Last week it emerged that a cancer patient in Sydney had the wrong side of his colon removed when the surgeon was misled by a botched pathology report that had mislabelled the site of cancer. The response was swift, involving no less than the state premier. The patient received an apology and is now receiving his third corrective surgery. The family was offered support and privacy.
Every doctor at some point is involved in some kind of a medical error; it’s a lonely place. Sentinel events such as wrong-site surgery are thankfully rare, and one is sufficient to derail a doctor’s career. Since more surgery broadly equals more complications, none of this will be solace to the damaged patient. But in terms of open disclosure, the doctors and health authorities did the right thing. They named the mistake, apologised to the patient and pledged greater oversight. Reading the news, I couldn’t help thinking of all the patients who would be happy with a fraction of this care.
Take the case of a man in a teaching hospital who makes dinner plans with his family before attending a brief elective procedure but calls to say he’d remain in hospital afterwards as he didn’t feel so well. A visiting relative immediately senses something amiss but the staff disagrees. The next day, the relative’s concern grows but the staff is still unconcerned. Later that day, the family receives a panicked call from the man headed to emergency theatre and dashes to his bedside where informed consent takes place in the form of a hurried explanation. The patient has a perforated organ and potentially fatal peritonitis. As the relatives wait, they are reeling with shock, disbelief and a hundred questions. How did a routine procedure go so wrong? How do organs become perforated? Hadn’t they said he didn’t look right?
In intensive care, other doctors interpret the complication as best as they can. Everyone knows that the surgeon who presided over the error (and who also fixed it) owes the family a detailed explanation, but no one wants to be the one to tell him when he doesn’t show up. Feeling helpless, the family take continuous shifts at the bedside. Hours pass and then days before the surgeon arrives unannounced, but any anticipated disclosure falls flat.
He says he has never made this mistake before. The family doesn’t quite perceive the apology in this but out of distress and exhaustion lets it pass, focusing on recovery and the real need to retain the surgeon’s goodwill in case of another complication.
Watching these events unfold from a distance, I have pondered three questions. Would this happen to a doctor’s relative? Would this happen to an English-speaking patient? And finally, would this happen to a famous patient?
The first answer is a resounding yes. This happened to the parent of a colleague who felt cowed by medical hierarchy and lost hope that anyone cared to debrief the family once the patient survived. The doctor was acutely aware of the repercussions of appearing “demanding” although every aspect of the case demanded explanation.
The second answer is a more qualified yes. Patients who speak fluent English, know their rights and are well enough to insist on them can fare better. This man spoke conversational English well, but was sick, elderly and from an ethnic minority. Not even his top private health insurance could make up for this shortfall. Squeaky wheels aren’t the only ones to get the grease but they get preferentially early grease so doctors can get on with their day.
The third answer makes me uncomfortable because, as a public hospital doctor, I want to believe otherwise. But I can’t deny that a degree of popular fame, obvious wealth, or some perceived societal influence would have secured the patient and family earlier and better explanations and even an apology. Perhaps it’s human behaviour to be attentive to the rich and famous but it shouldn’t have to come at the cost of nameless patients who are known only by a bed number. To argue that the patient emerged alive, so the care wasn’t really compromised is to adopt the narrowest of definitions of care. And to invoke a hectic schedule as the reason a surgeon might not personally discuss an adverse event is to set a low bar for high achievers.
The list of mandatory training for doctors is unending. Besides demonstrating professional competence, we must know how to deal with fire, threat and catastrophe. Then there are the modules on cultural diversity, inclusivity, social media and avoiding back injury. Most tests require a perfect score to pass. Buried among this training is one on open disclosure. If an artery is damaged during surgery, who should tell the patient? If the patient got the wrong dose of chemotherapy but avoided toxicity, what should the oncologist say? If a dead body is accidentally dropped and the deceased breaks an arm, should the relatives be told? These are not trick questions but the stuff of everyday medicine and doctors who have jumped much higher hurdles instinctively know the right answer. And yet, despite getting the test right as a condition of their accreditation and despite the ethical and legal obligation of open disclosure, evidence shows a wide gap between what we know and how we act.
The vast majority of harmed patients want a factual account of an adverse event, an acknowledgement of their emotions, and a way forward. They are motivated by “preventing this from happening to anyone else” and use legal threats or media stories as a last resort. Hospitals and insurers remind doctors that being open and demonstrating remorse is the way to not get sued by an angry patient. Experienced clinicians say that the forgiveness that follows is the most powerful, and possibly the only, catharsis. Nonetheless, the fear of litigation, damage to reputation and diminished income looms large in the minds of concerned doctors.
Sometimes, doctors must hold systemic failures responsible for the deficiencies in patient care. A bloated elective surgery list, a scarcity of nurses or a leaky bathroom are not for an individual to fix. But when it comes to open disclosure of error, personal integrity is paramount. One definition of integrity is what we do when no one is looking. In clinics, operating theatres and at bedsides, the sacrosanct relationship is between the patient and the doctor and the administrators temporarily fade from view. When things go well, doctors rightly garner praise. When things go wrong, we must step up to have conversations that feel awkward and humbling and threaten to take the sheen off our otherwise perfect record. These conversations help not only the affected patient but also make us better providers for the next patient and the patient after that.
Open disclosure is not a luxury. Patients don’t have to do anything extra or be somebody special to deserve it. When doctors injure patients, honesty and transparency along with a dose of compassion is the best medicine.
• Ranjana Srivastava is an Australian oncologist, award-winning author and Fulbright scholar. Her latest book is called A Better Death
