Yesterday I heard a phrase on the news I hadn't heard before. It came from an academic who studies how we protect children. It was: "Dominant Mode of Understanding". With that phrase, I had a label for the thoughts that had been swimming through my head, regarding those professionals who, though qualified up to the hilt, manage, on occasions, to get it all very and tragically wrong.
As I write, a woman is awaiting sentence for starving her four year old son to death. She was well known to those whose job it is to protect the vulnerable, but teachers, social workers and the police all failed to see the danger the child was in.
I have some anecdotes, regarding pregnancies: one was wrongly diagnosed when another, far more serious problem was the cause, one wasn't diagnosed for five months because the doctor thought "Who would?", and one wasn't diagnosed until labour set in because, like the baby's parents, the doctor simply wasn't expecting it to ever happen.
I have a young friend, a physicist. She came from what we can call the 'rough end' of her town, and at fourteen years old, her belly began to swell. Despite her protests of virginity, and also (incredibly), despite several negative pregnancy tests, the health professionals declared her pregnant. She was within a week of being terminally ill with ovarian cancer when her parents finally managed to get through the social prejudice that the diagnosis was based on, to someone who would listen. The operation was a success; but at fourteen she was left with skin and scars that shouldn't have been there.
Another friend, one who never escaped the low aspirations and income of her neighbourhood, and who also never managed to find the long-term relationship she longed for, discovered in her forties, that her belly was swelling and she felt unwell. Her younger male doctor never even considered pregnancy (he actually diagnosed wind) until, at five months, she complained that her swollen lump was wriggling. My friend wasn't that bad looking, but the young doctor seemed not to be able to conceive that she might conceive and didn't even ask the obvious question; though there was no record of any birth control on her medical history.
I also have a relative. She and her husband had wanted children for a dozen or so years, but she never conceived, only to discover she was pregnant when she went into full term labour in her mid-thirties. Months earlier (of course!) weight gain and billiousness took her to her (female) doctor, who prescribed some panacaea or other and sent her away. In the doctor's defence, my relative did have two negative pregnancy tests; but her weight continued to increase. She spent evenings on an exercise bike in front of the TV in an attempt to control it. She helped her husband carry a dead washing machine into the garage (why do husbands want the dead equipment there, I wonder?). She returned to the doctor in each trimester of (what turned out to be) her pregnancy, which would have been discovered in a moment with the most cursory of physical examinations (her father had already pronounced her pregnant, but she told him "No, Dad; the doctor says I'm not"). At nine months, the inevitable happened. My relative thought she was dying as her husband phoned the doctor, who finally arrived at the correct diagnosis and phoned an ambulance.
What have all these incidents got in common? They all have what the expert I mentioned at the start calls a Dominant Mode of Understanding. This means that the social, physical or environmental story surrounding the patient is so strong, so dominant, that it is the main input in the diagnosis, and medical evidence is not sought. My friend at fourteen, from a rough area, with a swelling belly MUST be pregnant, because that's what girls from there do. My partnerless friend in her forties CAN'T be pregnant; she's not attractive enough. My relative CAN'T be pregnant, because she's tried for years and nothing's happened.
In other words, the diagnoses of all three were based on circumstances and observations based on prejudice, and not on any medical evidence. This prejudice is what the academic on the TV called the Dominant Mode of Understanding. The woman who starved her toddler to death was drug and alcohol dependent. It was HER the professionals were worried about. She was the one needing protection, according to the files, and with that focus they failed to realise that her children were suffering. It took a freshly recruited community police officer who was also a Mum herself, to realise the implications of what she saw from the door.
Recently, the mental health charity Mind has highlighted that the existence of a mental disorder can become the peg on which health professionals can hang the diagnosis when such patients present themselves with physical complaints. A report goes at length into the handling of the physical wellbeing of mental patients.
I believe that most of those employed for our health and protection do not suffer from the blindness caused by a dominant mode of understanding; but enough still do so that tragedies happen, or people are whisked from the brink of it. Until we properly train our health/safety/education professionals to look beyond what they think is obvious, or to discount it altogether so they can see what's before them for what it really is, we will continue to have serious case reviews of dead babies, and life-changing (or life ending) misdiagnoses.
