mishaps may occur due to complications, ‘subjective’ clinical judgement, incompetence, inexperience or medical negligence. While the response of the uninformed lay person to any case of mishap is ‘medical negligence’, this is in many instances not the reason
Mishaps can occur even in the best of medical centres in the world. One of the most notorious cases, which happened in 1995, was that of the mother of a famous Indian actress who died recently, Sridevi. It was reported in the New York Times under the title ‘Surgery Is Done On Wrong Side of a Brain’.
The operation took place at the prestigious Memorial Sloan-Kettering Cancer Center in Manhattan, for a malignant tumor on the left side of her brain. However, by mistake the neurosurgeon took another patient’s X-rays into the operating room and therefore operated on right instead of the left side of the brain. As he could not locate the tumour, he closed the wound and the patient was returned to the room. Later, though, the lady was ‘transferred to New York Hospital-Cornell Medical Center, where another surgeon removed the tumor’.
In extreme cases mishaps can lead to death, as happened a few months ago to the newborn of a young couple for which the Minister of Health & Quality of Life had to answer in Parliament last week. Or they can leave the patient with major disability, such as mental handicap and paralysis. As with everything else in life, such unfortunate incidents can be reduced but alas cannot be eliminated altogether. That is why the appropriate response to what is a very complex and emotive issue has got to be a calculated and comprehensive one. Besides helping the family to cope with the immediacy of the situation, it must also strengthen the medical system so as to prevent similar incidents in the future. There must also be an established procedure in place for compensation of patients where this is found to be mandated.
The mishap in New York was clearly due to a human error, which may have many reasons, such as fatigue or hurry because of pressure of work. A few years ago WHO has come up with what is known as a ‘Surgical Safety Checklist’ to deal with such errors, and its use has significantly reduced them.
But mishaps may also occur due to complications, ‘subjective’ clinical judgement, incompetence, inexperience or medical negligence. While the response of the uninformed lay person to any case of mishap – which the media pound upon like vultures – is ‘medical negligence’, this is in many instances not the reason. That is why it is important in such situations to avoid complicating matters further for the already distressed patient/family by putting ideas into their head and disappearing from the scene afterwards, leaving them to fend on their own especially when their means are limited.
In analyzing the aforementioned causes a little further, we will all agree that incompetence is totally inexcusable. However, strict eligibility criteria for basic medical education and post-graduate training to become specialists, supplemented by programmes of Continuing Professional Development (CPD) will take care of this aspect. There is no substitute for continuous learning, and this is the responsibility of professional medical organisations, the appropriate regulatory bodies and governments with each having their role to play, roles which must of necessity be mutually reinforcing.
When it comes to inexperience, which is also a fact of life – for all fields of human activity isn’t it – here it concerns the junior, non-specialist doctor and the freshly qualified specialist. To be inexperienced is not a sin, and in a proper set-up both these categories of doctors will be supported by their peers and seniors in the superior interest of the patient. This means that these three levels must work in a close-knit and integrated manner, and cooperate amongst each other.
Unfortunately, very often there are ego issues and personal animosities which vitiate the working atmosphere, with the result that it is the patient who suffers. Some fresher specialists pretend to be of the conne-tout (‘know-all’) type and display arrogance; and some seniors are not prepared to share their experience. Under such circumstances only a change of mindset will help – both the doctors and their patients.
Complications may arise during procedures for diagnosis or from treatment. An example of the latter is drug allergy, which is impossible to anticipate, and can be fatal in rare cases of an extreme form of allergy known as ‘anaphylaxis’ if the patient cannot access medical care promptly.
We are on more tricky ground when it comes to clinical judgement, for this can affect even the most experienced practitioner. The issue here is interpretation of data: the volume of data that comes from questioning (taking a clinical history) and examining the patient, and from the reports of investigations carried out such as blood and urine tests, X-rays, scans, etc, relying on the accuracy of the results which depends on the equipments that are used. Besides, as regards say MRI or CT Scans, often it is the case that the treating doctor must rely on the interpretation of the radiologist who too is subject to the same constraints, that is the equipment, and his own training.
Putting all this together may find two specialists, for example, reaching differing conclusions concerning the same case. Why? Because training takes place within the historical context of the development of medical education in any country, or in the same country within institutions which have their own approaches to a given problem. One can begin to appreciate the complexity of arriving at a proper diagnosis, admittedly not in all cases, and the same kind of reasoning applies to treatment modalities as well.
Such subjective clinical judgement would be the equivalent of ‘dissenting judgement’ by judges in a court of law.
The medical establishment has been conscious of this conundrum for long, and for some decades now has been trying to improve diagnostic accuracy, by minimizing the element of ‘subjectivity’ where this is possible. The advent of information technology and computational capacity has been exploited to increase the accuracy of data interpretation, which Artificial Intelligence will enhance further. However, there are cases where clinical judgement will still be the mainstay – because what we call the ‘clinical picture’ does not tally with what investigations show up. Or when investigations are all negative, meaning they do not show anything abnormal in the results. It is then left to the doctor’s judgement as to the further course of action.
As regards medical negligence, from what precedes any rational person will realise that there’s more to diagnosis and treatment than sensational headlines in the papers. It is never easy to establish medical negligence, which is too complex a subject to be discussed here. Suffice it to say that no doctor ever sets out to knowingly do harm to any patient, for the golden ethical premise of the medical profession is ‘Primum non nocere’ – ‘First, do no harm’. But yes, there definitely are cases where medical evidence is established through due process, and it is never a pleasant outcome for either patient or doctor whose reputation can be forever tarnished and career suffer.
A very simple and practical way to improve medical practice and to avert mishaps is to hold weekly clinical meetings at departmental level in hospitals, in addition to attending Continuing Medical Education (CME) – the former appellation of CPD — sessions that have now become mandatory for practising doctors. In these meetings, the usual format is case presentation and discussions, reviews of morbidity and mortality, update on specific topics, smoothing the rough edges in the running of the department, reinforcing bonds of mutual understanding and trust so that, among other things, the young doctor on duty in hospital – the frontline soldier as it were – knows that s/he is embedded in a robust support system that s/he can call upon at any moment without hesitation, confident that s/he will not be let down.
That’s what good medicine is all about, and I have been fortunate to be a participant in it in my specialty with my numerous colleagues in different hospitals of the country for many years. All of us doctors can do it, and we should – for the sake of our patients.
* Published in print edition on 20 July 2018