- Email: [email protected]
Monitoring of medical practice
CORRESPONDENCE
is to leave humanity where it has always been—at the mercy of monsters. Until systematic studies on Shipman’s mental disorder have been done by a team of psychiatrists and the details made public, draconian efforts at prevention will rank with tabloid hysteria. Julian Lieb 22 Rimmon Road, Woodbridge, CT 06525, USA 1
2
Horton R. The real lessons from Harold Frederick Shipman. Lancet 2001; 357: 82. Hershman DJ, Lieb J. A brotherhood of tyrants: manic depression and absolute power. Amherst: Prometheus Books, 1994.
Sir—I approve of Richard Horton’s initiative1 in encouraging doctors to report examples of their mistakes and the lessons learned from them. I wonder whether, within this frame, it would be useful to encourage clinicians, pathologists, or both to furnish examples in which a necropsy has been important in the discovery of such errors. Necropsy has always been a privileged occasion for discussion and frequently clarification of a diagnostic difficulty. The practice of the necropsy has decreased greatly in most countries, which might represent a prejudice for quality assurance. Hopefully a database of examples will convince clinicians and pathologists that having necropsy data is useful for both, and important for medicine in general. Giulio Gabbiani Department of Pathology, 1211 Geneva 4, Switzerland (e-mail: [email protected]) 1
Horton R. The real lessons from Harold Frederick Shipman. Lancet 2001; 357: 82.
Sir—Another important outcome of the Harold Shipman case that Richard Horton does not mention1 could be to institute a reform of the death certification system. At present, medical practitioners might be vulnerable to adverse public scrutiny since they are paid for signing the second part of a cremation certificate (Form C). This action is confirmation of the statement of the doctor signing the death certificate, and is frequently done by a colleague with whom the certifying doctor is familiar, other than a partner or relative. We propose that experienced medical practitioners are employed, part or full time, by local health authorities to adhere to a consistent assessment protocol for all deceased patients, whether for burial or cremation, to confirm the findings of the certifying doctor. The protocol would include a
1444
review of a patient’s medical records and, if deemed appropriate, interviews of relatives and health-care professionals involved, as well as an examination of the deceased. The current assessments vary widely in quality dependent on differing interpretation of the questions on Form C and the time allowed by the doctor to complete the form. Many sudden deaths referred for necropsy could be reviewed according to the same assessment protocol. If the likely cause of death is natural and beyond reasonable doubt, some unnecessary necropsies and distress to relatives could be avoided. The salary for the medical practitioners would come from a central pool of fees currently paid for completion of Form C and the crematorium medical referee’s certification (Form F). Payment would therefore be through contractual agreement instead of fees. Potential conflicts of interest would be avoided, accuracy of mortality data improved, and audit of deaths possible for individual practitioners, general practices, and NHS Trusts. This practice would reassure the public, improve accountability, and be an aid to clinical governance. *Rodger Charlton, Christina Faull *Centre for Primary Health Care Studies, University of Warwick, Coventry CV4 7AL, UK; and Department of Palliative Care, University Hospital, Birmingham
or bad. To ask our colleagues to acknowledge past mistakes without asking them for the details of the process to prevent similar mistakes is more titillation than progress. I was impressed with Beaglehole’s courageous willingness to confess his mistakes. However, as an active clinician for almost 30 years, and knowing I continue to make mistakes from which I learn, I was taken aback by Beaglehole’s statement “ . . .with great relief, I gave up clinical practice.” I could see every medical student and resident with whom I have interacted reading that statement and believing that once they made a mistake of missing a serious diagnosis, they should abandon clinical practice. I trust that many more factors contributed to Beaglehole’s decision than just a missed diagnosis. No-one would practice clinical medicine if they all had to stop after one mistake. We will continue to learn from our mistakes and we need not do so privately, but let us do it in a way that assists ourselves and our colleagues in the process of improving medical care. Herbert L Muncie Jr Department of Family Medicine, University of Maryland School of Medicine, Baltimore, MD, USA 1 2 3
1
Horton R. The real lessons from Harold Frederick Shipman. Lancet 2001; 357: 82–83.
Sir—I applaud Richard Horton, in his Jan 13 commentary,1 and Robert Beaglehole in his Jan 13 item2 in encouraging physicians to acknowledge and learn from their mistakes. My two grown children probably hate me for asking them all their lives, “How do you learn?”—the required answer was “By making mistakes”. I wanted my children to know that we all make mistakes and we can only make progress by attempting to do things differently and finding out what did not work. I believe we learn more from our mistakes than from our successes. However, I was disturbed by the approach suggested for learning from mistakes. While quoting Gostin’s public-health approach to preventing medically induced injuries,3 Horton encourages an anecdotal description of mistakes. To describe an error only as a bad outcome without discussing the process that could prevent similar mistakes might lead to mere confessional catharsis or finger-pointing. We should not practise medicine on the basis of anecdotes, whether they be good
Horton R. We all make mistakes: tell us yours. Lancet 2001; 357: 88. Beaglehole R. Uses of error: clinical and epidemiological. Lancet 2001: 357: 140. Gostin L. A public health approach to reducing error. JAMA 2000; 283: 1742–43.
Sir—Surely Richard Horton1 is too late in asking readers to own up to their clinical errors. Serious mistakes, even if committed in good faith, have been leading in litigation for some years. Obstetricians have practised audit for decades and have contributed to the reports on maternal mortality with improving results. Most units have meetings about perinatal mortality and morbidity. In-house enquiries can easily develop into witch hunts, causing resentment among medical staff. The public’s ambivalent approach to the medical profession is part of the main picture of distrust of science and scientists as a whole, heightened by the bovine spongiform encephalitis saga. Perhaps the public requires education in some features of medicine, just as the profession will have to ensure periods of retraining. Alan M Smith Handsworth Wood, Birmingham B20 1LH, UK (e-mail: [email protected]) 1
Horton R. We all make mistakes: tell us yours. Lancet 2001; 357: 88.
THE LANCET • Vol 357 • May 5, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
is to leave humanity where it has always been—at the mercy of monsters. Until systematic studies on Shipman’s mental disorder have been done by a team of psychiatrists and the details made public, draconian efforts at prevention will rank with tabloid hysteria. Julian Lieb 22 Rimmon Road, Woodbridge, CT 06525, USA 1
2
Horton R. The real lessons from Harold Frederick Shipman. Lancet 2001; 357: 82. Hershman DJ, Lieb J. A brotherhood of tyrants: manic depression and absolute power. Amherst: Prometheus Books, 1994.
Sir—I approve of Richard Horton’s initiative1 in encouraging doctors to report examples of their mistakes and the lessons learned from them. I wonder whether, within this frame, it would be useful to encourage clinicians, pathologists, or both to furnish examples in which a necropsy has been important in the discovery of such errors. Necropsy has always been a privileged occasion for discussion and frequently clarification of a diagnostic difficulty. The practice of the necropsy has decreased greatly in most countries, which might represent a prejudice for quality assurance. Hopefully a database of examples will convince clinicians and pathologists that having necropsy data is useful for both, and important for medicine in general. Giulio Gabbiani Department of Pathology, 1211 Geneva 4, Switzerland (e-mail: [email protected]) 1
Horton R. The real lessons from Harold Frederick Shipman. Lancet 2001; 357: 82.
Sir—Another important outcome of the Harold Shipman case that Richard Horton does not mention1 could be to institute a reform of the death certification system. At present, medical practitioners might be vulnerable to adverse public scrutiny since they are paid for signing the second part of a cremation certificate (Form C). This action is confirmation of the statement of the doctor signing the death certificate, and is frequently done by a colleague with whom the certifying doctor is familiar, other than a partner or relative. We propose that experienced medical practitioners are employed, part or full time, by local health authorities to adhere to a consistent assessment protocol for all deceased patients, whether for burial or cremation, to confirm the findings of the certifying doctor. The protocol would include a
1444
review of a patient’s medical records and, if deemed appropriate, interviews of relatives and health-care professionals involved, as well as an examination of the deceased. The current assessments vary widely in quality dependent on differing interpretation of the questions on Form C and the time allowed by the doctor to complete the form. Many sudden deaths referred for necropsy could be reviewed according to the same assessment protocol. If the likely cause of death is natural and beyond reasonable doubt, some unnecessary necropsies and distress to relatives could be avoided. The salary for the medical practitioners would come from a central pool of fees currently paid for completion of Form C and the crematorium medical referee’s certification (Form F). Payment would therefore be through contractual agreement instead of fees. Potential conflicts of interest would be avoided, accuracy of mortality data improved, and audit of deaths possible for individual practitioners, general practices, and NHS Trusts. This practice would reassure the public, improve accountability, and be an aid to clinical governance. *Rodger Charlton, Christina Faull *Centre for Primary Health Care Studies, University of Warwick, Coventry CV4 7AL, UK; and Department of Palliative Care, University Hospital, Birmingham
or bad. To ask our colleagues to acknowledge past mistakes without asking them for the details of the process to prevent similar mistakes is more titillation than progress. I was impressed with Beaglehole’s courageous willingness to confess his mistakes. However, as an active clinician for almost 30 years, and knowing I continue to make mistakes from which I learn, I was taken aback by Beaglehole’s statement “ . . .with great relief, I gave up clinical practice.” I could see every medical student and resident with whom I have interacted reading that statement and believing that once they made a mistake of missing a serious diagnosis, they should abandon clinical practice. I trust that many more factors contributed to Beaglehole’s decision than just a missed diagnosis. No-one would practice clinical medicine if they all had to stop after one mistake. We will continue to learn from our mistakes and we need not do so privately, but let us do it in a way that assists ourselves and our colleagues in the process of improving medical care. Herbert L Muncie Jr Department of Family Medicine, University of Maryland School of Medicine, Baltimore, MD, USA 1 2 3
1
Horton R. The real lessons from Harold Frederick Shipman. Lancet 2001; 357: 82–83.
Sir—I applaud Richard Horton, in his Jan 13 commentary,1 and Robert Beaglehole in his Jan 13 item2 in encouraging physicians to acknowledge and learn from their mistakes. My two grown children probably hate me for asking them all their lives, “How do you learn?”—the required answer was “By making mistakes”. I wanted my children to know that we all make mistakes and we can only make progress by attempting to do things differently and finding out what did not work. I believe we learn more from our mistakes than from our successes. However, I was disturbed by the approach suggested for learning from mistakes. While quoting Gostin’s public-health approach to preventing medically induced injuries,3 Horton encourages an anecdotal description of mistakes. To describe an error only as a bad outcome without discussing the process that could prevent similar mistakes might lead to mere confessional catharsis or finger-pointing. We should not practise medicine on the basis of anecdotes, whether they be good
Horton R. We all make mistakes: tell us yours. Lancet 2001; 357: 88. Beaglehole R. Uses of error: clinical and epidemiological. Lancet 2001: 357: 140. Gostin L. A public health approach to reducing error. JAMA 2000; 283: 1742–43.
Sir—Surely Richard Horton1 is too late in asking readers to own up to their clinical errors. Serious mistakes, even if committed in good faith, have been leading in litigation for some years. Obstetricians have practised audit for decades and have contributed to the reports on maternal mortality with improving results. Most units have meetings about perinatal mortality and morbidity. In-house enquiries can easily develop into witch hunts, causing resentment among medical staff. The public’s ambivalent approach to the medical profession is part of the main picture of distrust of science and scientists as a whole, heightened by the bovine spongiform encephalitis saga. Perhaps the public requires education in some features of medicine, just as the profession will have to ensure periods of retraining. Alan M Smith Handsworth Wood, Birmingham B20 1LH, UK (e-mail: [email protected]) 1
Horton R. We all make mistakes: tell us yours. Lancet 2001; 357: 88.
THE LANCET • Vol 357 • May 5, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.