Medical Matters: Since the broadcast of the Prime Time Investigates programme on medical error on RTÉ last month, there has been intense debate within the medical profession on the issue. A recent opinion piece in this newspaper, by the series producer, Mary Raftery, has contributed to that debate.
In general, the response of the profession, as enunciated to this writer, is of a programme "out to get doctors". Medics of all specialities have described it as one-sided, with particular objection to the naming of some doctors alleged to have committed medical error without a right of reply being included in the broadcast.
I must emphasise this impression is based purely on conversation rather than systematic inquiry. It is not, as pointed out in the letters page of The Irish Times by Prof Denis Gill, professor of paediatrics at the Royal College of Surgeons in Ireland - who complained of the media's extrapolation of US figures on error being reported as statistics - based on any kind of objective research!
In many ways the negative reaction of many doctors is not entirely unexpected. Medicine is still a relatively closed profession. Inquiries into doctors fitness to practice are not held in public and so there is not a culture of open discussion of error. What medicine does do, but not as openly as it might, is to publish the results of ongoing medical audit. This process, by its very nature, would reveal medical error as something that happens on an ongoing basis despite the best efforts of all concerned.
It is important to emphasise the term medical error encompasses mistakes made by all professions involved in the care of patients and not just doctors. So a mistake by a nurse, pharmacist or physiotherapist will be labelled medial. Clearly, we need a better definition of medical error; future research should differentiate between the contribution to healthcare error by different professional groups. It must also delineate institutional error; the sort of mistakes that are caused by a poorly performing system, a point made in an editorial in the current issue of the Medico-Legal Journal of Ireland.
Dr Bill Tormey, consultant chemical pathologist at Beaumont and James Connolly Memorial Hospitals, has just published a book, A Cure for the Crisis - Irish Healthcare in Context (Blackwater Press). The book, which, to the author's credit, offers solutions to the crisis in healthcare as well as contextualising the problem, has the following to say in a chapter on medical error:
"A recent US study demonstrated the difference between doctor and the public in relation to doctors dealing with error... According to the authors, physicians believe that confidentiality will promote openness among colleagues; lay people favour transparency and the pressure of public accountability." Tormey says, in his opinion, if medical errors can be addressed without the threat of public humiliation, the assessment is more likely to be open and honest.
He adds: "Undeniably, the medical profession usually avoids conflict. Doctors are busy and are orientated towards individual professional autonomy rather than towards organisational effectiveness. I do not believe, however, that doctors have earned enough trust to deal with all quality of care issues privately. Furthermore, no organisation dealing with the public should be immune from routine open scrutiny."
Medicine does need to open its doors to ongoing scrutiny. The present Medical Council has worked hard to push such an agenda; arguably, it has achieved as much as it can under the outdated 1978 Medical Practitioners Act. With an election for a new council in progress, it remains to be seen whether fitness to practice proceedings will be held in public in the future, as is the case in Britain.
Donald Irvine, immediate past president of the UK General Medical Council (GMC), writing in his book, The Doctors Tale: professionalism and public trust, had this to say about the future of medicine: "A more confident, more assertive profession working with and for the public, should play a more influential and proactive role in shaping the future direction of medicine, explaining its limits as well as its potential."
Where to now with healthcare error? Firstly, let us acknowledge it happens every day for very human reasons and without malice. The Government must provide funding to conduct a large-scale study of the problem in the Republic, encompassing large and small hospitals as well as primary care. We can then move beyond any uncertainty provoked by the extrapolation of figures from other, quite different, health systems. And finally, if we are to maintain the trust that is central to the relationship between healthcare professionals and patients, we must put energy and resources into minimising error. Professional trust must be earned and never taken for granted.