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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 a physical problem as a patient, we expect perfection. But it is not easy to get. So, we have to understand how the doctors may make mistakes.


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
     the uncertainty of the moment,
the standard required treatment is missed.

Some common mistakes:
  1. Large metal instrument left in patient’s abdomen.
  2. The biopsy was done on the wrong breast.
  3. During heart operation, a small key step is skipped.
  4. The 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, the 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 an 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.

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

Anaesthesia 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 of vigilance in waning.
  • Mistakes in managing the 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 an 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 due to the 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 the 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 orthopaedic 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 a lethal dose of narcotics.
  3. Brown, a surgeon without a license, killed a patient of gangrene by wrongly doing an amputation of a healthy patient.
  4. Burt, a gynaecologist wrongly did hundred of disfiguring clitoral circumcision and vaginal reshaping without consent.

Causes of losing medical skill:
  1. Alcoholism
  2. Addiction to 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 practising doctors are actually unfit to see patients.

Colleagues do not do anything because it is easy, or 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 behaviour
  3. Severe obsessive-compulsive disorder
  4. Transgression of proper professional boundaries
  5. Incurring a large number of lawsuit and complaints

Can Computer replace Doctors?
  • From the first day of medical training, it is clear that errors are unacceptable. So there is a quest for machine-like perfection in the delivery of care and so the doctor should be trained to act like a 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 the patient was relying on doctor’s decision; in fact, a good physician cannot simply set aside when the patient makes a bad or self-defeating 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 honoured doctors meet once a week. Thursday, 5 PM with the amphitheatre.
  • Laws protecting its proceedings from legal discovery.
  • Here they can gather behind closed doors to review the mistakes.
  • No one can cover up the mistake.
  • It is said, “if you are not a little afraid when you operate, you are bound to do a patient a grave disservice.”
  • The M & M we learn “mistakes are an 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 avoid 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 with the 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 an exact diagnosis of depression, drug addiction or psychoses.
  • b) Decide whether a doctor is fit to return to practice.
  • c) Specific recommendation to follow regarding the 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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Comments

  1. The M & M 'Morbidity and Mortality' Conference that you mentioned, is it something specific to the U.S.? Does it also happen in India? It would be worth knowing how candid doctors in India can be.

    On one hand how recent unfortunate events of beating the doctors have increased in different corners of the country, the ignorance (and in some cases genuine mistakes) by the doctors have been long existent in our country. Especially in remote places or backward localities many doctors consciously malpractice with the sole focus on commercial gains. I know my point side-tracks from the original topic of this article, but you being such a senior in this field, what is your take on it? Can we ever expect such doctors in our country to be caught and put to justice?

    ReplyDelete
    Replies
    1. M & M conferences are ideal places for doctors to develop.

      This system has not worked even in US, forget about India.

      Unfit doctors and dis -honest doctors are big threat to humankind. Only fellow colleague and staff working with doctor know and notice the finding about doctor loosing skill due alcoholism, social stress or physical inability. Their duty is to report this soon either to the concerned doctor asking him/her to to stop medical practice or should be reported to government authority to force him/her to stop practicing.

      Such ideal things are academic and never to happen facts.......

      Delete
    2. That's an interesting fact... and unfortunate that it's greatly prevalent in our society. I guess it's the 'commercial' view point that restricts any right-doing in this case, from all - the doctors, their colleagues as well as the victim patients and their families.

      Delete
    3. The take-home message is that great trouble exists amongst medical professionals and ideal Medical management is far to get.

      For getting ideal and ethical Doctors, society has to be ideal and ethical, because Doctors are part of present day society and have not born as Gods. To expect ideal is near impossible.

      Delete
  2. This comment has been removed by the author.

    ReplyDelete
  3. very true , i work in health care and i have seen this happening very closely. It's easy for a patient to say but it takes time to achiever expertise and doing practically.

    ReplyDelete
    Replies
    1. Thanks, Twinkle, for being first to respond. Yes, expectations of patients have gone very high due to new technology, but it is not easy.

      Delete

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