11


Be open about error Dr Aidan O’Donnell is a consultant anaesthetist who has practised mostly in the UK, but has recently moved to New Zealand. He says that the departments he works in have enlightened systems, where it is recognised that adverse events will happen, and should be treated as learning opportunities. He said: “Adverse events are collated and


presented anonymously at monthly meetings in a blame-free atmosphere – the focus is on improving systems. Both departments contain anaesthetists who are comfortable saying ‘I made a mistake, I got that wrong’.”


Be a good doctor Doctors should feel confident enough not to practise defensively if they practise safely with evidence-based medicine, and follow local guidelines and protocols. Dr O’Donnell adds: “I try to establish a therapeutic


rapport with my patients, and I’m comfortable with informed consent, eg, ‘I estimate you will have a 5% chance of dying in the one month following your operation’. I usually temper such statements with reassurance: ‘Whatever happens we will do our absolute best to look after you.’ Therefore, if things go wrong as a result of the anaesthetic, I know that I did warn the patient of the risks involved, and have an approach that (I hope) conveys open honesty and sincere regret.”


Moving forward Although defensive medicine will always exist in the modern world, over-investigation of “what if” scenarios will never guarantee medicolegal protection in the wake of a claim/complaint, nor improve patient care. As a doctor you cannot always be right and outcomes for patients will not always be the ones you strived for; however, if you can show that you’ve acted and managed your patient appropriately, based on the evidence you had at the time, litigation should not follow. Many doctors describe litigation as a


dagger at their back. However, it is good evidence-based practice, not defensive practice, that will deflect the blade.


REFERENCES


1 Andrews W, Defensive Medicine: Cautious or Costly? CBS news (22 Oct 2007)


2 Dove J et al, Medical Professional Liability and Health Care System Reform, Journal of the American College of Cardiology (2010)


3 Keren-Paz T, Liability Regimes, Reputation Loss, and Defensive Medicine, Medical Law Review (2010)


4 Hermer L et al, Defensive Medicine, Cost Containment, and Reform, J Gen Intern Med (2010)


5 Studdert D et al, Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment, JAMA (2005)


6 Tellefsen C, Lawyer Phobia, Journal of American Academy of Psychiatry and Law (2009)


7 Kravitz R et al, Omission-Related Malpractice Claims and the Limits of Defensive Medicine, Med Care Res Rev (1997)


8 Kessler DP et al, Do doctors practice defensive medicine? QJ Econ (1996) 9 Savage W et al, British Consultants’ Attitudes to Caesareans, Journal of Obstetrics & Gynaecology (2007)


10 Johnson C, Study: Overtesting in Late-Stage Cancer Patients, eWoss news (12 October 2010)


11 Chawla A, Defensive Medicine, Acad Radiol (2008) 12 Ibid 5 13 Jones M, Medical Negligence, 4th ed: Sweet and Maxwell, London (2008) 14 Budetti PP, Tort Reform and the Patient Safety Movement, JAMA (2005)


Once bitten


Sally was a 30-year-old single mother with two dependent children. She became concerned about a possible lump in her left breast. In March she attended her local surgery, and saw the practice nurse. Nurse M performed a breast examination but did not find any abnormality and reassured Sally.


Over the next few months, Sally noticed changes in her breasts, but felt reassured that nothing was wrong, as Nurse M had said that everything was fine.


In June, Sally attended the surgery again and saw Dr F, complaining primarily of persistent back pain. He looked back over Sally’s notes. Dr F was mindful that a few years ago he had been accused of inappropriately touching a patient during an examination. In light of this, and because the notes stated that Sally had recently undergone a breast examination with Nurse M, he relied on her diagnosis and did not repeat the breast examination. Sally was diagnosed with mechanical back pain. In November Sally returned to the practice, with an inverted nipple and skin discolouration. Sally saw Dr F again who performed a breast examination, and found a lump in the same place she had described to Nurse M in March. Dr F referred her for urgent investigation, which confirmed metastatic breast cancer.


OUTCOME


If the cancer had been discovered earlier, Sally’s prognosis would have been better. Nurse M’s breast examination technique was criticised by the experts involved in the case, as she had not been properly trained to perform such examinations.


Dr F was also criticised because he missed an opportunity to make the diagnosis at the consultation in June, when he failed to undertake a breast examination, relying instead on the examination carried out by Nurse M. The claim was settled by MPS, on behalf of the practice, for a large sum.


LEARNING POINTS


Dr F’s defensive practice put his personal feelings before his professional opinion. A doctor should never allow his personal experiences or concerns to affect his clinical judgment. Dr F should either have conducted the examination in the presence of a chaperone or, if he felt unable to examine Sally, he should have referred her to a colleague. When a patient re-presents with progressive symptoms (in


this case, further changes in the breast), particularly after a significant time interval, the doctor should not rely on the earlier assessment but should conduct a further examination.


SPECIAL FEATURE


UNITED KINGDOM CASEBOOK | VOLUME 19 | ISSUE 1 | JANUARY 2011 www.mps.org.uk


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