The Art of Medicine or the Medicolegal minefield

When Hippocrates started tutoring the first medical students on the steps of the Acropolis back in Ancient Greece, the art of medicine was born and the gradual understanding of disease processes and healing could really begin.

It really goes without saying that things have significantly changed from Hippocrates’ day. I would say that even forward thinkers such as himself, could barely imagine the advancements that we have achieved, wondering at our ability to treat a vast array of ailments which truly benefit humanity. He may, however, be a bit disappointed that the common cold still runs rife and that ‘man flu’ causes more sick days globally than dodgy curries.

I suppose one small facet of how things have changed over the thousands of years is the way we practice and what is our thought process and rationale behind what we do. Most decisions that we make are done so through our clinical judgment in the particular circumstances; whilst acting in the best interests of the patient we are caring for. When said like that, I think few would argue that its not healthy way to practice. But what else plays on our minds when we practice and make decisions?

After exploring and discussing the emotional burden carried by healthcare professionals, an interesting comment came up in regards to another area of strain on our mindset and emotional stability. It mentioned how the fear of doing the wrong thing can play on our minds, causing ‘frustration and distress’. The thought of causing harm or missing an important clinical cue can be just as big a weight on the shoulders of the tending healthcare professional. I feel this is a very apt point, especially given that we all get into this business to help people; it was said that first and foremost we should ‘do no harm’. The thought of causing harm worries us all, and god knows we have all made mistakes, some worse than others and that all comes part and parcel with the territory of the job. I can openly admit I made my blunder in under-dosing a patient in a certain case. Luckily the patient did recover but it’s a mistake I’ll never make again. At the time I found my colleagues and bosses extremely supportive, with many sharing their stories of steep learning curves and times where even the most experienced and intelligent of physicians can sometimes make the ‘schoolboy error’.

After the patient gradually recovered, of course relieved of his improvement, I did find myself on the concerned side as the week progressed. The environment of the medical workplace where we find ourselves today, is without doubt one where litigation is very much on the periphery. Outside the grounds of the hospitals, sometimes it seems that there is a slimy lawyer wearing a hand tailored pin striped suit lurking by the entrance handing out fliers with bold headlines in a similar grain to the ones on TV looking for punters to sue someone over their own clumsiness after tripping up on the footpath over their own shopping.

HAVE YOU BEEN THE VICTIM OF A MEDICAL MISDEMEANOUR?

I couldn’t help but fear the potential lawsuit. Perhaps this was unwarranted but the fear that after a mere two and half years since donning the robes for graduation in Dublin, that I would be back to the drawing board and no longer allowed to practice, was quite scary. Thankfully it never ended up like that but that fear still lurks in the dark corners.

It’s this fear of lawsuit, which I believe is becoming an accustomed part of the way we practice. ‘Have you documented?’, ‘What time did you speak to him?, ensure the conversation is put in the notes!’, Every little thing that goes on with a patient once they step through the door is documented; 2.37am Intern-on-call: Asked to review patient with abdominal bloating post beans on toast, passed flatus- symptoms relieved, Soft non-tender abdomen ?Bowel Perforation- Notified General Surgical Registrar. Will review patient.

Any bit of information we get we feel we need to act on and perhaps go overkill in regards to getting opinions and investigating. Now I will say a lot of the time it is done over real concern for a patient, as opposed to a rogue fart. However are we going over the top over fear of doing the wrong thing, having the fear of having to go to court to explain ourselves?

I think that as time goes on we are being geared to consider the legal ramifications of what we do, document this and that and filling out x and y forms. Interestingly I don’t think this is necessarily a bad thing. It encourages us to be thorough and give the very best clinical care. But what I fear is being lost is the ‘art of medicine’, and by that I mean the ability by those of us in healthcare, who over time and experiences develop an understanding of those who are sick and listening to that gut feeling in the pit of your stomach.

We run the risk of becoming automatic robots in our job and not treating the patient in front of us. We do certain tests or scoring systems as it reassures us because we fear to get it wrong. But what happens if all those blood tests and scoring systems get it wrong? Just because vital signs are normal and scans reveal nothing, does not mean they are not necessarily ill. Sometimes they just do not examine or look right and this is where the art of medicine comes in, being able to identify and persist with it until a diagnosis and treatment can be achieved. Sometimes I think we trust too much on scans and complex blood tests and because they proved normal we send patients home, knowing that we will be protected having done the obliged investigations for certain clinical scenarios. But do we really sit back and consider alternatives? Has the pressure of the law and medico-legal world encouraged us only to think of the textbook situations? Meaning that when these tests come back negative we sit back and relax, sometimes sending people home who are very unwell, knowing that the evidence and results we have, we will be safe in front of the judge. When you stand at the end of the bed however, you can see they are not quite right. This is particularly frustrating when working in the Emergency Department when trying to get inpatient teams to accept care of a patient, without seeing a patient for themselves and just looking at evidence on a computer screen and saying ‘bloods and observations are normal, send them home on oral antibiotics’.

I once saw practice with a very experienced GP in Dublin whose attitude really stuck with me. His persistence was unparalleled to that of other doctors I had witnessed up to that point, which I believe was born out of wanting to help his patients acting without a fear or reprisals or greedy lawyers. He would sit with patients with their problems and if all investigations proved fruitless up to a point he would start again from the beginning, going deeper into their history, probing like curious a Sherlock Holmes, deep in contemplation who would search for even the finest detail, which may yield a clue to their illness. No matter how many times his patients needed to come back, he persisted and ultimately it made him the fantastic community doctor, whom was respected by all in the full waiting room and those wanting appointments on the end of Cheryl the secretaries phone!

I will admit that following my incident, I practice even more cautiously than I previously did, not just in medical treatment regimes but also when considering differential diagnosis in the ED, and thinking what investigations I need to perform. In the world of Emergency Medicine this seesawing, weighing up the pros and cons is in constant swing, do I do the troponin or do I do the D-Dimer, or will I do both? Without doubt the majority will proceed in the best interests of the patient accordingly. However when your standing at the end of the bed looking at this 55 year old gentleman who has sharp pleuritic right sided chest pain after a fall, but recalls coughing up some blood, has a history of a small basal cell carcinoma excision from his nose and has had a swollen tender right lower leg. Your clinical gestalt tells you it musculoskeletal pain but the erring fear that the coroner asks you if you considered other differentials. You get the CT Pulmonary Angiogram – its negative for PE, it proves to be muscular this time. You sleep soundly tonight, but perhaps you unnecessarily investigated this man, exposing him to radiation, needlessly increasing his risk of neoplasm. Why not listen to that gut feeling and trust the clinical judgment acquired through your training and experience? This is where the idea of clinical gestalt I feel will soon no longer be an excuse for doing something and certainly not a form of defending an argument without solid backing from medical peers.

Its something I wish I had the final answer to. In regards to my attitude and thoughts, well, I try to practice like this GP; someone who does the right thing and persist within sensible means, creating plans with the patient’s involvement allowing them to be part of their healthcare directive as best as possible. Ultimately the relationship between healthcare professionals is where this is all built and by having a good relationship with the patient built on a mutual respect with kindness and courtesy, I believe that the fear of a court summons to the Medical Board gradually dissipates away. It could be even said that the ‘art of medicine’ does not simply rest on the power of diagnosis, safe practice and logic, but can extend to the art of being a conscientious, empathetic and caring individual who can build the confidence of his patient cohort, involving them in their own healthcare with two-way discussion, whilst remaining grounded admitting to fault in times of error. It is these individuals who rarely will find themselves on the wrong side of a court bench. One shouldn’t practice for fear; one should practice for the want to do the right thing!