"It's not science you call upon, but a doctor. A doctor with good days and bad days, a doctor with a weird laugh and a bad haircut. A doctor with three other patients to see and, inevitably, gaps in what he knows and skills he's still trying to learn." ... Dr Atul Gawande, US Surgeon and author

Gawande: Bad Medicine

Doctors & Accident Prevention

An aviation safety specialist was invited to attend a presentation on Medical Error. There were about 500 people in the audience, mostly medical practitioners. The briefing hadn't gone on long when the pilot noted - registered shock, actually - a fundamental difference between aviation and medical safety practice. Rather than being introduced to ways to reduce error rates, these doctors were being counselled on best practice in Claims Management.

Claim Management was prevalent in "first generation" Workplace (Occupational) Health and Safety (WH&S or OH&S) arrangements. When legislation mandated accident prevention in workplaces, Claim Management was seen as a smart way to minimise it's potential to cost a company. There would only be a claim on the insurance if an injury resulted in time out of the workplace. Basic First Aid facilities began to resemble intensive care wards as provisions were put in place to treat injuries in the workplace. No absence, no claim, no increase in the premium. More recent OH&S legislation renders Claim Management practice obsolete. You really do have to eliminate hazards. Trying your hardest isn't good enough anymore.

The advice to the doctors was vintage Claim Management: As soon as you realise you've made an error, let the patient know and explain the "recovery" processes. By being frank upfront you begin to forge a bond. It is intensified as you describe, then take the lead in effecting, the rescue. People don't sue doctors who've just saved their lives - or been at their side through a bad experience. And it works. Statistics quoted showed that fewer than 10% of medical accidents give rise to a claim. (Or, more than 90% don't.)

Airline passengers may be relieved to know that accident prevention is the aim in aviation safety, not insurance claim prevention. You'd expect the medicos to think along similar lines - try to eliminate accidents, practise Claim Management on the few that slip through. But they have a point: another statistic tendered in the presentation was that over 90% of claims do not originate in a medical accident. In other words, the cause of complaint -- the legal issue taken to Court -- say, its a permanent disability, was a natural outcome and not caused by medical error. Doctors pay huge insurance premiums, much of which goes to pay for problems -- real enough problems -- that were not really the fault of doctors.

Medical training is like aviation courses in that the safety factor is built-in. Before, during, after procedures, it is the foremost consideration. However, the general consensus is that the accident rate is too high. (See ABC Report, below.) In many places, moves are afoot to emulate transferable aviation practices. But it's early days yet and patchy. As Professor Reason says in his ABC interview, much more could be done.

Professor Reason interviewed

From an ABC radio report "According to the World Health Organisation's 2002 Report Australia has the highest rate of medical error in the world."

• 16% of our hospitalised patients will suffer a significant adverse event that is totally unrelated to their original medical condition. This translates as 1 patient in 6, four times the reported occurrence of medical error incidents in the United States, and a full 6% higher than Britain's 10% error rate.
• 18, 000 Australian patients die each year as a direct result of avoidable injuries and complications.
  Another 50,000 Australian patients per year are left with permanent disabilities, and hundreds of thousands more are avoidably injured to some greater or lesser degree.
• 80,000 Australian patients per year are hospitalised due to medication errors, syphoning a massive $350m from the Federal Health Budget annually.
• These figures do not take into account the recognised errors which take place in other clinical outpatient settings such as GP surgeries, radiology suites, and other outpatient clinics where the error rate has been found to be at 23% in one Sydney study."

Transcript from ABC radio website: The WHO Report.

Case Study

The condition was Gout. A great source of humour for cartoonists – Colonel Blimp type with swollen foot resting on ottoman – apparently, for the victim, it is an excruciatingly painful ailment. (One sufferer says that a person, approaching-but-not-touching, will trigger anticipatory spasms of agony.) Over the years it got worse. However, for as long as it was treatable with over-the-counter pain-killers, he stuck with them. To go on to more potent remedies would mean a lifetime of the tablets, every day. Put that off. Eventually, he finds the lite stuff doesn’t work anymore and the pain is unbearable. Time for the heavy-duty medication.

The doctor prescribes two medications. The first is a stronger anti-inflammatory. Once the swelling is down, start taking the prophylactic stuff (the whole-of-life pills).

It doesn’t work. The anti-inflammation medicine has no effect. Back to the doctor.

The first doctor isn’t there so he sees another in the same practice. He endorses the prescribed remedies, but says take both medicines at once.

The Gout gets worse.

Back to the practice – and a third doctor. She recoils in horror at the idea of taking the two medicines together. The first has to do its work, she says, then you use prophylaxis. At first, it will exacerbate the condition – and that’s why the swelling has to be controlled first.

Two doctors, two completely different views on treatment. They can’t both be right.