BMJ  2005;330:737 (26 March), doi:10.1136/bmj.330.7493.737

reviews

PERSONAL VIEW

Will the lead clinician please stand up?

Medicine is not a pure science, and doctors are human. Although individual mistakes are inevitable and can even be enlightening, complacency remains unacceptable. Healthcare systems must minimise errors and should require an approach that is as evidence based as our approach to prescribing (and with an impact that is at least equivalent). In the case I describe here the "uncontroversial" progress in multidisciplinary working by the cancer team undermined, paradoxically, the traditional role of the lead clinician, allowing avoidable harm to the patient to occur without evoking concern.

A fully independent elderly woman presented with lithium toxicity early last year. Depression was her only recent illness. She was discharged after her lithium dosage was reduced, without specific assessment or follow-up for mild renal impairment (her creatinine concentration was 180 µmol/l).

She presented again two months later with a 5 cm lump in her breast. An outpatient review followed within two weeks. Subsequently a breast malignancy was confirmed, and she underwent surgery within six weeks. Although oestrogen receptor tests were positive, there were less favourable features: intermediate grade, heavy lymph node involvement, and suspicion of residual disease. Treatment with tamoxifen was begun, but oncological review discounted the need to complete staging (to exclude metastases) or provide adjuvant chemotherapy. Her rising creatinine concentration—by then 220 µmol/l—was not addressed.

The hospital care was spread across three sites, delivered by six teams

Within seven weeks anaemia prompted her referral to the colorectal clinic under the two week referral rule for anaemia of unknown cause. Subsequent investigations excluded carcinoma of the bowel, but her increased creatinine concentration of 303 µmol/l was again ignored.

Nine months from the initial presentation her progressive renal failure led to her admission to hospital. Investigations showed a pelvic mass causing bilateral hydronephrosis with obstructive uropathy (creatinine 524 µmol/l). She underwent bilateral urostomies. An ovarian primary was then presumed, precipitating referral to the gynaecology team, though she remained under the care of the urologists. No gynaecological follow-up was planned once carcinoma of the ovary was excluded. "Their" biopsy result was not to hand three weeks later. No diagnosis or plan had been made. A medical lead was not clear. The histology results, when accessed, confirmed metastatic breast cancer in the pelvis. Unfortunately preventable harm had already occurred. Second line hormone manipulation could have been tried sooner. Her persisting renal dysfunction limited options for chemotherapy and symptom control. Indeed, she continued to decline and died shortly after-wards, with the time to address end of life issues unnecessarily shortened.

Sequential shortfalls in assessment and poor continuity of care went unchecked, with failings unsuspected. Worryingly, it was the system—increasingly engineered to medical technicians rather than to professionals—that seemed to be responsible. The presiding tick box culture allowed and even fostered suboptimal assessment. All the teams can identify that they did what they were asked to do within their specialist multidisciplinary team guidance (but, sadly, they did no more than what was required). The patient's waits in the accident and emergency department were less than four hours; the three referrals were met under the two week rule; and her operation was timely. But clearly such a potentially star earning description would flatter the care actually delivered and underestimate the resources wasted. Biases towards quantitative measures (which are used to guard against litigation) can neglect the quality of care.

We need to revitalise the role of the lead clinician. Clearer ownership of patients should minimise oversights generated by ever expanding teams and should improve continuity of care. An explicit responsibility for ongoing and thorough assessment should prevent everyone retreating behind specialist remits. Admittedly the necessary handover within and between teams may not be easy. With our patient the hospital care was spread across three sites, delivered by six teams and by numerous members within each team, while the information passed to her GP was patchy. Also, administrators coordinated her two week rule referrals without liaison with the relevant clinician; this is questionable, no matter how convenient. Initiatives within the "hospital at night" and "modernising medical careers" may help address these concerns. Is this optimistic? Time will tell... as long as we look as critically at our systems as we do our treatments.

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Esher, Surrey craiggannon{at}pah.org.uk

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