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Complications - When Doctor Commits Mistakes

When a new doctor is learning for the first time or when a senior doctor is learning or not learning a new technique, who suffers? Naturally, a patient. When we visit a doctor with physical problem as a patient, we expect perfection. But it is not easy to get. So, we have to understand how the doctors do mistake.

We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, all enterprise of constantly changing knowledge, uncertain information and fallible individuals. It is not only science, but also habit, intuition and plain guessing. This article is about dealing with mistakes made by doctors and their remedy.

When do doctors make mistakes? 

For whatever reasons like,
     hubris,
     inattention,
     hesitation,
     wishful thinking, or
     uncertainly of the moment,
the standard required treatment is missed.

Some common mistakes:
  1. Large metal instrument left in patient’s abdomen.
  2. Biopsy done of the wrong breast.
  3. During heart operation, a small key step is skipped.
  4. Doctor assumed kidney stone with CT Scan and found big abdominal aortic aneurysm.

We call such doctors ‘negligent’, ‘incompetent’ or ‘unethical’ and act by malpractice lawsuits, media scandal, suspension or minimum firing. And still, central truth remains:
In the medicine field, all doctors make terrible mistakes.

1991: New England Journal of Medicine did Harvard Medical Practice study of 30,000 admissions.

The study found:
  • 4% hospital patients suffered complications from treatment, resulting in disability or death.
  • 66% of them were due to error in care.
  • One in four or 1% of admission involved actual negligence.
  • 44,000 patients die each year, at least partly, as a result of errors in care.

1995 Study: ‘Mistakes in administering drugs’ – wrong drug or wrong dose leading 1% with serious consequences.

Anesthesia: American Society of Anesthesiologist has “VIGILANCE” as their Key word, because anesthetist takes control of breathing, heart rate, blood pressure and all the vital functions and complete control of patient’s body.

Anesthesia has inborn dangers due to human errors, carelessness or negligence.
  • Starting of general Anesthesia through thought to be dangerous, it is not. It is the middle of Anesthesia because vigilance in waned.
  • Mistakes in managing airway, misconnection of tubing for breathing, inadequate familiarly with equipment, inadequate experience, haste, inattention, fatigue and poor communications amongst team are major causes of problems.

Autopsy: Autopsy means “to see oneself”.
  • Doctors are instructed to request an autopsy on everyone as a means of confirming the mistake of diagnosis if any.
  • Today, we have MRI, Ultrasound, Nuclear Medicine, molecular testing and what not. So, we wrongly think we do not need autopsy to find out the cause of death.
  • Beware, Autopsy studies tell (1) One third (33%) of the misdiagnosis of the patients would have been expected to live if its proper treatment has been administered and (2) Two out of five (40%) who die have of wrong diagnosis and still we fail to improve over time. (3) Lastly, physicians missed a quarter of fatal infections, a third of heart attacks and two third of pulmonary emboli in their patients who died. In fact, Physicians fail to order perfect test or scan which was already available.

Mistakes during 'Learning':
  • Skill, surgeon believe, can be taught tenacity can not.
  • I am, I have found neither gifted nor maladroit. With practice and more practice, I get the hang of it.
  • Practice, it turned out, did not necessarily make doctor perfect.
  • As patients, we want both expertise and progress. In fact, they are just contradictory desires. There should be no learning curve as far as patient’s safety is concerned, but that is entirely wishful thinking.
  • You cannot train novice doctor without compromising patient care.
  • Do we ever tell patient that because we are still newer at something, the risks are inevitably higher and that we are likely to do better with others who are more experienced?
I have never seen it.

It would certainly be a graceful and happy solution. We would ask patients-honestly, openly and they would say yes.

In general, while learning patiently does eventually benefit often enormously but the first few patients may not and may ever be harmed.


2. Good Doctor Going ‘Bad’
Even good doctors can go bad; and where they do, colleagues tend to be almost entirely unequipped to do anything about them.
  1. Goodman, renowned orthopedic surgeon, highly respected sought after and busiest doctor one time, started doing wrong surgery and hurting patients.
  2. Shipman, a physician, killed more than 300 patients giving lethal dose of narcotics.
  3. Brown, surgeon without license, killed a patient of gangrene by wrongly doing amputation of healthy patient.
  4. Burt, a gynecologist wrongly did hundred of disfiguring clitoral circumcision and vaginal reshaping without consent.

Causes of losing medical skill:
  1. Alcoholism
  2. Addiction of narcotics tranquilly and barbiturates
  3. Serious mental disorders: major depression, mania, panic disorder or psychoses
  4. Ill, old age and distracted by their own difficulties
At any given time, 3 to 5% of practicing doctors are actually unfit to see patients.

Colleagues do not do anything, because it is easy of so to say, no one has the heart for it.


Symptoms (Behavioral events)
  1. Persistent poor anger control or abusive behaviour
  2. Bizarre or erratic behavior
  3. Sever obsessive –compulsive disorder
  4. Transgression of proper professional boundaries
  5. Incurring large number of lawsuit and complaints

Can Computer replace Doctors?
  • From first day of medical training it is clear that errors are unacceptable. So there is quest for machine like perfection in the delivery of care and so doctor should be trained to act like machine.
  • Human beings are inconsistent and human are not good considering multiple factors and reasons.
  • Now a day, systems have been designed to read their X-rays, mammograms and nuclear medicine heart scans.
  • No doubt, something vital is lost by machine and medical care is about life and death and so we always need doctors to help us understand what is happening and why and what is possible and what is not.
  • No doubt machines can decide, but we still need doctors to heal. Doctors have to serve as knowledgeable guide and confident.

Who should decide the treatment plan – patient / doctor or both?

Patient autonomy gives full right to decide. “Informed consent form” describes all the complications and possible treatment outcome. Signing this means you (patient) have understood and accepted the risk. It was not long back when patient was relying on doctor’s decision; in fact, a good physician cannot simply sit aside when patient makes a bad or self defecting decision.

So, is there any remedy to this problem? Can we let doctors keep taking decisions, and ensure not making mistakes? Let’s look at options.



Is there a remedy?

M & M 'Morbidity and Mortality' Conference

A place where doctors can talk candidly about their mistakes not with patients, but with one another. When things go wrong, it’s almost impossible for a physician to talk to a patient honestly about mistakes. At most, a doctor might say “I’m sorry that things didn’t go as well as we had hoped.
  • The honored doctors meet once a week. Thursday, 5 PM with amphitheatre.
  • Laws protecting its proceedings from legal discovery.
  • Here they can gather behind closed doors to review the mistakes.
  • No one can cover up mistake.
  • It is said, “if you are not a little afraid when you operate, you are bound to do a patient a grace disservice.”
  • The M & M we learn “mistakes are inevitable part of medicine.”
  • The M & M sees avoiding errors as largely a matter of will – of staying sufficiently informed and alert to anticipate the myriad ways that things can go wrong and then avoiding problem by anticipating before it happens.

Professional Assessment Programme by Kent Neff, MD

Neff’s Professional Assessment Programme with Abbott Northwestern Hospital at Minneapolis, Dr. Neff established a centre for assessment of fitness for pilots, judges and doctors in the Hospital Campus. He did assessing very thoroughly and dispassionately. Steps:
  1. Gather Information from many interviews of concerned person. Made to tell their story again and again half dozen times. Ask the colleagues around about his work and Nature.
  2. Full Physical Examination: Full medical check-up including any illness laboratory and radiological surgery.
  3. Psychological test:
  • a) This lead to arrive at exact diagnosis of depression, drug addiction or psychoses.
  • b) Decide whether doctor is fit to return to practice.
  • c) Specific recommendation to follow regarding treatment plan. 

Yes, mistakes are human and doctors are no exception. To expect total perfection from doctors is too much. Doctors and society should be aware and awake to remediate them by either morbidity and mortality conference or professional assessment programme.


Reference

Book title: “Complications: Notes from the Life of a Young Surgeon”
Author: Dr. Atul Gawande, M.S
Publisher: Penguin Books Ltd., England (2002)
Page: 270, Price: Rs. 350

Dr. Atul Gawande, a surgeon performing surgery became a writer with scalpel pen! Outlook describes him as a doctor who understands his patients beyond their illness. He has also written “Better”, “Being Mortal” and “The Checklist Manifesto”.

He is a surgeon at Brigham and Women’s Hospital in Boston, U.S.A. He is also a staff-writer for the “New Yorker” and a professor at Harvard Medical School. He lives with his wife and their children in Newton, Massachusetts. 





Written by,
Dr. Bharat M. Desai
Desai Eye Hospital, Bilimora
(M): +91-99240-63045 | (E): bharat@desaieyehospital.com




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