Intercepted Letter

1358

Intercepted

Letter

THE MAN WHO NEVER COMES BACK DEAR MARY,

The other

day a professor of social science said to me, "You not sure whether you are poisoning me or not". He intended no personal slight, our meeting had not been a professional one-and he did smile. But he was serious and he would hardly have found reassurance in the recent ruling by the General Medical Council that the prescription of a lethal overdose of a largely discontinued drug is not profesknow, my problem is I’m

sional misconduct. I do not see how anyone can now be entirely free of misgivings as he carries his prescription to the chemist. There is scarcely a week without its headlines announcing a serious medical mishap. 10% or more of illness is now thought to be iatrogenic, and large damages are awarded to the victims of negligence. To add to published reports, there are the rumours. I know from my general-practice experience that a great many worries brought to me by patients or their relatives arise from remarks they have misinterpreted, or dark hints from those who should know better. Not long ago a medical student was to be heard relating anaesthetic disasters that had taken place in his teaching hospital. The basis of his information, it turned out, was hearsay from a junior nurse. Thus do rumours grow. The public, I feel, are in the position of a man gazing into a hold full of glistening fish. They look healthy enough, but his nose tells him that one or more of them is bad and the fisherman will not indicate which. Indeed, the reaction of many of the leaders of the profession when faced with requests for medical audit is to form a tight laager, and pronounce that there is no cause for concern; all doctors are caring and dedicated, and if a few minor mistakes are made it is because they are overworked and underpaid. When pushed into a corner they reply that for those who feel aggrieved there are always the courts. I have seen this reflex reaction at work. Some years ago a child who had been an inpatient a few weeks before was brought back to hospital with sepsis over the site of an intravenous infusion and osteomyelitis of at least two bones. The history was complicated, and it probably involved a degree of parental negligence. This was a case for careful and unemotional inquiry, yet the reaction of the first consultant to be told was: "saYÌlothing at all". The bewildered and frightened parents were confronted by silence. During my spells of hospital work over the past ten years I

6. Pocket book of health statistics. New Delhi: Directorate General of Health Services, Government of India, 1975. 7. Wyon JB, Gordon JE. The Khanna study. Cambridge, Massachusetts: Harvard University Press, 1971. 8. Desai PB. Size and sex composition of population in India, 1901-1961. Bombay: Asia Publishing House, 1969. 9. Singh AJ, Sidhu DS. New farm technology and agricultural labour In: Pandey SM, ed. Rural labour in India. New Delhi: Shri Ram Centre for Industrial Relations and Human Resources, 1976: 41-51. 10. Gopalan C, Naidu AN. Nutrition and fertility. Lancet 1972; ii: 1077-79. 11. Graves PL. Nutrition, infant behavior, and maternal characteristics: a pilot study in West Bengal, India. Am J Clin Nutr 1976; 29: 305-19. 12. Census of India: series I, provisional population totals. New Delhi: Registrar General & Census Commissioner, 1971. 13. Pandey SM. Rural labour in India. New Delhi: Shri Ram Centre for Industrial Relations and Human Resources, 1976: 90-109. 14. Critical issues on the status of women. Advisory Committee on Women’s Studies, Indian Council of Social Science Research. publication no 107. New Delhi, 1977. 15. The Narangwal population study Baltimore: Department of International Health, Johns Hopkins University, 1975. 16. Srinivasan K. Interaction of nutrition with family planning programme. Proc Nutr Soc. India 1976; 20: 6-13.

have constantly been impressed by the conscientiousness of the medical profession. Orthopaedic surgeons strive to get the alignment of the prosthesis "just so". Gynaecologists mop the paracolic gutters with the utmost vigilance. Consultants are to be seen unattended at very unsocial hours dropping in to take a look at a worrying patient. And not only consultants: more than once I have caught a militant uMT-conscious houseman sneaking back to the ward. The future of medicine is, on the whole, in very good hands. It was the juniors who led the call for medical audit at this year’s annual representative meeting of the B.M.A. I cannot do better than quote Dr Stephen Horsley : "the medical profession has been dilatory in setting up its own workable procedures for intraprofessional audit and if it did not do so control would pass to someone else". Indeed it will: already the heavy tread of the Ombudsman can be heard approaching, and the chief characteristic of that gentleman’s decisions (or any non-professionaljudgment) is that they often seem erroneous to anyone with a clinical training. There must be a medical Murphy’s law which states that where alternative expert opinions are available the judiciary opts for the more zany. That does lead to defensive medicine, for who is to know what is reasonable, bearing in mind some court decisions. Is taking a temperature an invasive procedure requiring written permission? No? Well-it may soon be.

What has so far inhibited many doctors from pressing for any sort of judgment on their fellows is an uncomfortable feeling of "there but for the grace of God ...". Knowing that we all make mistakes many members of the medical hierarchy are loath to sit in professional judgment on their colleagues. There is also the natural but less commendable reason that they will have to spend the rest of their working lives with them. But they forget two vital points. The first is the grave consequences of error. The negligent doctor may kill you, cripple you, reduce you to a vegetable, or leave your children motherless. Only those in old-fashioned general practice (or those afflicted) can fully appreciate the heavy responsibility which doctors bear. The other factor is what we might call the "Wilde principle". Anyone can make a mistake, and to make one is a misfortune. To continue to do so is usually carelessness. This was put to me by a locum surgical registrar who alluded to past experience in a small northern town. "I worked for two men: one had every complication in the book, everything I had read about, his patients had; and the other had no problems at all". He was stating a simple fact: that fortune largely favours the diligent. The conscientious doctor soon becomes knowledgeable; after all, if you constantly look up the correct doses of drugs or seek information on the best way to tackle a procedure, you must inevitably augment the current account in your information bank. This is known, at least by the juniors. I recollect that as an occasional anaesthetic s.H.o. my heart rose or sank according to which surgical team was on duty, and I have known anaesthetic registrars prepared to strike for a change in the rota after six months working with the surgical second division. The juniors know in a way denied their seniors and I suspect that is why they are the advocates of audit. They should be supported, for not only can negligence have the devastating sequelae I have indicated, not only does it envelope the whole profession in a miasma of suspicion, but it is also expensive. (To my certain knowledge one department has had two major undefended cases in the past five years with damages totalling over 120 000 awarded against it.) Nor should we forget the strain on the conscientious doctor who finds himself covering for his lazy or incompetent colleague. I have brooded over this problem for some time, ever since I met the Man Who Never Comes Back. Did I tell you about him? A big, bluff, personable, Anglo-Saxon, product of one of our older universities and a London "centre of excellence"; a neat surgeon and a clock-watcher. He did a partial gastrectomy late one afternoon for a S0-year-old man with an uncontrollable haematemesis, and bowed out, leaving his registrar to sew up. When I extubated the patient he bled profusely, and

1359 he continued to bleed in spite of all resuscitative measures until he died four hours later. A post-mortem later showed he had bled from the suture line. Twice the surgeon was told and declined to come in. I was drawn into a corner by the consultant anaesthetist the next day, who was clearly upset. "The trouble with Mr X," he said, "is that he never comes back." I was to receive independent confirmation of this a few months later when a friend told me his son was applying for Mr X’s registrar job. "I do not expect to be called after six o’clock," he was

told firmly. How shall

we deal with the ignorant, the greedy, and those without conscience? Clearly not by the "three wise men". Whoever thought up that idea was a splendid theorist, but could hardly have given it much practical thought. Between the desire and the reality falls a very large shadow. Imagine the scene: the gathering of the sober-suited gentlemen followed by either the summons to the prefect’s study, or the visitation, accusations, denials, the questioning of juniors, and the division into partisan groups. Possibly in the worst cases the loaded revolver laid on the desk, the meaningful look from

totally

In

Socrates: I hear there has again been some disquiet in you profession this past year. Is this, may I ask, over payment? Eryximachus: In part. But it also concerns other matters connected with our work. S. I see. Until your National Health Service began, almost all persons had a direct financial undertaking with their doctors. When the doctor was called it was clearly understood that the patient would pay for his attention? E. Certainly. But a form of support called National Insurance was sometimes provided. Moreover, unlike the position when those who could not afford what they wanted did without, our profession often supplied service without payment. S. When your great change of 1948 was introduced the State agreed to pay for the doctor’s services out of the nation’s taxes. Did that mean that the State rewarded the doctor for each visit to a patient in his home or for each attendance in the doctor’s

chambers? a

doctor

as

not go unattended. In present circumthe doctor contract out of his commitments when the patient makes unreasonable demands on his time? E. He can, by having the patient’s name removed from his

patient would

stances can

MORE DISCOURSE ON THE NATIONAL HEALTH SERVICE

adviser, that doctor

yours, MARTHA

S. So the

England Now

E. No. For each citizen who chose

the door. Come, come, this is 1979. It didn’t work at Normansfield and it hasn’t a hope anywhere else. I believe we disregard the most potent force we have: the power of public opinion. I should like to see every hospital hold a "death and complications" meeting at which attendance would be customary, if not compulsory. It should be an open forum for any patient, relative, nurse, or doctor to discuss cases worrying them. If necessary anonymity could be stipulated to avoid possible victimisation. I do not think it would be abused. Most anxieties would be found to result from misunderstandings and swiftly disposed of. The ignorant would be educated, and the Mr Xs would find it difficult, I suspect, to refuse to come back if this refusal were to be made public. There need be no suggestion of criticism, no flavour of sitting in judgment, no violation of professional autonomy, no Star Chamber-and no Ombudsman. I do not pretend that it would solve all the problems of negligence, but it would be a start. Best wishes,

his first medical

paid so much in every year. When a doctor’s work was of a particular kind-say, that of a physician or a surgeon or another specially trained doctor-payment was made annually for his regular attendance at his hospital or elsewhere. S. I understand that no limit was placed on the number of calls each year on the doctor’s time. If I were your patient I could call you to see me daily, or I could call to see you daily. And you must see me? At any time during the day or night? was

E. Yes. S. But would this not inevitably lead to neglect or at least inadequate attention to the other persons on your register? How, if some persons monopolise your services, can you possibly fulfil your part of the bargain? E. I find it hard to do so. S. You have deliberately entered into a contract in the certain knowledge that you cannot always fulfil its terms? And you did this willingly and without coercion? E. I understand there were some initial misgivings. S. Let us suppose that under the old relationship, before the N.H.S., a sick person could not pay, or even refused to pay for his attention, what would happen? E. The doctor would refuse to see the patient. S. What would the patient do then? E. He would be attended by doctors who were employed by the State wholly to deal with such patients.

register. S. And placed on another register. But this only means that the problem is moved geographically and not solved. To take again the analogy of things purchased; if I want something I give money in return for it. What happens when the cost of the services the doctor provides increases? As, for example, when the cost of food, of clothing, of housing, of education, of recreation rises, if it costs the doctor more per unit of his time to live then he will be forced to charge more for his services. If he does not raise his price he will be forced to deprive himself and his family. I suppose there must be some machinery for determining the increased payments? E. There is. S. You mean that if there is a recognised increase in the cost of providing for himself and his family, this will be reflected in his salary? E. Yes. But as the body responsible for reviewing our payment makes recommendations only once a year there is an unavoidable delay. S. That I take to be inevitable. Am I right to suppose that the individuals who make up this Review Body, as you call it, are carefully chosen and responsible, persons who are aware not only of the doctors’ position but also of the position of others who work for the State? Their recommendations are not carelessly made, so to speak, in a vacuum? E. Indeed they are not. S. When the Review Body makes a recommendation is this accepted by the State? E. Not necessarily. The State has reserved the right to decline to meet its side of the bargain. For this and other reasons in recent years dissatisfaction among doctors has often been severe.

S. When the original discussions took place there was no mention of a clause forbidding you to strike as there is, for example, in the contract for the Armed Forces and the police. Yet the doctor is as important to the State as the sailor, the soldier, the airman, the policeman, is he not? E. Yes. S. Was it recognised that the doctor will never strike? E. That is certainly the embodiment of our ethic. S. Was there no recognition by the State that you alone among its employees will not use the weapon of the market place where all those others who sell their labour to the State can enforce payment by strike?

E. No.