Lessons from the front line

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In the summer of 2002 I was sitting in an Oxford café with a professor of medical ethics. I had just finished a masters degree in the history of medicine and, intrigued by the dubious conduct of some doctors in the past, was contemplating a career in medical ethics. “What do you want to do?” asked the professor. “I want to help doctors,” I replied. And so started my journey in medical ethics.

Fifteen years later, now working as a barrister, I sue doctors.

The way to reconcile these two facts is that lawsuits, though miserable affairs, can lead to better, safer practice. But this only occurs if lessons are learnt, and this column has been an outlet for those lessons. Here are further reflections from the past two months.

I represented a medical student in a fitness to practise hearing. The chief concern was his lack of insight into his rudeness towards others. Insight can be defined as the ability to understand intellectually and emotionally why a behaviour is wrong. Without this ability, learning is stifled and poor practise goes unchecked. A compulsory question for interview panels, whether they are selecting medical students or consultants, should be: does this person have insight?

On occasion I advise on cosmetic surgery cases. I attended a course on the topic last month, in which the case study, a fictitious one blending the stories of several patients, was a schoolteacher who underwent breast augmentation.

During the operation a nurse dropped one of the implants on the floor and, with no spare implant available, the surgeon decided to insert two larger ones. The operation was a success, but the patient was distraught. So obvious was the change that she became the butt of teenage jokes at her school, fell into depression, and quit.

Coincidentally, the next week I received a new case involving a patient who underwent a knee replacement operation. She was allergic to nickel and had asked for a nickel-free product. In the operation the surgeon removed the old knee, opened the packet for the new knee, and to his horror discovered that it contained nickel. Faced with a large defect cavity, he thought he had no choice but to implant the knee. The patient developed complications.

The lessons: do not skip or rush through surgical checklists. Remember that if the patient consents to one thing (a certain cup size or a nickel-free knee) you should not do something else unless there is a medical emergency and asking the patient is impossible. In short, do not stray beyond the scope of the original consent.

In the knee case the surgeon said nothing about the mishap to the patient until she asked some weeks later. She was distraught and lost faith in the surgeon. The lesson: be honest when you make a mistake, however daunting the prospect. You will be surprised how often patients forgive. Remember also the legal duty of candour.

Finally, last weekend I had the misfortune of attending an emergency walk-in centre with an eye problem. Sitting there, I witnessed the depressing sight of sick and injured people walking in, some propped up against a worried helper, others with bloodied tissues packed into their noses, and others pale as ghosts. They looked so despondent that the very experience sunk my spirits. When my turn came, the doctor was cheerful, diagnosed conjunctivitis in an instant, and prescribed some eye drops. I can now see perfectly. The lesson, all too easily forgotten in these litigious times: medicine is a noble vocation admired and appreciated by all, including clinical negligence lawyers and other wicked folk.