loved ones. But the person who stands on the other side and treats that patient. And this doesn't just apply to the doctor, but to all other medical professions. It is this second victim and it affects our psyche. And there is a phenomenon that is called the second victim syndrome. It's actually similar in its characteristics to post-traumatic stress, which is what soldiers have when, when a bomb goes off next to them and they have to experience that. And as a result, when someone experiences such a syndrome, they experience anxiety, they experience worry, sleep problems, lowered mood, potentially depression.

Monika Rachtan
But the fact that patients die is somewhat inherent in the medical profession.

Sebastian Goncerz
It's embedded in the medical profession, that doesn't mean it doesn't affect us. Because accidents are introduced into the profession of professional driving. What it doesn't mean is that when that accident happens, that person can be traumatised to the bone. Therefore, just because something is inscribed in our profession, it is inscribed in our profession to fight suffering and illness and death. It doesn't mean that we, that it comes down to us, quite the opposite. When such a study was done in Germany, on the professional group that I represent, that is young doctors, mainly working in a hospital, it turned out that 60% people experienced such a syndrome in them and what is more, only half of them got help.

Monika Rachtan
Who is this help from?

Sebastian Goncerz
This help is most often from colleagues, from friends.

Monika Rachtan
So I've had that too, I know what it's like?

Sebastian Goncerz
On the one hand it's good that we support each other in a sense, but on the other hand it means that in a sense this trauma is so shared and we have such a collective trauma. And I still remember and still resonate with me such words, of one of the paramedics who, during the white town protest in 2021 or 2022, who said that sometimes the only person I can confide in is a colleague in the ambulance. In second place, of course, are family and loved ones and that is the same problem.

Monika Rachtan
Exactly how does this translate?

Sebastian Goncerz
We have the support. But it also sheds this trauma on them. Forty-something per cent are helped by supervisors in this situation. I think that's low, because I think that every time something happens, there should be a meeting the next day. Listen, there was such an incident. For the future, the procedure should look like this, this and this. You who have experienced, have experienced such an incident, this is where you can get help and so on.

Monika Rachtan
So it's already the system, it's not just the goodwill of the supervisor, because it's not a question of whether he has goodwill or not. It is only the system that should impose such an obligation on him. It should tell him, give him such a manual on how to behave towards his employees if such a situation arises. So here is the first systemic solution that needs to be introduced.

Sebastian Goncerz
The worst part of all this is that only 4% of these people have received specialist help, psychiatric, psychological. And I see two reasons here. Firstly, the fact that we as doctors don't always go and treat ourselves. The doctor is not at all the healthiest person in the room. And here we are the ones who have to beat our breasts. But the other element is that there is no systemic care, that there is no psychological care when, for example, a police officer is involved in some kind of shooting. Well, here there is psychological help, so to speak, there is leave, there is all that. And at the moment when we resuscitate a man whom we have been treating for a month.

Monika Rachtan
Or a young girl.

Sebastian Goncerz
Or he had a young girlfriend. And to illustrate this under chest compression, the ribs shoot out. And one fails to save that person.

Monika Rachtan
It shoots through your mind afterwards. That's how you know you feel what you did, that's how you're reminded?

Sebastian Goncerz
I personally haven't had that experience yet, but anyone who has experienced it resonates within them in some way. They may have different coping mechanisms, but it stays.

Monika Rachtan
But one more question, not from me, from the public. You're a doctor yourself, you can't help yourself, you can't give yourself medication, give yourself advice, sit down with yourself for a moment and say okay, listen Sebastian, well this happened and this happened. You need to work through it. Now it's work it out for a while, you're a doctor, then you talk to yourself again about something and it's all done. Don't they teach you that at school?

Sebastian Goncerz
I do not advise conducting your own therapy in front of yourself in the mirror. It doesn't work. Specially and obviously we have some of our own mechanisms. But let's agree that the moment we talk about mental health, we're talking about the issue of trauma. We're talking about serious stuff, well, because it's an increased risk of attempted suicide.

Monika Rachtan
So do doctors commit suicide because of their work or attempt suicide because of what they experience at work?

Sebastian Goncerz
Yes, more often than the general population. For female doctors it is about three times more often, for male doctors 1.7 times more often. And that's overall, because if someone else experiences second victim syndrome, it's even more. But that's why this lack of systemic care, that something happens, please here this day and this day, you go to a psychologist, you talk about it. No, you grit your teeth, you move on. Well I'm sorry, on this approach this system of ours will not last long, because you can only bite your teeth for so long.

Monika Rachtan
Until they are finally peeled off. And it's not that this skin gets thicker and thicker as the years go by, because I had Dr Kamila Żur Wyrozumska with me, who deals with multiple sclerosis patients, but is also probably one of the most prominent Polish specialists dealing with SLA patients. She sits where you sit. I don't know how old Kamila is because I didn't ask her, rude. But I think she has some experience, she said she's been a doctor for more than 15 years, she's a lecturer, she works in a hospital. And you know, as she was telling me about the patients, how her family gets, I can't use this word, but how the family gets for what she's going through at work, she has to tell somebody, you're going to die in three months. The fact that you have to tell someone that you have SLA, that it never goes from that to normal. You know, when I come in here, I put a card down, I have another interview. I say cool. It's not like you get used to it.

Sebastian Goncerz
And I've been stressing that all along. I had, so that I don't get it wrong now, but I think the first time I was at a pronouncement of death was when I was 22. And my first contact with a corpse, at anatomy, was when I was 19. Something around that.

Monika Rachtan
Then did you see these corpses often? Is it that there some 2, 3, 4 classes.

Sebastian Goncerz
114 clock hours of classes in the dissection room.

Monika Rachtan
Well you should get used to the view.

Sebastian Goncerz
One gets used to the view, but to a certain awareness. I am actually very grateful for these photographs, because I think it teaches us humility towards the human body, towards death, towards this person who, when he was alive, said that my corpse would be of service to the training of the next generation of doctors. I'm grateful for the experience and I think if it wasn't for that, it would have been much harder later on. Changing the subject a bit quickly, but why is it that the medical community reacts with such resistance to all these new medical schools where, for example, someone teaches anatomy on pig hearts, or on plastic models, or on virtual ones. Because leaving aside the whole issue of the inaccuracy of these methods in technically teaching the subject.

Monika Rachtan
Then you won't get that empathy.

Sebastian Goncerz
So where is that element of, as it were, contact with human death, which will then accompany us throughout our, our whole history. Where is that element of understanding and acceptance and adaptation to this phenomenon? And as I say, you never fully adapt, because you can so many times, and then there will come that one situation where you're guiding someone for a month, and in my studies I also observed a patient who I was guiding for a month and finally one day I walk into a room and he's not there.

Monika Rachtan
And what did you feel then?

Sebastian Goncerz
It's so hard to describe always. Because we have it drummed into us that this is part of our job and there are some other patients to see and already, already here you have to run, no?

Monika Rachtan
Well, but then as for the cold.

Sebastian Goncerz
There is such, I would say a bit of an emptiness and such a loss. I knew this man, I talked to him every day, I studied him, I knew his name, I knew his wife's name, I knew how many daughters he had.

Monika Rachtan
And you start to get a bit attached to the man.

Sebastian Goncerz
In a way, yes. And now yes, is it better if I wall myself up? And I'm going to approach everything coolly.

Monika Rachtan
I think not. Because you know what?

Sebastian Goncerz
Well, yes, but I raise it as a bit of a question. In a sense left with a question mark, is it better for me to surround myself with these walls, as a consequence of which I will empathise less with the patient, but I will be safer from such contacts. Would I go in there with this understanding of empathy, with a smile of befriending, trying to get to know this person, but at the same time opening myself up in a sense to this risk of being hit. And now the question, if you prefer the other doctor, you have to know that there is a price. There is, simply if this doctor comes to you smiling, engaged, with understanding, with empathy, you feel it. There is a price, because he suffers more every time he loses someone. And on the other hand, if this doctor comes to you who is surrounded by walls. It's a question of why, and what did he experience with 22 years as an undergraduate? Or the 30 years he spent in residency and what led him to this state?

Monika Rachtan
If every patient looked at the doctor that way and thought that way. Again, it goes back to the fact that the doctor is a human being, that he has feelings, that when a patient dies. I don't know if that's the case, but I think to myself, sometimes he goes to that room of his and when he knows the name of his daughter's granddaughter, that he was waiting for his grandson's second birthday. And when you know all that, you come in there and you just roar. You just roar because you're terribly sorry because you've just watched him for a month, two months you gave with him. It was cool to tell him something about yourself too, even though you probably don't do that often, but it was so cool to talk to him and it's just so. It's so scary.

Sebastian Goncerz
But you have eight other patients? I would still add to that. In the sense I agree with all of that, I'll just add for perspective that you can cry when you're writing another patient's records. Very, very bluntly, that there is simply no space in our work sometimes for this unwinding of sorts.

Monika Rachtan
And then there's this wall just forming between you and the next, the next, the next, the next, the next patient, because you can't afford it, because you don't want to cry over those papers anymore, because you also want to write them quickly and not be so emotional. To go home, just to do the things that you need to do, that everyone else does. Go to the gym, go on holiday, that you can afford to do. And it gets to the point where you're that doctor who we all know from stories, who we all know from experience, who says come in, name, pesel. What's wrong? Here you have it written down what to do. Thank you, goodbye.

Sebastian Goncerz
For me, I mean for me it is obviously an undesirable phenomenon, something like that. It just comes from something. In the sense of course, some, there are 150,000 or so doctors in Poland. They are different people and this should always be accepted. It's not that doctors are all the same. They inherently have different personalities, different abilities to talk to people, different predispositions. But as I say, by working with what we have and this human diversity, you can get as few people as possible traumatised. And with that trauma left behind. Because trauma is professional burnout. Trauma is job abandonment. Trauma is the risk of suicide attempts.

Monika Rachtan
Depression, alcoholism, drugs are all things that come up.

Sebastian Goncerz
And the thing is, it comes from something. And apart from the fact that we can look at it and think well that's hopeless. This can be counteracted.

Monika Rachtan
Well, this system, we have a system and we can mobilise superiors to just talk to you.

Sebastian Goncerz
Yes, well, because I'm obviously speaking here, I'm trying to speak for, I mean on behalf of all health care, but I'm also mainly representing these young doctors. If this young doctor has experienced something like this, the system cannot afford to let this person, to let the work destroy this person. You can't afford that out of the twenty-something thousand specialised doctors that there are now, 60% will experience second victim syndrome and won't get help and will be left with this sense of anxiety, depression and nightmares waking him up at night. Because this is a loss for the system and for the patient already, even if we put aside for a moment the question of simply having compassion, towards this particular person, and look only at the numbers. The system cannot afford it, that 60% out of twenty-something thousand future doctors experience such a phenomenon and that only half of them experience help. And there was another interesting statistic in this study, that 15% appealed for help and did not get it.

Monika Rachtan
I just wanted to ask whether this kind of help provided by a supervisor, who is also a little bit in the system today, he is the doctor who did not get help most likely when he was a young resident doctor, so he is already surrounded by such a wall, is this 50% help, that you're de facto getting is effective help, because it's also worth discussing whether someone who is traumatised himself, depressed, burned out professionally, fed up with his job, pissed off that he doesn't have enough holiday time, worried about his family because things are happening, because he doesn't have time for them. Can he give you some good advice? Probably some of it can, but I think most people totally though, even if it is, it will be so you know.

Sebastian Goncerz
Just the thing is to stimulate this work, this kind of teamwork in a way, which means we all sit down at the briefing in the morning and we talk about what happened. We speak openly, we sort of say and communicate to that doctor who has experienced it that we see it and he has support in us. And also from such a systemic perspective we think about what to do to prevent it for the future, if it was an adverse event.

Monika Rachtan
You come into contact with young doctors, I think every day. Do your colleagues, do your colleagues talk about the fact that, as young doctors, they are afraid of patient contact, afraid to go to work, afraid of what might happen there? Do many of them, those who haven't yet entered the hospital corridors in earnest, talk about maybe changing all that after all and going to peel shrimps in warm countries, Because being a doctor is not at all as great as I thought it would be when I was 19 years old.

Sebastian Goncerz
It seems to me that such situations certainly exist. I will say straight away that this is not some mass phenomenon that everyone is so afraid of, no, but it does exist and this is enough for me to think about whether we can solve it. But it does happen because, for example, if someone is on duty in a mono-specialty psychiatric hospital, that is, one where there is psychiatry and only psychiatry and the second-year resident doctor is himself a psychiatrist, an internist, an anaesthetist, an emergency medicine doctor, etc, etc, etc. He goes crazy and has under him attention, attention 300 patients on call because, for example, in a hospital with six hundred patients, there are two night duty doctors.

Sebastian Goncerz
Does he have a right to fear? Does he have a right to fear that he will not embrace it all?

Monika Rachtan
But on the other hand, the conclusion is that there is a shortage of doctors in this situation. It is, after all, a great Ministry of Health. I'm not saying the current one, but the one we had some time ago came up with a super thing, let's add doctors, let's add doctors, let's add these diplomas and just let there be more of them and then there will be 5 on call.

Sebastian Goncerz
The only thing is that someone else has to want to remain on call. I may surprise you here, because there is a conviction that there is a terrible shortage of doctors in Poland, but physically, there are not so few doctors in Poland, because we are about 22 000 short of the European average, and with the current quotas, we will be able to fill this gap for about five years, including doctors who are retiring. So these staff shortages in the system, looking at how many doctors we have, are not that many. The only problem is how many specialists do we have working specifically in public hospital medicine? And here the situation is no longer so colourful simply because the working conditions as we have had throughout this conversation. This is the worst part of the system. It's the hardest one, because which doctor, specialist, who in a sense has professional freedom and can go to work wherever he wants and doesn't even have to work with a patient, can start writing texts or do something else, will want to take a job in a hospital where he will be on duty for 300 patients. The thing is, adding doctors doesn't at all mean, first of all, that they will want to work in this system, that they will want to work in this country and that they will have the knowledge to treat these patients.

Sebastian Goncerz
Because if a university is being set up somewhere, where 46 academics have been given teaching incompetence, anatomy is taught on plastic models and virtual anatomy, where there is one big tablet. If there's this big anatomy table where you display a picture from an atlas and they don't have access to clinics, they don't have access to internships and according to our analysis in September, they already have a little bit, so these figures may update, but out of 20 medical faculties, they don't have access to teaching hospitals, they only teach in provincial and district hospitals, which don't have that kind of infrastructure for teaching.

Monika Rachtan
But also in general they don't have patients with such a wide range of different cases, because that doctor will go to some city, he'll be a bit more, he'll finish his studies, he'll do his specialisation, but he won't really see everything that he could see in a big clinical hospital. He'll go to some smaller town where he'll be more independent, because that's where it's like, he's left to his own devices. And he will be totally unable to diagnose these people. This is a very, very serious problem. So here again these system changes.

Sebastian Goncerz
I'll add something else here, we had clinical classes, the ones where we go to the patient, examine the patient, learn to take a history, talk to the patient, in groups of up to six people. I even had two-person ones in sixth year, which is great. And now imagine our surprise when we read these opinions of the Polish Accreditation Commission. This is a body that analyses the preparation of faculties to teach a given course. That, for example, there is a university that plans 15-person clinical groups or 10. A bit better, no? This is absurd. I will emphasise it directly and you cannot work with a patient like that. It is a disrespect for the dignity of the patient, for their safety too. And, on the other hand, what is the quality of preparation for training, for the medical profession, when there, through the backs of three other colleagues, we will see that one person is auscultating, and we have written a position paper in this area. Five experts spoke in the position paper and we asked them if they could imagine such classes being held on the ward at all. We called for a clear change in the regulation that defines this, that it was written in the regulation that you cannot conduct clinical classes with patients over six people.

Sebastian Goncerz
This position was supported by 62 organisations, including patient organisations, the Council of Patient Organisations under the Minister of Health. And we are waiting for a move from the Ministry of Science and Higher Education, because there is simply no agreement to teach in this way, because, as I say, it is not just knowledge, but learning to talk to people. I have these ideas as well. I have this concern that since anatomy is not taught on cadavers, but on plastic models, then will there be a phantom or an actor instead of a patient class? And to be fair, this is a very cool supplement for certain elements, but it's not a replacement for that. I already know I'm going into detail, so please forgive me. But there is only a minimum percentage of hours in this regulation. This was put in place by the previous Minister of Education and Science, there is only a minimum percentage of hours that practical patient activities can replace simulation. You need a minimum of probably 10%. There is no maximum. This means that according to this regulation you can conduct, for example, the whole gynaecology on Phantoms and with actors. And that will be in accordance with the regulation. And again the ball is in the court of the Ministry of Science and Higher Education whether they will listen to 62 organisations or not.

Sebastian Goncerz
So it is to be hoped that this regulation will be amended, because it would be nice if the quality of education and training could be raised rather than lowered, so that everyone could get over it. It's just that this step would have to be set a little high and these rules fulfilled.

Monika Rachtan
To have the competence to treat.

Sebastian Goncerz
So clearly the production of doctors and increasing the quotas by 500, by 1,000 places in one year was not a bit of an afterthought. Because so logically and on peasant reasoning, which we generally try to avoid, but if one year 14 new faculties are opened.

Monika Rachtan
It is where to get teachers from.

Sebastian Goncerz
Where do you get the teachers from, but also how do you reliably assess them? That so on the scale it's usually maybe 1 opens for 2 years so far and suddenly one year boom 14. And now imagine having to assess them all and see if they have the staff, if they have the infrastructure, if they have the resources not for the first year, for the whole 6 years.

Monika Rachtan
We all remember ER. I think everyone watched that series. There, the doctor who was teaching the students was followed by two young doctors who could watch everything. So if we don't want to have in six years' time only aesthetic medicine specialists who graduate from some college and go out to see patients, then we need to make systemic changes. These should be called for by the ministry. And it is not only the doctors, not only the decision-makers, but all of us who are responsible for them. Because if we all raise our voices on this issue, I think Sebastian we can achieve something together.

Sebastian Goncerz
I have such hopes and that's what I'm here to fight for.

Monika Rachtan
With me today was Sebastian Goncerz, and this was the programme 'First Patient' and Monika Rachtan. Thank you very much for your attention.