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Checks and balances
ESSAY
in health. Intellectual opposition to injustice is only the beginning of social understanding. Solutions must be framed in causal explanations of the problems being addressed. We need policies that will make a difference and resources to ensure that good medical care is provided where it is most needed. Acknowledgments I thank Julian and Mary Hart for many years of friendship and inspiration. The views expressed are mine alone.
References 1 2 3 4
Hart JT. The inverse care law. Lancet 1971; 1: 405–12. Hart JT. BMJ 2001; 322: 1363–64. McKeown T. The role of medicine: dream, mirage or nemesis. London: Nuffield Principal Hospital Trust, 1976. Tunstall-Pedoe H, Vanuzzo D, Hobbs M, et al. Estimation of
contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations. Lancet 2000; 355: 688–700 5 Scottish Executive Health Department. Fair shares for all: report of the National Review of Resource Allocation for the NHS in Scotland. Edinburgh: Scottish Executive Health Department, 1999. 6 Starfield B. New paradigms for quality in primary care. Br J Gen Pract 2001; 51: 303–09. 7 Stirling AM, Wilson P, McConnachie A. Deprivation, psychological distress, and consultation length in general practice. Br J Gen Pract 2001; 51: 456–60. 8 Hart JT, Thomas C, Gibbons B, et al. Twenty five years of casefinding and audit in a socially deprived community. BMJ 1991; 302: 1509–13. 9 Kaul S. Twenty five years of case finding and audit. BMJ 1991; 303: 524–25. 10 Watt GCM. The example of Dr Julian Tudor Hart. Br J Gen Pract 1999; 35: 503. 11 Toynbee P, Walker D. Did things get better? An audit of Labour’s successes and failures. London: Penguin, 2001; 87.
Uses of error Checks and balances Richard Hobbs Arriving to do my first 2-week clinical placement as a fourth year medical student, I was informed by the consultant that the house officer was sick and I would replace him for the duration. I was pretty shocked, not that I could show it. I knew remarkably little medicine: lots of theory but little practice. That 2-week stint was a formative experience: I gained fantastic clinical exposure and mugged-up in the library on my nights off. My saviours were excellent senior house officers, but pride prevented me from involving them too frequently, hence my first big clinical error. An elderly man was admitted with chest pain and shortness of breath. I diagnosed a myocardial infarction and used the normal range of drugs available in the pre-thrombolytic days. However, his condition did not stabilise despite my best efforts and I couldn’t quite work out why, although I thought he was in congestive heart failure. It was the early hours of the morning and I didn’t want to wake my senior house officer again. Despite significant reservations, I decided to give the patient some diamorphine as was advised in the books. He died 30 min later and I spent the rest of a sleepless night panic-struck that I had killed him with my morphine bolus. I couldn’t bring myself to talk about it but awaited the post mortem in trepidation that my career would end before it had begun. The post mortem revealed that he had suffered a pulmonary embolus. No one seemed to notice the fact that I had missed it. This error left me with an increased interest in the diagnostic process and less reluctance to seek advice. My second big error, or rather lesson, was in my early years as a general practitioner in a difficult inner city practice. We did 11 clinics a week each which were
often long and packed with extra patients. Demands were excessive and I adopted a somewhat gung-ho approach to patients wishing to be seen on an emergency basis for a problem of convenience. I would start the consultation with a lesson on why it was not appropriate to abuse the appointment system (we ran 10 min appointments even in those days). To some of my more pugilistic patients, a red mist would descend and a difficult consultation would ensue. One evening a mild-mannered chap who had received my lesson of the day paused at the door and suggested I should check a patient’s history before complaining about their use of the service. It transpired that he had recently been released from prison having served a second term for grievous bodily harm. To avoid ongoing anxiety I called and apologised on my way home that evening. This communication error taught me to be more selective with what I say to patients. I remain as reluctant as ever to respond to unreasonable demands, but I am much more polite about it. Many of my subsequent errors relate to a delay in diagnosis; the inevitable consequence of investigating undifferentiated symptoms is that serious problems may only become obvious after several consultations. In most cases, a diagnosis might have been made earlier, but this is always easy in hindsight. However, such delays can appear as stark errors in the minds of family members. I wish it were possible to openly discuss why one managed cases in a particular way, rather than defend oneself against the backdrop of complaints and medical negligence claims. Unfortunately, the system does not allow doctors to make errors.
Department of General Practice, University of Birmingham, B15 2TT, UK (Prof R Hobbs FRCGP)
254
THE LANCET • Vol 360 • July 20, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
in health. Intellectual opposition to injustice is only the beginning of social understanding. Solutions must be framed in causal explanations of the problems being addressed. We need policies that will make a difference and resources to ensure that good medical care is provided where it is most needed. Acknowledgments I thank Julian and Mary Hart for many years of friendship and inspiration. The views expressed are mine alone.
References 1 2 3 4
Hart JT. The inverse care law. Lancet 1971; 1: 405–12. Hart JT. BMJ 2001; 322: 1363–64. McKeown T. The role of medicine: dream, mirage or nemesis. London: Nuffield Principal Hospital Trust, 1976. Tunstall-Pedoe H, Vanuzzo D, Hobbs M, et al. Estimation of
contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations. Lancet 2000; 355: 688–700 5 Scottish Executive Health Department. Fair shares for all: report of the National Review of Resource Allocation for the NHS in Scotland. Edinburgh: Scottish Executive Health Department, 1999. 6 Starfield B. New paradigms for quality in primary care. Br J Gen Pract 2001; 51: 303–09. 7 Stirling AM, Wilson P, McConnachie A. Deprivation, psychological distress, and consultation length in general practice. Br J Gen Pract 2001; 51: 456–60. 8 Hart JT, Thomas C, Gibbons B, et al. Twenty five years of casefinding and audit in a socially deprived community. BMJ 1991; 302: 1509–13. 9 Kaul S. Twenty five years of case finding and audit. BMJ 1991; 303: 524–25. 10 Watt GCM. The example of Dr Julian Tudor Hart. Br J Gen Pract 1999; 35: 503. 11 Toynbee P, Walker D. Did things get better? An audit of Labour’s successes and failures. London: Penguin, 2001; 87.
Uses of error Checks and balances Richard Hobbs Arriving to do my first 2-week clinical placement as a fourth year medical student, I was informed by the consultant that the house officer was sick and I would replace him for the duration. I was pretty shocked, not that I could show it. I knew remarkably little medicine: lots of theory but little practice. That 2-week stint was a formative experience: I gained fantastic clinical exposure and mugged-up in the library on my nights off. My saviours were excellent senior house officers, but pride prevented me from involving them too frequently, hence my first big clinical error. An elderly man was admitted with chest pain and shortness of breath. I diagnosed a myocardial infarction and used the normal range of drugs available in the pre-thrombolytic days. However, his condition did not stabilise despite my best efforts and I couldn’t quite work out why, although I thought he was in congestive heart failure. It was the early hours of the morning and I didn’t want to wake my senior house officer again. Despite significant reservations, I decided to give the patient some diamorphine as was advised in the books. He died 30 min later and I spent the rest of a sleepless night panic-struck that I had killed him with my morphine bolus. I couldn’t bring myself to talk about it but awaited the post mortem in trepidation that my career would end before it had begun. The post mortem revealed that he had suffered a pulmonary embolus. No one seemed to notice the fact that I had missed it. This error left me with an increased interest in the diagnostic process and less reluctance to seek advice. My second big error, or rather lesson, was in my early years as a general practitioner in a difficult inner city practice. We did 11 clinics a week each which were
often long and packed with extra patients. Demands were excessive and I adopted a somewhat gung-ho approach to patients wishing to be seen on an emergency basis for a problem of convenience. I would start the consultation with a lesson on why it was not appropriate to abuse the appointment system (we ran 10 min appointments even in those days). To some of my more pugilistic patients, a red mist would descend and a difficult consultation would ensue. One evening a mild-mannered chap who had received my lesson of the day paused at the door and suggested I should check a patient’s history before complaining about their use of the service. It transpired that he had recently been released from prison having served a second term for grievous bodily harm. To avoid ongoing anxiety I called and apologised on my way home that evening. This communication error taught me to be more selective with what I say to patients. I remain as reluctant as ever to respond to unreasonable demands, but I am much more polite about it. Many of my subsequent errors relate to a delay in diagnosis; the inevitable consequence of investigating undifferentiated symptoms is that serious problems may only become obvious after several consultations. In most cases, a diagnosis might have been made earlier, but this is always easy in hindsight. However, such delays can appear as stark errors in the minds of family members. I wish it were possible to openly discuss why one managed cases in a particular way, rather than defend oneself against the backdrop of complaints and medical negligence claims. Unfortunately, the system does not allow doctors to make errors.
Department of General Practice, University of Birmingham, B15 2TT, UK (Prof R Hobbs FRCGP)
254
THE LANCET • Vol 360 • July 20, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.