An attempt to restore order in medicine is in full swing. It does not take a week for news of the bringing of the lawsuit for rendering inadequate assistance, not rendering assistance at all, negligence, mistake, etc. Since we are accustomed to considering that the foreign healthcare system is more rational and effective, then the question is “Do they have similar problems?”
For clarification, we asked Professor Vladimir Alexandrovich Anikin, who has been operating patients in England for many years.
- Vladimir Aleksandrovich, what is the name of the clinic where you work, and what position do you occupy?
I work as a thoracic surgeon at the Harefield Hospital, which is part of the Royal Brompton and Harefield NHS Foundation Trust. It is a specialized cardio-thoracic hospital, which is based in two institutions - the Royal Brompton Hospital in central London and Harefield Hospital in north-west London.
My position is called Consultant Thoracic Surgeon. In the UK, this position means that a person has the right to make independent clinical decisions, the right to practice independently. Practically there is no analogue in Russian medicine. Well, the closest is the head of the department.
— How long have you been working in England?
In the UK I have been working for almost 26 years, since 1992.
— Do English doctors commit mistakes, does it happen?
Of course! Medical errors, doctor’s errors are committed everywhere, including in the UK. The attitude here for the mistakes is extremely serious and different measures are constantly being taken to prevent such errors.
All medical errors can be classified into several categories. It may be a wrong diagnosis, it may be wrong medical actions: either related to the technical unpreparedness of the doctor who performs any medical manipulations, or deliberately failing to follow the prescribed necessary rules that the doctor should be guided by. These are the three main categories of errors that occur. Of course, there are other types of medical errors, but they are fewer.
— What does it mean - the doctor does not perform the prescribed actions? It means, that he wants to harm somehow the patient, or is he just thinking that the standards are not suitable in this case?
This may be when the doctor believes that his personal opinion on the treatment in this case will be better for the patient, and he does not follow the generally accepted recommendations. This is one option. And the second, when his opinion about the clinical situation is not sufficiently balanced and is on the incorrect path.
— If the doctor did not agree with the standards, he decided that his personal opinion was more correct, and everything ended well. Will this be investigated as a mistake or the winner is not judged?
Of course not. No one will investigate. The fact is that medical errors are closely investagated here in a few basic cases. This can occur in the case of a complaint from a patient or his relatives, or if certain rules are grossly violated as a result of actions. In addition, the investigation may begin in case of a series of adverse outcomes or in case of an unfavorable outcome of the intervention with an expected low risk. In case of deviation from the standard rules, the medical staff fills in a certain form, which goes to the administration, and in this case, these actions will be analyzed, investigated, and some actions will be taken.
— The staff fills in this form if something happens to the patient. Yes?
No, not necessarily, it is filled in any case. Even if everything worked out.
— And what's the point?
The point is to prevent such violations and in no case prevent the concealment, not only a medical error, but simply an unfavorable outcome. These rules are very strictly enforced. Currently, in the UK, medicine has also introduced a concept that is absent in Russia, the so-called “Duty of candor”. This can be literally translated as “the duty of candor” or “the obligation to be frank”. Approximately it means this: if something extraordinary or wrong happens during medical actions, the doctor must inform the patient about it, even if nothing terrible has happened. Even if the outcome turned out to be expected and good, the patient must know that during, let’s say, the operation, well, let's say, the ligature have been torn, unexpected bleeding began, which was quickly stopped, and there was no necessary tool in place and the surgical team had to wait for it or use another tool.
— Clear. As for patient complaints, do they often complain, and do they complain only when something really bad happens, or can they complain about the rudeness of the doctor? What is your patient behavior?
Complaints can be of different types. As a rule, in many cases, relatives complain through the so-called “PALS” system. PALS is an abbreviation for Patient Advice and Liasion Service. Literally, you can translate the "Service Council patient and communication with the patients." This hospital service is the first thing a patient sees when he crosses the threshold of any medical institution in the UK. And patients can go there and complain about everuthing; that the doctor does not look good enough, that a person waits too long for medical care, and if relatives or the patient himself believes that there was a violation, a medical error was committed - of course, this also. Very often, this is the first step for patients before they sue a doctor or hospital.
— Do you often, or especially you are faced with situations when suing? As I understand, they often complain, but what about the courts?
They also sue often, the fact is that in Britain, a system of legal assistance to people is very developed, operating under the motto “No win, no fee service,” which means that without winning a lawyer does not receive payment. This explains why lawyers are interested in considering cases that they can win. This is a whole industry in the country. That’s why, when the patients talk to a lawyer on this topic, they immediately consider whether there is a chance to win this case in court. And if so, they form a letter of claim to the institution to which the claim is made.
— Clear. If we go back directly to medical errors - we realized that patients complain about everything, we understood that there is a certain classification of these errors, and now - how do doctors pay for these errors? That is, these are fines, this is suspension from activities, this is imprisonment?
It depends on the outcome. If a medical error occurred unintentionally, then in this case, after the investigation, well, as a rule, nothing happens. If there were serious consequences, especially if the errors were systematic, then in this case, it is possible that the doctor will be sent to the medical council of Great Britain to consider his situation. If the commission, that works there, considers that this doctor is a threat to the patient, he may be removed from the practice.
— Suspend at all or for a while? Perhaps he will have to take some courses, learn a little?
In the UK, a doctor is easily removed from medical care! Even if in general he is only suspected of committing something, his activities are suspended in order to be restored. In England, in medical jargon, this is called "gardening leave," that is, "gardening leave (russ.)". They can last a very long time - up to a year or more. Then the doctor can restored, and he can return to normal medical practice. But it may happen that the doctor will be removed from the practice of medical practice completely.
Yes, relatives of the patient or he himself can sue, and the case can end with a judicial investigation and even a court sentence, but this happens extremely rarely, usually in the case of deliberately harming the patient.
— Well, if you remember, maybe you had a loud case when the doctor was sentenced to prison over the past three years?
No! I do not remember such cases.
— Can you say that in England the law treats doctors enough, well, let's say, carefully? The profession is hard, people, specialists are valuable, so they try to teach more than publicly punish?
There is the so-called “crown indemnity” - literally “protection provided by the crown”. This means, that all professionals working in the national health care system automatically are under the legal protection of the national health care system. If a doctor is sued for a case that occurred during his work at a state medical institution in the national health care system, he does not pay for a lawyer. The hospital and special institutions deals with everything in these cases - hiring lawyers, conducting internal investigations in order to protect their specialist. If a medical error or legal action occurred in private medicine, in this case the doctor is not protected by “Crown indemnity” and for this you need to buy individual insurance for cases that are in private practice. The fee for this insurance is very high.
— That means, that the doctor insures himself against medical error, right?
Not certainly in that way. The doctor insures himself against the costs of prosecution. But, again, this does not guarantee that he will have a favorable sentence.
It simply allows him to attract experts who will speak on his side, to attract qualified, specialized lawyers.
— How does the medical community respond to their brethren who have made a mistake? Is it suspended or are their colleagues trying to cover up a bit if there is such an opportunity? After all, it is no secret that in medicine a lot can be interpreted, in two ways, threefold, etc... That is, do you cover up each other?
No, it is almost impossible to hide something in Britain. Because everything is so transparent here and there are so many different controlling factors... And hiding a medical mistake is one of the worst sins a doctor can commit. A medical mistake can be forgiven, it can be understood, but nobody can understand the attempt to hide a medical mistake, and this can have serious consequences, including deprivation of the right to practice medicine.
— That is, if you made a mistake and realized that you have made a mistake, it is better to go and admit it?
It is always better to speak openly and in no case try to hide something.
— If we go from general to particular questions: many Russian doctors are concerned about the percentage of discrepancies between clinical and pathologo-anatomical diagnoses. Is such situation a reason for the analysis in Your country and the for the reports, that here was a mistake?
Such a parameter in Britain, as far as I know, is missing.
— How is it? That means, that the doctor can treat for a long time and persistently, for example, a runny nose, and then at an autopsy it turns out that it was a tumor. Is it not a reason then to present any claims to the doctor?
This is an error, but it is not a specific indicator of the frequency of errors, as in Russia.
— And since there is no such indicator in reporting, then, accordingly, you and your administration, do not have the desire to reduce it as much as possible? You work and do not think about it.
Of course.
— If the doctor made a mistake, he was removed from his activities for a while, and he returned later. Is this previously committed mistake some kind of stigma that will haunt him? Is this taken into account?
In general, no. These people continue to work. But if the case is loud, at a professional level, then, as a rule, this can interfere the doctor in his future career. Well, as an example, I can bring the loud case of infant mortality in cardiac surgery in Bristol many years ago. This case has thundered all over the country for several years. Then, gradually everything was somehow forgotten, although a lot has changed, of course, since then.
In particular, in surgery in Britain is now introduced, as one of the measures to prevent errors, the so-called check in the style of the World Health Organization. When a patient enters the operation theatre, the responsible surgeon who will perform the operation must physically be in the operating room and must read the name of the patient on the identification bracelet on his arm, the number of the medical history, the date of birth. And these data will be checked by other documents of the operating sisters in the operating room, confirming that this is the person who is going to be operated. Then you need to read out loud what is written in the informed consent to the manipulation or procedure. After that, the operating surgeon should tell the patient about the plan of the operation, what is will be done during the operation. At the same time, the anesthesiologist should say what kind of anesthesia is planned, what measures that increase safety will be carried out, and so on. In addition, there is a special form of testing for the operation on paired organs, paired sides and one-side operation - a large arrow with a poorly erasable felt-tip pen is applied. And one of the doctors signs the document, indicating that the right lung will be operated, or the left mammary gland, or the right foot, and so on, in order to exclude the cases that still occur in the world when the healthy side is being operated.
— How long has this protocol been in your clinic?
For quite a long time, probably four or five years, I do not remember exactly.
— Is it visible to the naked eye that it really has allowed something to improve, to reduce the number of certain errors, such as the removal of healthy organs or improper anesthesia, or something else? Are the results noticeable?
I think yes. Such cases have happened, maybe not in our hospital, because we have a highly qualified specialized institution. The flow of patients, of course, is large, but not so much, and mostly the operations are planned. But if there is a huge flow of patients, then in this case it is much easier to commit a mistake. But in recent years I have never heard, either in the press or anywhere, that someone was operated on the wrong side. Because this test is now mandatory to perform in any medical institution in the UK.
— How long does it take to pronounce such thing?
About two minutes.
— Did you have a case that you caught some mistakes of your colleagues at this moment, or, perhaps, your team corrected you: “Professor, you just said something not right”?
There were no such cases, thank God.
In addition, it may be interesting to your listeners, in surgery exists a specially designed system for preventing the leaving of foreign bodies in the body. At first, all medical devices, wipes, whatever, necessarily have X-rays mark, so that you can determine on an X-ray whether this object is in the body or not. The second is a mandatory account of gauze napkins, needles, tools, and so on, which is carried out during and at the end of the operation. If there is a suspicion of leaving a foreign body, they must make a radiograph directly on the table of the area where the foreign body could have been left. And this is only part of the whole algorithm of actions aimed at preventing the abandonment of foreign bodies.
— Tell me, please, how is the patient protected from medical errors? Standard insurance covers the cost of treatment, or must be suing, so that the institution, where it happened, later would pay for “solving” the problems?
In Britain, medicine is completely national. That means, that patients do not pay a penny for their treatment. At the same time they pay a small tax, which is levied on income. This is the national health care system. Of course, there is insurance medicine in Britain for private patients who seek treatment in the sphere of private practice.
— So, if there are any consequences, then within this national system there will be …
Eliminate the consequences.
— And the later compensation for moral and physical damage…
So for this you need to sue. This is the case when the patient or the patient’s relatives may sue for compensation for the damage caused.
I remembered the story of a medical error that occurred with one of the people I knew. This man had his father operated for a small orthopedic pathology. As a result of an unfavorable set of circumstances, the patient woke up in a state of "terminaly vegetable state", that is, the cerebral cortex died. As far as I know, in this case, the national health care system pays for the stay of this person in a rehabilitation facility, and then, if necessary, long-term care.
— Errors related neither to the surgeon's actions nor to the actions of the anesthesiologist, but, for example, the surgical tools were incorrectly sterilized, or, for example, the patient was put on a not very clean operating table and received a septic process. Does this occur?
Well, probably such cases occur, but very rarely. In such cases, these medical mistakes will be detected only if the patient got some harm, and he decided to seek for a legal assistance.
— To summarize briefly: if a doctor makes a mistake, he should, preferably, as soon as possible, tell about it to his colleagues and, then, to a special commission as part of the investigation. Right?
Not necessary. If a medical error was made and did not lead to any consequences, then no investigation will be conducted in this case. But the patient must know about it! The patient must be informed about this, and recently it is necessary to inform in written form, telling what happened and how the consequences were eliminated. If there is any mistake that led to death or other serious adverse effects, then a special form is filled in and the responsible doctor in the institution decides whether to conduct a special investigation in the form of a commission on this occasion or not. In this case, usually, experts in this field are invited from another institution to investigate the situation, but this happens quite rarely.
— In a situation where it becomes immediately clear that the mistake was made due to, for example, the doctor’s extreme fatigue or an unstable emotional state, is this a mitigating circumstance or what should be done?
If a person is not able to perform his actions - he should not perform them.
— Do you have cases similar to cases in Russia, when doctors combine two full-time, three full-time works to earn more? Is this allowed for you and is there any such practice?
Well, the fact is that here the payment system is completely different ... Yes, of course, it happens at different levels, including quite high, when the doctors are overwoking. But for junior doctors, the rule of the European working week is now established. In which, they can not work more than a certain number of hours during the week, it is to prevent such cases.
— But if you still work more? Or law-abiding British do not do that?
No, such cases happen. They work more, but this is not a mitigating circumstance, because this may be an aggravating circumstance.
— Have there ever been cases when, due to a doctor’s mistake, the right to practice medicine was deprived, for example, in surgical practice, but he could go into therapy? Or if the right to treatment is being withdrawn, then it is being revoked completely and is not allowed to go anywhere?
The right is revoked completely.
— That means, that changing of the practical field is impossible here?
No, in this case either practice medicine or do not practice medicine.
— For what other faults the British doctors have been punished, in addition to medical errors?
Here are some examples of misbehavior. For example, one of the most terrible sins that a doctor can commit in the UK is an intimate relationship with a patient. This is considered absolutely unacceptable here.
— But if they both agree?
It does not matter. If a doctor comes into intimate contact with a patient, this will almost automatically entail deprivation of the right to practice medicine. This happens, nevertheless, but everyone knows about it.
— What else bad can a doctor do?
The next very serious sin of a doctor is writing a prescription for oneself or one's relatives. Not a long time ago, it was prohibited to write prescriptions only for sleeping pills, narcotic, potent drugs, and recently it is believed that in general no prescriptions can be made for oneself or relatives.
— So, intimate contact and writing oneself prescriptions. And if you estimate the frequency of cases, for which doctors are often punished - for such sins or medical errors?
Well, for medical errors, of course. Unfortunately, they happen in spite of this whole set of measures that exists here for their prevention.
— A study was recently published, where the authors tried to bind the burnout of the doctor and the frequency of medical errors among American doctors. And a fairly high percentage of doctors, about 8%, admitted that over the past three months they have made at least one major medical error. That is a mistake that entailed some consequences for patients. Do these numbers seem real to you? Or did the researchers mess something up?
I think these numbers are close to reality, especially in the United States, where the number of medical actions per patient is much higher than, let’s say, in the UK.
— That means, that your systems cannot be compared?
Healthcare systems in Britain and the United States are very different and cannot be compared.
— This is very interesting, because, when you look at the situation from Russia, then there is a good "overseas" medicine thriving in developed countries, and "our". And all the "overseas" medicine seems about the same. But this is a question of another conversation.