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Over to you

We welcome all contributions to Over to you. We reserve the right to edit submissions. Please address correspondence to: Casebook, MPS, Granary Wharf House, Leeds LS11 5PY, UK Email: casebook@mps.org.uk

A dangerous cough

I must take issue with one of the usually excellent learning points associated with a case report published in Casebook 20(2) entitled “A dangerous cough”. You recommend: “When administering anaesthesia during an elective procedure, it is preferable to stop should you encounter difficulties and reassess for surgery at another time.” Although it is apparent that this would have been the correct course of action in the case described, this is not always so.

Can I suggest the slightly more verbose but much more accurate:

"If you encounter problems that you cannot be completely confident you have diagnosed accurately, and resolved fully when a patient is under general anaesthesia for an elective procedure that has not yet started, you should consider abandoning the procedure and waking the patient up."

Dr William Harrop-Griffiths
Consultant anaesthetist, UK

All in the detail

I am having increasing difficulty relying on Casebook for considered advice. The editorial standard is at odds with the excellent verbal advice I have received from the organisation over the last 20 years or so. What amounts to an apology regarding poor DNACPR advice given in January this year appears in the same edition as the following example of clumsiness: “Your first obligation is to act in the patient’s best interests and you should not be pressured by the patient into doing anything that is counter to this” (learning points, “A dangerous cough”, Casebook 20(2), May 2012). This seems to suggest that the patient does not know what their best interests are but the doctor does.

Modern medical ethics tend more towards the notion that if a patient is able to make a decision regarding their own best interests it is not for the doctor to paternalistically impose their own views of best interests on them: “A person is not to be treated as unable to make a decision merely because he makes an unwise decision.” s1(4) Mental Capacity Act 2005.

In the instant case I would have hoped that the advice given by the MPS would have been along the lines of: "Your first obligation is to act in the patient’s best interests and you should not be pressured by anyone else into doing something that is counter to this."

In this case, more comprehensive preoperative assessment may have led the anaesthetist (in consultation with the surgeon) into concluding that the surgery would be safer once the chest infection had fully cleared. Presented with this information the patient would very likely agree to the postponement. If she felt her best interests were served by proceeding anyway the anaesthetist and surgeon would have the opportunity to seek second opinions from colleagues. A doctor is under no obligation to provide treatment he feels would be detrimental to the patient’s health simply because the patient demands it.

This seems to suggest that the patient does not know what their best interests are but the doctor does

The notion that a vaginal hysterectomy under spinal anaesthesia might have been a reasonable alternative in the presence of pneumonia is a contentious point (particularly in an elective setting) that detracts from the otherwise sound advice regarding good communication.

Also, condensing what appears to be a very complicated case into a single glossy page might look attractive but for those experienced professionals reading the piece it usually leaves more questions than it provides answers. The poor writer has a Herculean task on his hands. Perhaps a much fuller summary could be provided online as might be found on Westlaw.

I do feel that the glossy Casebook does something of a disservice to MPS. There should be greater use of references and quotations from statute, case law and guidelines from professional bodies and considerably less reliance on well meaning, but sometimes ill-considered, bullet points.

Name and address supplied

Response

Regarding your point about patients’ best interests, from a medicolegal standpoint you are of course correct – and no authority can impose treatment on them against their wishes, save under the provisions of mental health legislation.

However, the principle applies to the patient’s rights, and not the doctor’s responsibility; in other words, the patient cannot insist on being provided with inappropriate or negligent treatment simply because they believe it will be in their best interests to have it. The doctor has responsibilities and duties both in law and – in the UK at least – as imposed by the GMC to exercise their judgment and professionalism in assessing what treatment options are appropriate for the patient’s condition. After a proper informed discussion it is then for the patient to decide which option is best for them.

I agree with your comment about the wording of the first learning point; precision and detail can be lost at the expense of limitations on space. I also recognise that in seeking to provide material that is interesting, practical and relevant to the very wide range of doctors who receive Casebook, we do not always provide the level of detail in case reports which an experienced specialist in your position might wish.

The principle applies to the patient’s rights, and not the doctor’s responsibility

We have recently started publishing more specialty specific material, including an anaesthetic e-bulletin, and would welcome ideas for topical issues to cover in future editions.

Casebook does not purport to be an academic or peer-reviewed journal; the case reports are based on MPS cases from around the world but, unless otherwise stated, facts are altered to preserve confidentiality and to focus on generic learning to be gained rather than clinical detail. We do include some links to relevant reference material and guidelines (bearing in mind the worldwide spread of members) but quotes from statute and case law have not been considered to be a natural fit with the overall nature and purpose of this publication. We do publish a wide range of country specific factsheets, which include greater reference to statute and guidelines.

Dr Stephanie Bown, Editor-in-Chief

Oh by the way, doctor

I would like to offer a comment on your latest “Oh by the way, doctor” in Casebook 20(2), May 2012. Fair enough, the GP did miss the SUFE and didn’t make any notes, but when you examine the structure of the consultation, there would be few GPs in any country who couldn’t have ended up in the same unpleasant situation. The advice about the limping child is all apt but, just as importantly, there needs to be training and advice about managing the structure of consultations and demands that you cannot meet in a busy day that is already fully booked.

When you examine the structure of the consultation, there would be few GPs in any country who couldn’t have ended up in the same unpleasant situation

For example, the GP could have made a one-line entry in the mother’s notes about the request and then insisted she book in for a proper consultation for the child. Yes, she might have been angry and demanding, but it is ok to set boundaries with patients: “I’m sorry Mrs Smith, but assessment of a limp in children is not a quick thing and I really want to do my best for Johnny, I can give you an appointment tomorrow.”

Or: “I’m sorry Mrs Smith, but I am heavily booked today, and in fairness to the booked patients who are already waiting I cannot provide you with a double appointment.” Better to weather some short-term annoyance from the patient and create a long-term understanding with the patient that you practise good medicine, and that off-the-cuff double bookings are not part of that practice.

Better to weather some short-term annoyance from the patient and create a long-term understanding

In my own practice I will oblige with minor “quick look” things, eg, checking the child’s tonsils for which I gave antibiotics last week when he accompanies mum for her appointment. This sort of quick follow-up is useful for me and creates goodwill, but new assessments, of the type above with the limping child, should be deferred.

It is also important that both your reception and nursing staff have clear guidance about what is acceptable to double-book and that you should be consulted about double bookings. This creates a consistent culture across the practice, which prevents the doctor being overloaded and resentments developing within the practice team.

Dr Phillipa Story
GP, New Zealand

HIV testing

(Please note – this article appeared in the UK version of Casebook. To read it on the UK MPS website, click here)

I read with interest the article “Spreading the use of HIV testing”, and entirely agree with the need for “normalisation” of the investigation of this virus. Encouragement to present to healthcare services and the stage at which patients present may be outside our control, but from their point of contact with healthcare professionals we have a window of opportunity to modify their prognosis.

The demonstration projects clearly identify key educational needs among practitioners to dispel the myths around investigation and build professional confidence

Proactive consideration of the condition among our differential diagnoses of patients presenting with signs of immunosuppression (recurrent infections, atypical infections), PUO, obscure dermatological changes and non-specific signs (weight loss), should prompt investigation at the time of disease consideration, like any condition.

The demonstration projects clearly identify key educational needs among practitioners to dispel the myths around investigation and build professional confidence (consent, results management, insurance fallacies). Empowerment of junior doctors to consider the disease in their diagnoses and to elucidate risk factors among patients they encounter on the acute take or new outpatient referrals could improve early investigation. Through junior doctors presenting their reasons for investigation choice to senior clinicians, as any investigation with signifi cant implications (genetic testing tumour markers, radiation exposure, invasive procedures), test appropriateness could be confirmed or refuted.

We are failing patients by potentially delaying diagnosis and thus denying life-preserving treatment at the earliest interval

Also teaching communication skills to develop patient rapport prior to enquiring into the sexual history may assist clinicians. If the barriers are not in diagnosis consideration, but clinician fears in discussing the investigation – what will the patient think? What if I cannot answer their questions? How do I tell them they have a positive result? – we are failing patients by potentially delaying diagnosis and thus denying life-preserving treatment at the earliest interval. Any concern regarding managing the results is our responsibility, to nurture the working relationship with sexual health services. By the time the doctor with all the answers is encountered, it may be too late.

Dr Claire Brough
Specialty trainee, cardiology, UK

Correction

A normal appendix

In the third column of the case report “A normal appendix” (Casebook 20(2)), it is stated that: “A subsequent radio-nucleotide scan confirmed evidence of active disease at this site”. Nuclear medicine diagnostic imaging procedures do not use radio-nucleotides, but rather radio-nuclides. Casebook is happy to point out this error. Thank you to Professor Iturralde for this information.

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