Ownership

Not in my name

 

A recent coroner’s report caught my attention (highlighted by HSJ’s Shaun Lintern via Twitter). A patient died from a ruptured aortic aneurysm, and during the investigation it was discovered that it had been seen on a CT scan four years earlier. However, the patient never came to hear of it, the GP was not informed, and no follow-up was arranged. The coroner now requires the Trust, through a letter to the Secretary of State for Health, to review its arrangements for flagging up ‘non- cancerous but significant and potentially life-threatening findings’ on scans.

The aspect that worried me was that the consultant, who had read the report and was intending to tell the patient in clinic 5 days later, never saw him. He was seen by a trainee, and the trainee either did not see the scan result or did not understand its significance. This made me think about clinical decisions being made in consultants’ names, but without consultants being aware of them. Does this really happen? Yes.

Consultants lead teams. In some clinics, 30 or 40, even 50 patients will be seen in a consultant’s name, but because the consultant is only able to see perhaps a third of those personally, the rest will be seen by trainees. Those trainees will have some specialist knowledge, but they may be three or four years out of med school. As trainees, they are supervised, but the level of supervision will vary.

During my training, I never saw a clinic where trainees discussed all of their patients with consultants. Rather, consultants relied on trainees to use their judgment and ask questions about challenging cases when they felt it was necessary. Then, as now, many patients were seen, investigated (and perhaps discharged) without the consultant having been directly involved in the decision. This is more common in bigger hospitals, where there are more trainees and larger clinics. It may sound alarming, but just as junior doctors see patients in the emergency department or on the wards, and make important decisions day after day, so they do in clinic too. (In fact, the terms ‘junior’ and ‘trainee’ sit uncomfortably with experienced professionals in their thirties.) Nevertheless, if a trainee misses the point entirely, or overlooks a subtle sign or important result, there is always the possibility that a dangerous conditions could slip through the net.

On the wards, every action and decision is made in a consultant’s name. I remember explaining to relatives, and on one occasion a coroner, why certain clinical decisions were taken by another – perhaps at night when I was not even in the building – but ‘in my name’. When pressed by both whether I thought those decisions were ‘right’, I had to pause. If it had been me on the ward at that time, I might have interpreted the information differently. I might have prescribed a different drug, or referred to another specialist sooner, but… it wasn’t me. It was a trainee, and they did what they thought was best. It wasn’t wrong, but it wasn’t necessarily, in retrospect, as right as it could have been. If there were errors in judgement, short of outright negligence or something amounting to an incident that requires reporting and the duty of candour, it will be dealt with through their educational supervisor. It would seem wrong to allow the full weight of responsibility to lie on the trainee’s shoulders. After all, I have to remember – a few years ago, that trainee could have been me.

So what is the consultant’s responsibility here? Are they truly responsible for the patient’s outcome, even though certain important decisions are not in their control.

Well someone has to be responsible. Consultants stay in one hospital for a whole career (usually), while trainees move on. In the case of the missed aneurysm there was a delay of four years before the error was noted. The trainee who may or may not have seen the result, or who failed to chase up the results of the scan, would have moved on. They are out of the frame. It was the consultant who had to explain what happened to the coroner. In that case, ‘the system’ took the blame (the way in which x-rays were reported and flagged). This is often the case, and in a blame-free culture that encourages reporting of error, it often has to be the case.

The system is often inefficient. The system may have intrinsic gaps which are unsafe. As doctors, we complain about the system all the time, but perhaps this is where our responsibility truly lies. To be open to the possibility that the system we are working is imperfect, and to accept of our role in improving it. That is why consultants must also be continual improvers of quality. It is not enough to moan. If weak areas are identified, we must engage in strengthening them. If we find gaps, we must close them. We must complain, escalate, and help to fix. That is the quality that should be scrutinized, rather than the (superhuman) ability to detect and personally manage every patient who passes through our service.

 

Ownership

6.30PM, and Dr D was leaving his office. The next train was at 6.45, and if he ran he could catch it. In the corridor a medical registrar looked up, her face brightening as she recognised him.

“Ah, Dr D, one of your patients was just admitted. He’s having a flare up I think, not well. He said you knew him. Thought you’d want to know.”

“What’s his name?”

“Ah! I’m really sorry, I can’t remember it now. I saw your letter in his notes though. He said to make sure you were informed.”

 

The request has been made, implicitly. Dr D turned mournfully about and headed towards the medical assessment unit. Should he? It might make a difference, especially if it was a complex case. One glance and he might be able to sort it out in five minutes, save the on-call team a lot of guessing and faffing about. He entered the ward and scanned the names on the white board. None of them rang any bells. He asked the charge nurse, who instantly directed him to bed 6. Dr D pulled out Bed 6’s case notes. He flicked through the correspondence. Two letters, from clinic visits three years ago! Then the patient DNA’d (Did Not Attend) twice before dropping out of the system. ‘One of your patients…’ the registrar had said. Dr D eyed bed 6. He scrutinised the patient from across the ward. Yes, he recognised the face. Eye contact was made. Dr D was committed. He would get the next train; or perhaps the next train but one.

 

Two weeks later.

It was 6.20PM. The next train was still gettable. Dr D hurried towards the main entrance, buttoning up his coat. The same registrar approached him, this time from over his shoulder. She had seen him ahead and hurried, stealthily, to catch up with him.

“Dr D! Sorry. I’m on call again. One of your patients again. You do seem to have a lot! Deteriorated. He came in this afternoon. I thought you should know.”

“Name?”

“Oh! Sorry. I’m awful with names. Derek. David…  something.”

“How well do I know him?”

“I’m not sure, I just saw your initials on the front sheet. He comes to your Thursday clinic.”

“Did he ask for me?”

“No. He’s not up to asking for much to be honest.”

“OK. Look. I’m not bring unhelpful but I’ve got something I need to go to. I’m sure the on-call team can handle it overnight. I’ll come and see him tomorrow first thing, before the main ward round. OK?”

“Yes, of course, whatever you think Dr D.”

“OK. Bye.”

 

He caught the train. As he sat back he wondered who it could be. But not for long. After ten years in the job Dr D had seen many thousands of patients. Each one of them were, in a way, and to some degree, ‘his’. He had a responsibility, albeit shared, for them… but only to a degree. He could not be expected to rush to their bedside as soon as they entered the hospital. To be fair, very few patients had that expectation. It was colleagues, more often. They threw around the term ‘your patient’ with freedom, forgetting that the possessive implied something rather significant… duty. And if the requirements of that duty took shape at inconvenient times, what was he to do? Drop everything? Go back in? No way. The system was safe. There were many good doctors around to assess and treat and explain.

Next morning.

Dr D went to the assessment unit. He scanned the white board. There it was – Daniel. Daniel Spencer. No! Not him! Dr D rushed to the corresponding bed – bed 8. It was empty. The sheets were clean and straight. He found a nurse,

“Where’s Mr Spencer, bed 8?”

“Oh, he died Dr D. At three o’clock in the morning.”

Dr D lost focus. The assessment unit consultant came round the corner.

“Oh, morning Dr D. Sorry about your patient. I didn’t call you, the treatment plan was very clear from your letters. Really sad case. Only 36. He went quite quickly, and peacefully…”

“Did the family…?”

“They asked if you were around, they were very grateful for all you’d done, getting pall care involved, being honest with them. You were seeing him every week or two by the looks of it.”

“I wish I could have seen them.”

“I think the registrar let you know, she said she had anyway.”

“Yes… No… She couldn’t tell me who it was. If I’d had the name…”

“The family were fine. Really. Slight shame it couldn’t have happened at home but they weren’t set up for it.”

“Are they still around? I’d like to speak to them.”

“No, they went home earlier.”

 

Dr D avoided the lift and trudged up the stairs to the ward. He thought about ownership, continuity and duty. But he still wasn’t sure how he would react next time the registrar grabbed him in the corridor.