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Eye of the storm


This dilemma was received on the MPS advice line. It should act as a strong reminder to never practise beyond your skills and expertise – even when a task has been delegated to you by your senior. Junior doctors have a duty to refuse to either carry out a procedure or take consent for a procedure (as in this case) if it lies beyond their scope of competence. Likewise, when you yourself are the senior figure, you must be satisfied that the person to whom you are delegating has the appropriate skills, knowledge and qualifications to take on the task.


Dr Liz Meyer, MPS medicolegal consultant, Pretoria D


r X was a newly- qualified intern and did not often have


responsibility for obtaining consent. Whilst on-call for surgery he was asked to attend to a patient in the Eye unit. On his arrival he was presented with the medical records for an unaccompanied 90-year- old female patient who was hard of hearing and had early dementia. She had been admitted for a cataract extraction and lens implant. The sister explained that


the ophthalmic surgeon was on his way in but needed the patient consented prior to his arrival. The intern was unsure as to whether he should accede to the request and so decided to read through the medical records, which indicated that the patient had “a right eye nuclear sclerotic cataract +++” and that she was blind in her left eye. Unfortunately, the intern


had not received much exposure to ophthalmology as an undergraduate, and was unclear as to what some of the abbreviations meant.


He was uncertain of what the procedure “R Phaco + IOL under LA” on the theatre list actually entailed. He was also unsure of what information the patient had already been given. He explained his concerns


to the sister, who told him to “just get the patient to sign the form”, as the consultant would be unhappy if the patient was not ready for theatre and that they would all be in trouble. She handed him a patient information leaflet listing risks including those of infection, bleeding, reduced vision and the need for a vitrectomy. Dr X was keen to assist the nurses but did not feel confident that he would be obtaining a valid consent, as he did not understand the operation or the risks himself, and would not be able to answer questions the patient may ask. Concluding that he would


not be in a position to provide sufficient information about the operation, Dr X called the consultant on his mobile phone to express his


reservations. The consultant was very annoyed to have been called and told Dr X that he should just read out the risks as listed on the factsheet. He also told Dr X that given the fact that she was blind in one eye and had a hard cataract, he should probably mention that there was a small risk of a dropped nucleus. When Dr X enquired what


LEARNING POINTS


■■ All doctors have a duty to ensure that they have the necessary understanding of a procedure to take consent. Dr X is correct to challenge the consultant in this case.


■ ■ Don’t be afraid to challenge your superiors if you believe their actions present implications for patient safety.


■■ It is important not to practise beyond your skills and expertise.


■ ■ Any senior doctor who delegates care or treatment must be satisfied that the person to whom they are delegating has the appropriate experience, qualifications, knowledge and skills to provide the care.


■ ■ Written consent is essential for surgical procedures – except emergencies – and patients need to be informed of relevant side effects and complications.


■ ■ A patient information leaflet is a useful adjunct to have but does not replace the discussion about risks and side effects.


that meant and whether it would be better to wait for him to arrive, so that appropriate consent could be sought, the consultant became irate and explained that as an intern he should do as he is told. He then put the phone down. The intern was not sure what to do next, so called MPS. With thanks to Dr Pallavi Bradshaw for her valuable input.


DILEMMA


JUNIOR DOCTOR | VOLUME 2 | ISSUE 1 | 2011 | SOUTH AFRICA www.medicalprotection.org


JASON KELVIN/SCIENCE PHOTO LIBRARY


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