- February 13, 2016
- Posted by: emobile
- Category: Uncategorized
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Mistakes in medicine, whose side are you?
Mistakes happen. Some have serious consequences. Professionalism requires that doctors acknowledge their errors and figure out how to avoid making similar ones in the future. Until recently, doctors would generally only acknowledge errors to each other, not to their patients, if they acknowledged them at all. Over the last few decades, doctors have gotten better at acknowledging mistakes and apologizing to patients when a mistake happens.
Disclosure is especially complicated when one becomes aware of an error made by a colleague. Who, then, has the responsibility to deal with the disclosure? To whom should disclosure take place? Who is accountable to whom? We present a case in which consultant surgeons become aware that a colleague has made a serious error.
The Case
A newborn was diagnosed with Hirschprung’s disease on day 6 of life. A local surgeon, with limited pediatric surgical training, operated on the neonate. Postoperatively, the neonate developed serious complications. He was unable to take adequate nutrition by mouth, became malnourished, and, after a few weeks, was transferred to a children’s hospital. The surgeons there discovered that, during the first operation, the original surgeon had become confused about the child’s anatomy, and removed the healthy portion of the colon while leaving in place the diseased sigmoid colon and rectum.
In essence, his error converted a manageable case of Hirschprung’s into the total colonic type that was far more difficult to manage and vastly more costly for the patient and family to endure. Final reconstruction was not feasible for years.
The parents were unaware that a mistake had been made although they were aware that this was an unanticipated outcome. The surgical staff at the children’s hospital was deeply troubled by the child’s previous care and ambivalent about what to do about it. Should they confront the referring surgeon or inform his supervisors? Should they report the case to the state licensing board? Should they tell the parents what happened? Should they encourage the parents to sue the original surgeon?
it may be that the surgeon was doing what (in his or her mind) was best for the patient. Therefore, we should ask if there was a genuine impropriety, and if so, to what degree? A distinction must be made between disagreements over reasonable medical alternatives and actions that fall well out of the standard of care. In this case, more information is needed. Was the patient demonstrating instability and the original surgeon felt pressured to intervene? Was he/she concerned with the health of the proximal colon? Had he/she done this procedure before or did he/she call any colleagues for input? At the least, the pediatric surgeon at the receiving institution should listen attentively and then offer assistance in caring for complicated patients in the future.
Only after such a conversation should the pediatric surgeon consider discussing the previous operation with the parents. Complete honesty with the family is required to maintain the physician–patient relationship. With this in mind, the need for disclosing what has happened previously is obvious. Our priority should be to advocate for the patient. Facts should be shared about what has been done and what will be needed to correct the problem. The response by the parents and their decisions about future legal retribution will be based on a combination of their understanding of the case, the emotional response of the pediatric surgeon assuming care, and their own existing belief system. We must remain aware of how our own belief system affects our actions in these complex cases. We control how we present the situation, which nonverbal cues we manifest, how to advise between punishment and rehabilitation, and how to preserve the rights of the child.
There are 2 approaches to be considered: retribution and reconciliation. Parents will be acutely aware of the monetary costs involved in the care to date and for future care. Consequently they may act to recover the maximal medical charges. The pediatric surgeon may feel the need to professionally retaliate against the referring provider. This could be accomplished through licensing boards and the referring hospital’s credentialing process. While the referring surgeon may have acted inappropriately, removing his credentials may remove an additional physician from the work force. Conversely, the receiving medical team can steer the conversation toward an atmosphere of reconciliation, remediation, and forgiveness. This does not imply eradicating culpability or negating the importance of compensation but rather ensuring that the referring surgeon is given the option to meet with the family. This would also provide the parents the opportunity to forgive, even though they do not forget.
In summary, physicians should have a systematic response to complex cases that have resulted in injustice for a patient due to suspected malpractice. All important information should be obtained and used to inform the patient and their family. We should remain mindful of how we present these facts. Also, we are obligated to report unethical conduct as a patient advocate. Above all, our priority is to assume responsibility for this patient and treat him or her as we would any other, with the best care possible.
There are 3 levels of response to the mistake of a colleague. One involves responsibility to the patient and family. In this case, all respondents agree that the patient and family need to be told the facts. The second level of responsibility is to the colleague who made the mistake. Here, too, all the respondents agree that it is essential to discuss the mistake with the surgeon who was responsible. The third level is the most complex. What is the responsibility of physicians to society? How should we police ourselves? That one is the toughest. Many institutions have robust quality and safety programs to investigate errors and build safer systems. But should we also reports mistakes to authorities outside of our institutions?
Physicians are reluctant to criticize other physicians. The responses to this case suggest how carefully surgeons think about their responsibilities when they suspect that a colleague has made an error. Such caution is appropriate. But it cannot be an excuse for paralysis or complacency. Medicine and surgery are both so highly specialized that often only other knowledgeable practitioners can determine whether a mistake has been made and, if so, whether the mistake reflects an unfortunate but isolated event, or a pattern of incompetence. If the latter, it should lead to professional consequences. The privilege of self-regulation requires a willingness to uphold professional standards
The case described is tragic. A surgeon has committed an error that has resulted in an infant unnecessarily losing the entire colon. This error will lead to lifelong problems for a young child and inestimable health care costs over a lifetime. The treating surgeons at the children’s hospital where the child was transferred know that the original surgeon’s error has led to this devastating complication, but neither the parents of the child nor, presumably, even the original surgeon know of the error that has led to this complication.
The challenge of what to do when errors occur in the operating room has been a longstanding concern for surgeons. Although there is a history of surgeons not disclosing such errors, contemporary ethical standards require surgeons to disclose errors to patients or to the patients’ parents in cases involving children. The challenge in this case is that the error was not committed by the surgeons who have now discovered it. What is the ethical responsibility for disclosing the errors committed by someone else?
In this case, it is critical for the parents to understand what happened and why it happened. Although I would never encourage the parents to sue the original surgeon since such a lawsuit cannot undo the error, the parents must be informed that their child’s complication was not a random event, but the result of a surgical error. This disclosure is central to the honesty in the relationship between the parents (and eventually the child) and the surgeons who will be assuming care moving forward. However, it is not enough for the surgeons at the children’s hospital to disclose the original surgeon’s error to the parents. The original surgeon must also be made aware of the error. One of the challenges of the lack of knowledge is that we often do not know what we do not know. For the original surgeon to realize that an error was made, the current treating surgeons must confront this surgeon with the error.
In many circumstances, just realizing that one has made an error is enough. In this case, however, I believe that it would also be necessary to inform the surgeon’s supervisors or department leadership. This case must be reviewed by the Quality Management Committee at the original hospital and a full investigation of whether the original surgeon should be allowed to continue to operate on children should be undertaken. I believe that this review of the case and the consideration of what consequences the original surgeon should suffer should be done as part of the peer review process that is the foundation for all quality assurance programs. For this reason, I would not recommend reporting the case to the state licensing board. The issue is not whether the original surgeon should lose his or her license to practice surgery, but whether children should be protected from the possibility of being operated upon by this surgeon in the future.
A case such as this one raises many questions. How could the original surgeon have made such a horrible mistake? Did anyone else in the operating room during the original operation have any idea of the error that was being made? Were there other more qualified surgeons available to perform the original operation? All of these questions are important and would help to define the consequences for the surgeon and the institutional changes that should be made to minimize the chances of such an error harming any future patients. However, for any disclosure to occur, the parents, the original surgeon, and the surgical leadership at the original hospital all must understand the cause of the child’s current condition.