Tuesday, 22 July 2008

The worst

I promised last week that I would blog about the Worst Thing I Have Ever Done. I felt terrible about it for ages, but looking back now after many years it doesn't appear quite as awful as it seemed at the time.

In those days I was a GP trainer, and my Registrar and I were doing an evening surgery in adjacent rooms on a Friday night. We were nearly at the end of the surgery and both of us were in a rush to finish and get away. She called me through to see a teenage boy who had been brought by his mother, and asked “is this rash meningitic?” The story was that the boy had been unwell for a day with sore throat, fever and rash, he had felt a bit achey and had a slight headache. I looked at the boy, his throat and the rash, and advised that it didn't look like the rash of meningitis. Because my Registrar was experienced and knew about safety-netting I didn't say a lot to the patient or his mother, and left it to my Registrar to finish the consultation properly and write it up.

My partner Elizabeth was on call next morning, for we provided an on call service for our patients on Saturday mornings in those days. She received a non-urgent request to visit the boy and got to his house towards lunchtime. His rash now looked meningitic and she admitted him to hospital. (He went on to make a full recovery with no damage done.) Elizabeth didn't want to spoil my weekend, so she didn't ring me up to tell me what had happened until Sunday evening. By that time my recollection of what I had seen and said was a bit foggy, and of course I had not made any notes. I immediately went to the surgery to see what my Registrar had written. “Rash seen by Dr Brown,” it said, “not meningitis”.

The patient's mother made a complaint to the practice. She refused to see me but had a meeting with two of my partners and I sent a letter of explanation and apology. She did not take the matter any further. I think this was in part because I had seen her on several occasions in the past and been fairly helpful. This was an example of “money in the bank” which I had paid in during those consultations but now had to withdraw. However she has not consulted me again from that day to this.

The art of medicine is often a matter of presentation. If they had come to see me rather than my Registrar I would have said something like “he doesn't look particularly ill and his rash is not typical of meningitis so I don't think he needs to go to hospital at present, but keep an eye on him and if he gets worse or the rash changes then ring again straight away”. Then I would have been remembered as the doctor who warned that it might be early meningitis and was proved right. But since I only gave an opinion to my Registrar, I was the doctor who said it wasn't meningitis and was proved wrong.

My Registrar later told me that she had indeed said all the right things I mentioned above, so my faith in her was justified. But the patient's mother still remembered that Dr Brown had said it wasn't meningitis. The incident shook me badly and I almost gave up training as a result, although I eventually continued for several more years.

I can see now that it is my depressive view of the world that makes my job a constant worry. Like Chicken Licken I fear that the sky will fall on my head at any minute, and on this occasion it did so. And when the sky falls it will be All My Fault. So this week I am trying hard to be more cheerful and optimistic, and to trust not only my patients but myself. (I have heard it said from the pulpit that God trusts us but we regularly fail to trust either him or ourselves, and I think that is true.) I am trying to see my patients as people who mostly come to see me willingly and hold a good opinion of me, and also to see myself as someone who is worth consulting.

Recently I saw a woman in her eighties who has previously seemed something of a bother, always worried and fussing. Last time I prescribed her a low dose of flupentixol, an old-fashioned GP remedy which sometimes cheers up the elderly. Now she looked a bit brighter and less worried. She told me that her worry about her poorly husband gets her low, she is “always waiting for the bomb to drop”. But she went on: “I couldn't survive without him, I love him so much” and said she was happy to carry on until the good Lord takes her. Balint would say that I prescribed not only the flupentixol but myself. And I also think that she helped to heal me a little.


The Shrink said...

Safety netting was done, the outcome was right, but looking back with hindsight (however unhealthy that may be) is an all to inviting approach to remorselessly castigate oneself.

Bright-eyed said...

I am unsure if I will eventually go down the GP or hospital doctor route (as I am but a lowly 3rd year med student), but I think the way you reflect on mistakes (which are inevitable in life) and even your own character, would make me happy to have you as my GP.

Self-doubt, in moderation, I believe will surely lead to a more considerate and better doctor, as opposed to an overconfident and superficial person.

Jobbing Doctor said...

This case demonstrates a number of things:

The difficulty of General Practice
The personal relationship between GP and patient
The value of reflective practice
The way in which we fret about each decision and how low mood and depression can distort our perspectives

I agree with the shrink. You made a decision in good faith - "God blesses the doctor who sees the patient last"

I will blog about some things I feel bad about in my practice soon.

If that is the worst case you can come up with, then you are a fine doctor indeed

Jellyhead said...

Well see now you are just making the rest of us look bad. My worst mistake was much worse. I may have to blog about it, too, if we're going to get all confessional here!

Northern Doctor said...

It is difficult to see how you could have played things much differently and it certainly demonstrates one of the hazards of being a trainer. It struck me that it was probably a difficult post for you to write. Thanks for sharing!

Anonymous said...

The thing I always remember about doctors is that they are only human like the rest of us. I think one of the problems is that some patients treat doctors as if they were God and some doctors act like God. I have never suffered as the result of a mistake made by a doctor (GP or consultant) but a swollen knee was dismissed for a year before it was realised it was a symptom of osteoarthritis in my hip. The one thing that does stand out in my mind more than not realising what was wrong is the refusal of a GP to write a letter to my university faculty stating what was happening (I was only 21 and I had a history of lupus) and that my joints were flaring up. He said there was nothing wrong with me and refused to write the letter: I never saw him after. He's now occupational health doctor for the same university.


Anonymous said...

I'm among those who think if that is the worst mistake you have ever made you are indeed a fortunate man. You must have capital in some big bank somewhere as the patient recovered completely.

Interestingly you don't quite identify the big mistake - on first reading it is the non-diganosis if the meningococcus but could it be the non-recognition of the rash / the thoroughness of the examination / the fact that you did not personally do the safety-netting / the fact that you didn't make a record?

The outcome of the reflection would be interesting - apart from your feelings of remorse which are clear but maybe less useful.

The Little Medic said...

Everyone makes mistakes, that is the point, doctors are still human. It sounds like you handled the aftermath correctly. Well done for writing about it.

Dr Andrew Brown said...

Thanks everyone for your comments which are, as usual, helpful kind and full of insight.

I don't want to make anyone feel bad because my "worst" mistake was quite mild. Of course I have made many errors over the years, some of which have had adverse consequences for the patients concerned. A few years ago I noted that I discussed with Martha my failure to diagnose bladder cancer swiftly. She pointed out that the diagnosis had in fact been made about a month after the onset of haematuria (the earlier symptoms were much more vague). And on the very same day another patient thanked me for diagnosing his bowel cancer very quickly a few years earlier.

The reason this one upset me so much was that (a) a formal complaint was made, and (b) if things had turned out badly I could have been responsible for the death of a teenager who was exactly the same age as one of my own children.

Anonymous 18:16 points out that I don't actually identify the big mistake. I think it was that I didn't fully appreciate that the rash of meningococcal meningitis can appear benign in the early stages, and that consequently I didn't do enough to consider whether the patient should be admitted to hospital.

I now accept that my Registrar did all the right things and I was right to trust her, but I still think that I should have taken more time when I went into her room.