Observations Ethics Man

Listening to patients is not enough

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2670 (Published 02 June 2017) Cite this as: BMJ 2017;357:j2670
  1. Daniel Sokol, medical ethicist and barrister
  1. 12 King’s Bench Walk, London
  1. daniel.sokol{at}talk21.com

When taking a medical history, doctors (at all levels) must ask the right questions

A senior house officer working nights in an emergency department examines a 13 month old girl shortly after 5 am. Over the past few days, the patient has had a raised temperature and vomited three times. She has passed urine and opened her bowels. She has no rash or diarrhoea, and she looks well. The diagnosis is an upper respiratory tract infection. The senior house officer discharges the patient.

Later that day, the girl’s condition worsens, and she is readmitted to hospital. She is diagnosed with pneumococcal meningitis and suffers permanent brain damage. The parents sue the hospital trust.

The senior house officer did not record why the parents brought their daughter to hospital. The reason was that they noticed the child’s eyes rolling, and this prompted them to call the out-of-hours service. The parents did not volunteer this information because they were not asked for it. At the trial, the judge accepted that the parents would have given the information if asked, and this would have led to a paediatric referral.

In court, the senior house officer said, “Usually, if [there are] rolling eyes, that is scary. I wouldn’t need to ask the right question; the parents would tell me first of all.” The question for the judge was whether it was substandard practice for a senior house officer in this position not to obtain that information.

The question for the judge was whether it was substandard practice for a senior house officer in this position not to obtain that information

The judge found that an emergency medicine consultant or paediatrician would have elicited information about the eye rolling episode, perhaps by asking, “This child looks fine to me, how was she different earlier?” But the judge said that a senior house officer could not be measured against the standard of an experienced clinician, and the case was dismissed.

The family appealed and the case was heard last March. The judge in the first trial had placed much weight on the trust’s medical expert, who said that many parents attended emergency departments “without there being any direct and obvious precipitating factor.” The Court of Appeal was unimpressed, saying “The fact that there is no clear precipitating factor in many cases is not an answer to a failure to elicit such a factor when there is one.”

Asking parents why they brought their child into hospital was not beyond the competence of a senior house officer; if a consultant would have asked the question then so should the senior house officer. The Court of Appeal overturned the decision of the High Court, and the trust lost the case.

In short, the law expects history taking to be the same, whether it is by an inexperienced junior doctor or a senior consultant. Lord Justice Jackson said that history taking was a basic skill that hospital doctors at all levels should possess.

The senior house officer made two mistakes. Firstly, thinking that the parents would offer clinically significant information without prompting; secondly, thinking that the reassuring history and examination obviated the need to ask why the child had been brought to hospital.

William Osler reportedly said, “Listen to the patient. He is telling you the diagnosis.” This case shows that listening is not enough. You must also ask the right questions.

In an Oslerian vein, and no doubt aware of the crisis in morale among junior doctors, Lord Justice Jackson ended the judgment with an uplifting message: “Even good and conscientious doctors may, from time to time, fall short. That is not a reason to lose heart or (even worse) to abandon medical practice. Those who have learnt from past mistakes often have even more to offer.”1

Footnotes

  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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