Reducing Members' risk and promoting good medical practice

• Listen to your patients and determine their ICE – ideas, concerns and expectations. Clarifying these will minimise any misunderstandings and enable appropriate advice to be provided as well as set realistic expectations for all.
• Regularly review and refine your working diagnosis especially if things aren’t going as planned, including if test results are unexpected or symptoms aren’t resolving or treatment options haven’t had the desired effect. Generating a list of differential diagnoses aids this review process. Don’t be afraid to “start again from the top”. Many errors occur from not considering diagnoses.
• Everyone wants to leave a consult knowing “what happens next”. Ensure your patient has a clear plan of management including: working diagnosis; any further tests required; follow up arrangements including duration; and clear instructions on how, where and when to present earlier. Providing written instructions, or having the patient take a photo of these, and using patient information aids is really helpful. Spend as much time on management, including answering questions and clarifying understanding, as you do on taking a history and performing a physical examination. This minimises error, risk and dissatisfaction. 

Good record keeping is the best defence. With the use of electronic records and auto text to speed up the writing of notes, GPs are at greater risk of the clinical record not containing all the information, examination findings, discussion and management plan that can occur in a doctor - patient consultation.

When auto cues are used, or results are ‘given’, these do not demonstrate the clinician’s discussion with the patient. The patient can claim that they were not made aware or were not provided with information to comprehend the meaning of a result. It is difficult to demonstrate that abnormal results were discussed if there is not more than ‘Results Given’ in the medical record. 

It is important to supplement these electronic record tools with some notes by the doctor.

A brief reflection and review of your notes during your consult with an eye to recording what has been communicated to the patient is essential.

Writing notes is an essential clinical tool for continuity of care and for medical defence.

I suggest a modification of the Golden Rule: "Do unto your patients as you would do unto you". 

For procedural Members this means making sure the rooms/practice environment is patient friendly and openly receptive. This includes staff and the layout of the rooms. Confidentiality is necessary – incoming telephone calls may be overheard in waiting rooms. 

Again, for proceduralists, the hospital admission process must be very smooth, including the consenting and its documentation.

Follow-up is still a very important part of good service and includes what we do when we go on holiday or other forms of leave. It is much better to have a very good handover to a colleague who stays in town than to take calls from interstate.

Keeping good medical records is in my opinion the best way to avoid being sued. The records need to accurately document discussion relating to informed consent for any procedure. Other options relating to treatment need to be noted as well as the advantages and disadvantages, and risks and complications of the procedure.

If a handout is given to the patient, then this should be recorded in the medical records. The doctor should ensure that the consent form is signed by the patient and conclude the informed consent procedure by recording that they ask the patient, “Do you have any questions?”

Ensure adequate and accurate notes are taken and kept after any consultation.

Don’t take on procedures you are not familiar and confident with.

Be ready to ask for a senior or other colleague's opinion or advice.

Be prepared to refer on if appropriate or have a co-surgeon with you.

Proper informed consent is essential, including discussion of possible complications and how they are addressed.

Give an, as accurate as possible, estimate of out-of-pocket costs.

If a complication occurs, open discussion is necessary without necessarily taking blame, and noting how it will be treated.

In my view, charging a fee for complication surgery is appropriate but at a no gap rate.

If going on leave after surgical cases, ensure that a colleague is notified and the patient is given the contact details if needed.

The one thing I would recommend to all doctors is to establish the patient’s expectations of proposed surgery. This applies mainly to elective surgery in any specialty, such as reconstruction after resection for malignancy, teenage surgery for cleft lip and palate repair, reconstruction for burn scars, as well as cosmetic surgery. This often provides revealing insights into expected outcomes which may be beyond the skill of any surgeon. By definition, unrealistic expectations cannot be met and subsequent surgery may lead to significant disappointment and legal ramifications.

Ask questions such as, “What sort of change do you think surgery will make to your life?” and “How does your present condition affect your life?”

Basics

1.  Be courteous, polite and respectful but not too jovial or silly. Remember a patient visits a doctor because they are ill or worried about their health.

2.  Always follow a system when taking a history from the patient so that you do not omit important facts.

3.  Explain ‘why’ and ‘how’ when examining areas that the patient may regard as intimate, e.g. breast and gynaecological examinations.

Surgeons – pre-op

1.  Procedure/operation – use diagrams where possible.

2.  Informed consent – make sure the patient understands why and how you will carry out the surgery. Ask the patient “any questions?"

3.  Other options – discuss, including not doing surgery.

4.  Risks and complications – document these as omission is a common cause of complaints and claims.

5.  When a patient has a chronic condition or history of previous multiple operations, or has been seeing several doctors: 

• Be slow to operate. 
• Thoroughly investigate, including chasing up previous doctors for relevant information.
• Seek a further opinion from a trusted colleague or discuss and document the case with other senior colleagues.

 Axiom: A good surgeon knows not only when to operate, but also when not to operate.

Surgeons – post-op

1.  For major surgery, consider phoning or contacting next of kin to inform them how the operation went and findings.

2.  Do not write discharge orders on the operation sheet. You must review the patient post-op or be certain the patient is ready for discharge. (Too many Writs involve a note on op sheet, “Home tomorrow – see me 2 weeks”. Common avoidable error!)

3.  If a patient appears ‘worried, unhappy or slow’ but otherwise ‘well’, consider a further period of observation before discharge and seek a review in your rooms within days, not weeks.

4.  If a patient (or their relative) rings with concerns, give the patient the option of an urgent review or admission to hospital. Do not reassure a concerned post-op patient without reviewing them.

5.  If the operation you performed is unsuccessful or the patient is unhappy, refer them to a colleague for another opinion. Even if the patient does not want to see another doctor, advise the patient that you want to seek another opinion.

6.  Never re-operate on an unhappy patient who has had several unsuccessful procedures for the same condition without seeking further advice from a trusted colleague. If you both concur that further surgery is indicated in such a patient then arrange to re-do the operation together with an experienced colleague.

7.  Consider seriously whether you should do a third or subsequent operation for the same procedure, even if the patient requests it. It might be better to refer them to a colleague.

Axiom: Doing multiple operations on a patient for the same condition is a recipe for a Writ!

My key recommendation would be – just because you can do a procedure does not mean you should!

Many claims that come to the Cases Committee relate to elective procedures where patients are unhappy with the outcome.

Many of these procedures are performed in patients who are desperate to ‘have something done’, even though evidence and common sense would suggest that the likelihood of a good outcome is doomed from the outset because of unrealistic patient expectations and/or poor patient selection by the proceduralist.

The more desperate a patient is to have a procedure, often as a last resort for a long-standing problem, the more the proceduralist should think long and hard about whether the procedure is a) indicated and b) likely to give the patient the outcome they are hoping for.