What makes a good doctor? If your life was on the line who would you trust to treat you or a close family member or friend? At the end of the day doctors are human and can make mistakes but the consequences of these mistakes are astronomical in comparison to say a school teacher who can return the following lesson and correct their mistake.
Brian Goldman gave a fantastic ted talk on this and gave a great example of baseball stats. A fantastic base baller will have a batting score of 300 (meaning 3 out of 10 times he will successfully hit the ball), a legendary batter will have a score of 400. But in medicine we don’t expect less that a score of 1,000 (10 out of 10)
What are mistakes?
How is malpractice different to negligence?
- Negligence is a sub category of malpractice but they key word is intent. Negligence is the lack of action by a medical professional normally without intent, especially not the intent to harm.
- In order to prove this evidence is prime.
Examples of malpractice – how many can you work out from the pictures?
- Medication e.g. dosage
- Lack of hygiene e.g. washing hands
- Incorrect surgery site
- Poor coordinated care
- Practical skills e.g. failure to do an emergency incubation
What can cause a mistake?
- A consensus is around the movement to prevent medical errors is that often patients are receiving an unnecessary or excessive medical care
- May argue that this is due to a lack of precise definitions for specific purposes – those that are responsible for making policy recommendations should say the exact features of what they want to study and say the ethical considerations, including what type of benefit or harm is recognised and who is the judge of this.
- Excessive technology
- Good: outweighs other price driving factors e.g. ageing population, increased public demand income growth & raising prices of medicine
- Over diagnosis – e.g. breast cancer mammography’s over diagnosis was taught to healthcare professionals but the number of tests did not drop greatly – people rather have painful cancer treatment than the cancer itself thus questions reliability and trust of evidence of the treatments themselves
- Good tests become poor – more accurate test can give a poor outcome if the test is used on healthy people. (Sensitivity with disease, specificity without disease) sensitivity and specificity will increase (more people diagnosed) but its commonness will fall e.g. 1 in 2 to 1 in 100, so the likelihood of a positive test that is true decreases cannot guarantee clinical improvements
How to learn from a mistake?
- Guilt – 2nd victims after patient and family are doctors. Correlation to fear, anxiety, anger & social withdrawal, disturbing memories. (post traumatic stress disorder)
- Confidence (bad doctor) – failure, worry about prestige, embarrassed to get support
- Doctor-patients relationship
- Suicide – difficulty forgiving
- Healthcare laws – states to increase number of reporting’s & patient safety but nothing for docs.
- Colleagues don’t address it – Medically Induces Trauma Support (MITSS) non-judgmental & confidential environment some institutions have 2nd hand trauma place but mainly in US.
When to say sorry?
- 1st April 2015 – change guidance: still doesn’t mention mistake but rather notifiable safety incident occurred + GMC say apologise when ‘something goes wrong’ = apologising for everything including not a mistake e.g. inherent risk of treatment or procedure so apologising for medicine being an imperfect art – ‘I’m not going to apologies, I didn’t make a mistake
- How soon to apologise? ASAP 10 working days – but questions whether both the patient & doctor are ready
- Who to apologise to? To patient or ‘relevant person’ – no obligation to tell relatives unless patient has died. GMC say to have a supporter there.
- What if it isn’t clear? No excuse to procrastinate. GMC says ‘all you know and believe to be true about what went wrong and why, and what the consequences are likely to be’ = patient doesn’t want to know details, take the burden off them and apologise. But royal college of psychiatrists says ‘giving incorrect info will potentially cause further harm and reduce rather than build trust’. GMC doesn’t address angry patients
What is doing the right thing?
- Moral courage – act on the conviction that something is morally right even though you believe that something of personal value may be lost e.g. breaking bad news or paralysation
- Duty of Candour: under England’s new duty of candour service NHS have to notify an incident of patient safety.