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Last Updated Wednesday May 03 2017 12:15 PM IST

Matters of the Heart | Should I disclose my error to a patient?

Dr Roy John Korula
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Matters of the Heart Errors usually are due to failure to make the correct diagnosis, or failure to apply the correct treatment. Photo: Getty Images

Recently, I read of a case, where the North Chennai District Consumers Disputes Redressal Forum absolved an Orthopedic surgeon, who was sued by a patient on whom he had operated on. The surgeon had left a bit of a broken drill behind in the patients arm. (I am not clear if he had informed the patient about this at that time). Two years later, the patient had gone and got this drill bit removed in another hospital. In the intervening years, he had suffered no problem. The Orthopedic surgeon had submitted a series of medical reports, proving that leaving behind bits of instruments broken during a surgical procedure did not necessitate their removal, as it may have involved complicating and unnecessarily prolonging the operation.

Accidents and errors do occur. Humans are fallible, and they will make mistakes in their lives and work – whatever their profession - be it engineers, bankers or IT professionals. And doctors are no exception.

Also read: Matters of the Heart | Beating heart surgery vs conventional coronary artery bypass grafting

Errors usually are due to failure to make the correct diagnosis, or failure to apply the correct treatment. But it can also often be a wrong action done in the process of treatment (such as an error during a surgical procedure). Inexperience in interpretation of complex tests (all doctors may not be able to interpret ECG’s or MRI scans with 100% accuracy) may also result in an error in treating the patient. And in many cases, the correct diagnosis may have been considered, but priorities may have varied, resulting in a wrong outcome at the end.

Matters of the Heart Humans are fallible, and they will make mistakes in their lives and work – whatever their profession - be it engineers, bankers or IT professionals. Photo: Getty Images

Finally, and more tragically, there are the problems of recklessness. And incompetence.

In the United States, about one million such errors occur annually in hospitals across the country. Besides causing serious harm to about 10% of these patients, about 70,000 of them lead to the death of the patient. These preventable adverse outcomes may be responsible for more deaths than breast cancer, motor vehicle accidents and AIDS in the USA. Medical errors will continue as long as humans and not robots or “artificial intelligence” are the clinicians. The issue is, once they occur, what should be our attitude and response?

Also check: Matters of the Heart | Fee-splitting – the unethical side of medical practice today

Do we withhold such information from patients (“if we don’t tell them, they can’t find fault with us”) Or do we blatantly cover up facts? And bluff our way out of the problem. Or camouflage the facts, and only partly reveal the truth? And portray that the worsening condition of the patient is as a result of the underlying disease. And in case of poor patients, don’t tell them any details, as the poor are really ignorant of their medical condition and treatment.

Or do we honestly disclose the truth (telling them that some of these are known well documented complications of the procedure), and face the distress, wrath and sometimes legal consequences of our actions. Besides the shame, humiliation, and the subsequent slur on our reputation and competency if we get penalized for it.

And above all, the fear of our licence being revoked. And risk losing our livelihood.

This is truly what hinders and prevents doctors from disclosing medical errors.

Also check: Matters of the Heart | Why patients do not trust their doctor

Most doctors will tell you, that in an ideal world, errors should be reported to the patient’s family. In reality this is often not the case. Statistics reveal that in about 50% cases, doctors (and institutions) never report such errors to the patient or their relatives. I suspect that in India, the figure is actually very much higher.

The problem is that there is no centralized registry or regulatory body in our country or state to monitor and assess protocols, infections, errors in diagnosis, or errors in technique. And more importantly to oversee and supervise treatment outcomes, complications and mortality in hospitals across the country. And to advocate, audit, evaluate and ensure that basic minimal norms of treatment and outcomes are achieved.

Matters of the Heart The problem is that there is no centralized registry or regulatory body in our country or state to monitor and assess protocols, infections, errors in diagnosis, or errors in technique. Photo: Getty Images

Because most doctors will not subject their results to scrutiny, unless forced to.

But unless stringent audits are done, the problem will continue, the issue will not be rectified or redressed, and patients will continue to be deceived.

Fortunately, in the West, the trend now is to disclose such errors to patients and their relatives. Because it is the ethical thing to do.

Most Medical Councils and Associations abroad insist on disclosure of errors and incompetence. I do admit that many times we do not disclose full details of mishaps that occur during the treatment of a patient. But “covering up” altogether, and lying to, and deceiving the patient and his relatives is not morally and legally right. After all, patients come to us in good faith, with trust and confidence that we will do our best for them. And not telling them casts a serious doubt on the trustworthiness of the medical profession as a whole (not that doctors are among the most trusted among professionals these days). Concomitantly, patients are more likely to sue the doctor, once they discover that an error has not been disclosed to them.

In spite of the consequences of our mistakes – including penalization, I still feel telling patients about the problem is the honest thing to do.

Medicine is not an exact science, and in treating patients, most doctors base their thinking and actions on their experience (sometime painful), and the numerous similar cases they have been confronted with or faced before. It is easy to make a perfect diagnosis, with perfect information available. But sadly, everyone, including patients, expect doctors to make a perfect diagnosis, with imperfect knowledge available to them.

I feel that when we take a detailed informed consent, we must tell them about most major complications that can possibly occur. This will to a large extent make the patients’ relatives aware of the seriousness of the disease and its treatment. I am more than ever convinced that poor communication before the treatment or operation is done is often the main reason patients want to litigate if and when complications occur.

And I would add to that our “attitude”. In my career, I have always found that kind caring gentle doctors, who are upfront and honest to patients and their relatives, are rarely, if ever, criticized by them – whatever the outcome. All that patients are looking for, is an honest communication of what transpired. Even if errors have occurred. And to be assured that the doctors have done everything in their power to save the patient. Trying to avoid litigation through non disclosure is not morally, ethically or legally sound.

It is the decreasing personal touch of the physician, the lack of ethical values, and the commercialization of medicine by corporate hospitals, which have corroded the patient-doctor trust relationship. Failure to disclose the problem also adds insult to the injury. Instead, by disclosing the error, we can tell them what steps are being taken to rectify the problem. And we can always be compassionate and write off the excess bill that would have occurred as a result of this mistake.

Matters of the Heart Most doctors will tell you, that in an ideal world, errors should be reported to the patient’s family. Photo: Getty Images

We need to have systems in place for doctors to know what to do when errors occur, how to report the problem to concerned authorities, and institutions need to support (both emotionally and legally) doctors when errors do occur. Then only are doctors more likely to acknowledge, and report their errors, and accept the subsequent consequences.

At the heart of not disclosing an error is duplicity and deceitfulness.

And if we do it even once, it is only going to happen again and again.

And then we wonder why patients don’t trust doctors.

(The author is a former head of the department of cardiothoracic surgery at Christian Medical College and Hospital, Vellore. He is currently the chief administrative of icer, and head of the cardiothoracic surgery department at Pushpagiri Heart Institute, Tiruvalla.)

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