Chapter 26: Risk management – keeping problems at bay
|"Risk comes from not knowing what youre doing. "
- Warren Buffett.
All doctors today are aware of the risk of being sued. While lawsuits against doctors used to be rare in the past, trends are changing rapidly and we are quite likely to follow the American example where practically every doctor has been sued at least once, and where being sued is considered to be one of the occupational hazards of practicing medicine. While this can be bitter medicine, there is little point in waxing nostalgic about the good old days; we need to come to terms with the new reality.
Learning how to minimize the incidence of adverse events in medicine, and their impact, is called risk management, and this has become a well-established science today. The practice of risk management involves identifying those aspects of problem behaviour on the part of doctors, that cause patients to sue, and then eliminating or controlling them to reduce the likelihood that a malpractice claim will be filed. Unfortunately, most doctors in India are still unaware of this field, and most of us learn about it the hard way.
Risk management is tied to the concept of quality control. The ideal solution to quality control would be to prevent all risks, but unfortunately this is impossible because provision of much needed medical care is unavoidably accompanied by the occurrence of injuries. What can you do to minimize your risks? Risk management focuses on preventing problems, and the most important issues are:
Medical knowledge requires maintenance: Keep yourself up-to-date! Do your homework: good doctors can prevent the most serious errors by being primed to recognize and treat them. The sequence of events leading to poor patient outcomes and eventually to malpractice suits can usually be clearly visualized. Failure to perform an adequate clinical assessment of the patient, omission of necessary tests, an improper diagnosis, and failure to treat the patients condition can lead the physician and his patient towards disaster. Fortunately, proper attention to the details of the clinical encounter and an awareness of the most common problem diagnoses can help you to avoid these pitfalls.
Remember, however, that being competent as an individual is not enough. You are in charge of the entire medical team caring for the patient, and you need to ensure that your staff too is competent. They will learn from you, and it is your responsibility to teach them well!
It is important to realize your own limitations, and to ask for consultations and referrals to seniors when necessary. Also, do not criticize other doctors and their care: after all, what goes around, comes around, and your criticism may backfire in the long run.
This means being able to manage high-risk situations, where the patient is likely to sue. Thus, the patient who has had a poor outcome (for example, the birth of a baby with birth asphyxia: the obstetricians nightmare) is like a time bomb which may explode if not handled with care and tact. The most important skill is that of patient communication: of being able to talk and explain to the patient what went wrong, and why. This is the skill of having a good bedside manner: of treating patients as human beings worthy of your time and attention. For many physicians that goes without saying, but for some it bears repeating. Unfortunately, arrogance seems to be second nature for some doctors in India and, as Tuthill puts it,
"If you act like God youll be expected to perform like God," and thats sure invitation to a lawsuit. Remember, patients who like their doctors and medical office staff, and feel a strong sense of loyalty and friendship towards them are much more inclined to resist the notion of suing even if things do go wrong. For example, if a complication does occur, do not try to hide it. It is best to explain it as some form of biological variation in the patient responsible for an unusual clinical presentation or therapeutic response, for in most cases this is the best tactical explanation.
Fortunately for most doctors, the majority of patients who experience an adverse event or poor clinical outcome because of an error do not sue their doctors. Nonetheless, an adverse event or unexpected bad result can serve as a red flag, warning the doctor that he may be slapped with an allegation of malpractice. The severity of the injury and the degree of patient or family dissatisfaction may be additional "early warning" signs that a lawsuit may be on the way. So what should you do to prevent problems if an adverse event does occur ?
First, remember what not to do - dont lie; dont hide; dont pretend; and dont push off the unpleasant duty of talking to the patient or his relatives to someone else - its your responsibility and only you can do it properly. Dont make a bad situation worse by running away from it ! Unfortunately, the first response is often to bury the error and hide it - but this often makes matters worse.
Junior staff members should report all incidents to their seniors, who can take appropriate steps. After all, with seniority comes experience - and often your seniors will have encountered similar problems in the past, and will know exactly what to do. Their advise and guidance can be invaluable.
The first priority should be to attend to the patients medical needs. Take responsibility
Be accessible for questions from the family and the patient. Repeated requests for an explanation of the event is a common reaction of upset patients and family members - be empathetic and dont get irritated ! Be honest with the patient and family - if you try to wriggle your way out by lying, you may find yourself trapped in a quagmire from which it may be very difficult to extricate yourself later.
Today patients have higher expectations of the medical care they receive, and they expect their doctor to have excellent technical skills and to apply his medical knowledge expertly to their problems. They expect value for the money they spend on medical services, and they also demand to be treated with respect, courtesy, and caring. When they find their expectations belied they turn into critics, and even plaintiffs.
Life is full of the unexpected, and this is especially true in an inexact science like medicine. No matter how competent and careful you are, problems are bound to occur. If you are prepared for these, and have a plan of action to deal with them, you will be able to cope much better when they do crop up.