How no one acted when they should have
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5366 (Published 16 August 2012) Cite this as: BMJ 2012;345:e5366All rapid responses
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I am greatly saddened by the experience of my retired senior colleague Russell Hopkins. His story mirrors the sub standard treatment of my daughter-in-law in the post natal ward in a famous London teaching hospital. It appears that a lack of medical input into the care of post-operative and post-natal patients has been allowed to develop for a multitude of reasons which have been explored ad nauseam (e.g. EWTD, loss of firm structure, loss of specialist wards).
In many units there is no scheduled visiting by junior staff and the “business” ward round by consultant or registrar does not happen.
I suggest that the following principles should be applied to all patients who are inpatients in surgical wards.
1. All patients should expect to be visited by their surgeon on the day after surgery. If this is not possible he/she must ensure that a nominated doctor will visit instead.
2. All patients must be seen at least once by a doctor every day they remain in hospital.
These were the normal working practices when I qualified in 1969 and were the principles which I followed until I retired. This is also the standard which is expected in the private sector and there can be no reason for any deviation.
I was also fortunate to work with anaesthetists who made a point of visiting patients after surgery. I understand that this may not the norm?
If there is a complication after surgery the responsible person is the consultant surgeon and/or anaesthetist. Every surgeon realises this fact and, in my view, it is his/her responsibility to make sure that their patients are seen by either themselves or their colleagues or the appropriate junior staff.
If these simple standards cannot be met then surgery should not take place until such time as the infrastructure is in place.
The multi-disciplinary team is essential for modern surgery but the operating surgeon is the leader and the person who, with his anaesthetic colleagues, must carry the can. One can read this article and conclude that the “system” has failed. There seem to be too many “system” failures and I propose that many could be avoided if the 2 principles above were followed.
The recognition and treatment of rare complications is always difficult and I cannot say if the suggestions above would have made any difference to the outcome for my unfortunate colleague, but at least he would have had a chance to talk to appropriate medical staff and then physical examination and diagnosis might have followed. I have no idea which individuals were responsible for Mr Hopkins’s care and I apologise in advance for any offence which I may unwittingly cause; I am only keen to emphasise what I believe to be the normal principles of good surgical practice.
Yours sincerely
Martin A P Milling OBE MA FRCS(Ed) FRCS(Eng)
Consultant Plastic & Reconstructive Surgeon (retired)
Formerly at St Lawrence Hospital, Chepstow and Morriston Hospital, Swansea
E: martin@milling.demon.co.uk
Competing interests: No competing interests
Re: How no one acted when they should have
The report by Russell Hopkins of his post operative care, or lack of it, in a well known teaching hospital, makes grim reading. (1)
You have published only one response in three weeks, from Martin Milling, who focuses on how such problems, and similar lapses elsewhere, might be avoided, by copying those “ ..normal principles of good surgical practice “ which he succinctly describes.
In contrast, over the past ten days, you have published eight responses by colleagues who are concerned at possible changes to their secretarial services.
Are we encountering a new aspect of poor practice, or are we, as a profession, less protected, personally, from the errors and omissions which were once more likely to be the lot of our patients ?
Nearly forty years ago, in ‘Awakenings’, Oliver Sacks described the experience of patients who were released, by L Dopa, from their post encephalitic Parkinsonism.
Widely praised and admired, his book went almost unremarked by our profession, except
that the British Clinical Journal chose it as “ the outstanding contribution to medical literature for 1973 “.
In his letter of thanks, printed in the Journal (2), Oliver Sacks wrote,
“ I agree with you that there is something fascinating and extraordinary - indeed symptomatic - about the way in which a book which is impassionedly concerned with the most central problems of Medicine has been neglected by everyone except the profession.
The reason for this is not hard to understand. The failure of ‘Awakenings’ to awaken physicians shows us something of the stupor into which the profession has fallen. In this century, by and large we have seen medicine swell into an enormous mechanical and commercial enterprise; we have seen it turn more towards the notion of power, while turning even further from the concept of care. Yet it is this fundamental business of caring for patients - recognising their individual needs and problems, responding to the uniqueness of each situation - which constitutes the first and last duty of being a doctor.
In writing it, and in my general development, I was deeply influenced by the late WH Auden - who saw the manuscript of my ‘Migraine’ more than five years ago, and was the only man ( apart from my publisher) to see the proofs of ‘Awakenings’.
WH Auden was himself the son of of a distinguished general practitioner, and to the end of his life remained passionately interested in every aspect of medical care.
I have before me the last letter which Auden wrote me ( dated a few days before his tragic death ).
In it he writes; “ Do you know a saying by Sir William Osler which my father used to quote to me ; ‘Care for the individual patient more than the disease from which he appears to be suffering ... ‘ “ .
Is it not strange that, and paradoxical, that it was a poet, a man of letters, and not my colleagues,who continually bore in mind, and as continually reminded me , of the central philosophy of medicine , and where my duty as a doctor lay ? “
One may wish to qualify Osler’s words in these days of scientific medicine, without needing to diminish the duty of care.
Forty years on from Sacks’ comments, is it not equally strange and paradoxical that one of Russell Hopkins’ non medical friends was moved to point out , ( to a very respected and caring surgeon) , “ If they can’t even look after you, who will they look after ? “
1 BMJ 2012;345:e5366
2 British Clinical Journal, Jan 1974
Competing interests: No competing interests