Saturday, 19 July 2008

A mistake

I have been reluctant to write about the following incident. I took a short cut which turned out to be a mistake and I feel that the patient did not get the best possible care from me. You could argue that what I did was reasonable, and the safety net prevented any serious harm from being done. Or you could be appalled by the poor standard of care. I flip from one point of view to the other. Naturally I am not keen to expose myself to criticism, but I don't want to write this blog as though I am perfect and never make mistakes. The incident illustrates some of the factors that operate in general practice.

A woman came to see me and we spent the allotted time talking about her main problem. I thought that she ought to have some blood tests and I knew that if we got a move on she would be able to have the blood taken straight away, thus saving her a separate visit to the surgery. As the consultation came to a close she mentioned that she had also had a watery discharge since her last period a week earlier. She agreed that it smelt a bit fishy. Now, normally I would conduct a vaginal examination when a patient complains of discharge, particularly if they hadn't had it before. But the problem is that this takes time. Being male I need a chaperone, and my usual procedure is to send the patient through to the nurse's room where the (female) nurse can assist me. However there is always a variable delay, since the nurse is also busy seeing patients. My problem was that I was running late (as usual) and I had already used up the time allocated to my patient. I was also aware that she needed to have blood taken before the specimens were collected by the courier. So I took a short cut. The commonest cause of a fishy-smelling watery discharge in a woman of her age is bacterial vaginosis. I therefore suggested to her that I prescribe some metronidazole on the assumption that she had BV and that I would do an examination if the discharge hadn't settled by the time she returned the following week to hear about her blood results. She happily agreed to this.

When she returned a week later she told me that the discharge was no better and had become brown stained. So we went through to the nurse's room and I inserted a speculum. There was some brown material next to the cervix, and with a pair of sponge-holding forceps I removed two fragments of retained tampon. These smelled foul (as you will know if you have ever come across this problem) and the odour stayed with me for hours afterwards. My patient was extremely relieved that the cause of the problem had been found, and didn't seem inclined to blame me for the delay in diagnosis. She had taken an unnecessary course of antibiotic and been exposed to a some slight risk of toxic shock syndrome. On the other hand she hadn't been in significant danger and the “safety net” had worked. Am I a sinner, a saint, or just sloppy?

One thing I have noticed over the past few months is patients making complimentary remarks about me or the practice. Of course patients have always done this from time to time, but it seems to be happening a lot at present. I think it is a reaction to all the negative press that GPs are getting from the Government. Our patients are kindly letting us know that they appreciate us, no matter what the Government think. I was talking about this with our senior nurse this evening, and she said that most patients think we are a good practice and so does she. She also told me that patients were very keen to sign the recent BMA-sponsored petition in support of general practice, and needed no persuasion to do so. Patients were still asking to sign it after the papers had been sent back to the BMA.

Politicians need to be careful. When they start announcing that GPs are providing a poor service but voters think well of their GPs, they make themselves look manipulative and self-serving. When health minister Ben Bradshaw appeared on BBC Radio 4's Any Questions recently (4th July) and said that he had been “inundated” with emails of complaint about GP practices, he was picked up on his statement by chairman Jonathan Dimbleby. Under pressure he had to confess that the number was “more than ten”, to laughter from the audience.

As an example of the positive feedback I have been getting: last week I saw a young woman about a stress-related problem. At the end of the consultation I said that I would be happy to see her again, or she could see one of the other doctors whom she had already consulted about the problem. “I'll see you, I think” she replied, “I like you”. This really pleased me because she had formed her opinion after just the one consultation. I hadn't been trying particularly hard, I'd just been me. And today I saw a Jamaican grandmother, salt of the earth with a charming accent and very fixed ideas, who usually sees Martha. I couldn't seem to get on her wavelength and by the end of the consultation I felt that we had got nowhere. But she suddenly smiled and asked “was it you that visited me at home the other year?” A glance at her notes revealed that it was. She told me that she was impressed because during my visit some of her young grandchildren had run past and rucked up the edge of a rug. I had bent down and straightened the rug. I have no recollection of this whatsoever but it is certainly possible. Strange that such a small gesture should have been remembered and taken as a sign of kindness. I suppose she can recall a time, fifty years ago, when a visiting white doctor would have been more aloof.

16 comments:

The MSILF said...

Lovely. Now that I again am getting to where I have to decide general practice vs. neurology, these kinds of stories (the rug) tip the scales.

Ian said...

Andrew, as usual a thoughtful and gentle post. I did not hear the programme, but according to a letter in this week's BMJ, the Ben Bradshaw moment was on Any Questions with Jonathon Dimbleby, but the point is, of course, the same. There has been a sustained campaign of abuse and manipulation from this government directed at GPs. A survey which showed 84% satisfaction is touted as showing 16% dissatisfaction and is a justification for forcing GPs to work in the evenings, or take a pay cut. Those who have started doing this known that the patients who use this service are not the commuters, but largely the older patients who could come at any other time. We have not taken up the "offer" of extending our hours, but have decided to start at 8am. When I asked my very patient how he was he replied, "tired! ---- 8 o'clock!". So much for patient demand!

Hospital Wallpaper said...

"Am I a sinner, a saint, or just sloppy?"

I think the answer is none of the above, just a human being. It would be wonderful if politicians realised this.

Safety netting is there for a purpose and this situation is a perfect example of why it should be used.

The appreciation of your patients (a recurring theme on this blog) shows that many of them aren't falling for the government hype and that you are doing a good job!

Elaine said...

I think it was a very good idea to blog about your admitted "error"; it makes for a more rounded picture of how you are as a GP - and it certainly seems that you are a good one, and also appreciated by your patients.

This government is in a hole and is continuing to dig.

Dr Andrew Brown said...

MSILF: I'm glad you liked the rug story. These are indeed the little things which make general practice worthwhile.

Ian: Thanks for pointing out my (additional!) error. You are quite right and I have corrected the details on the blog. I read the BMJ earlier in the evening but then couldn't find the relevant page when I came to write the post rather late at night. (Note to self - always examine part complained of, always check sources!)

HW and Elaine: Thank you both for your kind comments. I have a sneaking sympathy for Governments because they can never get things totally right, but the current one has got things very wrong about the NHS. But the insolence of power and their inability to admit mistakes mean that they just keep on digging, as you say.

BenefitScroungingScum said...

Having been on the receiving end of many medical errors, my overall feeling is that mistakes will always happen, so the important part is how they are dealt with.
I think the way you have reflected upon this situation and been willing to be open about it (even in an anonymous situation) says it all.

Out of interest what would have happened if the worse case scenario had been the result?
Bendy Girl

Delurking said...

"Am I a sinner, a saint, or just sloppy?"

I'm a health professional myself and recognise those feelings when one knows one might have done better.
However - we are but mere humans...

Incidentally, no-one's mentioned it thus far but doesn't the patient bear a degree of responsibility for putting the tampon there in the first place and then forgetting about it?

Dr Andrew Brown said...

BSS: Thanks. If and when the sh1t hits the fan I will get in contact with my medical defence organisation. I currently pay them nearly £5,000 per annum but the peace of mind it brings is priceless. If, heaven forbid, I ever make a mistake that seriously damages someone I will be upset enough about it without my family and I being driven into penury.

jellyhead said...

Andrew, after the preliminary words of this post, I was ready to read about something terribly neglectful you'd done. Then I read your post and thought - that kind of thing has happened to me, too. Lack of time is one of the hardest things to deal with in our job, and patients often mention other issues right at the end of the consultation (well, for me they do anyway!), so we just do our best to decide what can wait and what can't. If we thoroughly treated, then and there, everything that was mentioned in each consultation, many of our consultations would last an hour or more! To summarise, I'm completely unimpressed by your supposed 'poor standard of care' story ;-)

I'm glad you have had some complimentary remarks lately to lift your spirits. I can tell from how you write that you are a caring and conscientious doctor, and that's the best kind of doctor there is.

Anonymous said...

Don't worry about it - in your professional opinion it was the right thing to do at the time. Yes, you could have saved some time, yes, it was a risk hazard, but in these times, with so many targets to meet and people to get in and out of the doors, the NHS are effectively cutting off their nose to spite their face...

niceladydoctor said...

There will be very few of us who have not made a similar judgement call in our time. I certainly have. Sometimes our judgement is spot-on and we feel able to take the credit, but it won't always happen.

A bad GP wouldn't be reflecting on it and wouldn't be learning from it, that's for sure.

Dr Andrew Brown said...

Thanks everyone for your supportive comments. Jellyhead - I'm so pleased you are completely unimpressed!

"There was no wrecks... nobody drownded
'Fact, nothing to laugh at, at all."


I now feel emboldened to write about my Worst Ever Mistake, and will do so shortly. Once I have got the worst thing I have ever done off my chest I shall feel that I am not writing this blog under false pretences.

Unfortunately you will discover that nobody died or was even injured as a result of the Worst Ever Mistake, which goes to show that whether or not I am a fortunate man, I certainly have fortunate patients.

Nutty said...

I went to Westminster as part of an organised lobby and asked to see my MP. He didn't see me but wrote to me inviting me to make an appointment to see him locally. When I tried to make an appointment, I was repeatedly fobbed off by his staff.

It's funny, but I don't see cabinet ministers fulminating about how difficult it is to see MPs and whether they should see constituents outside their normal surgery hours.

Anonymous said...

Ah yes, Nutty, and nor will you ever see such a complaint aired by our "masters". One rule for "us" and another for everyone else. Twas ever thus....

GP wife

Ruth said...

My mother raves about her GP, and he made a much more serious mistake of not diagnosing her Stage 2 Diabetes in spit of severl visits she made complaining about symptoms.

My mum knows he should have picked this up; but as he is generally a really good, competent and caring GP she hasn't held this against him at all.

I guess what I am clumsily trying to say is that most patients know that no GP is perfect100% of the time. But if you are caring and usually competent (and you certainly sound it from your blog) most patients won't hold mistakes against a Dr. Although I agree with other posters that the 'mistake' is a very slight one.

Dr Andrew Brown said...

Thank you Ruth, that is most helpful in getting things into perspective.