Surgeons expected to be a cut above

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Australia

THE FINANCIAL and emotional cost of medical malpractice can last for years, even a lifetime. It’s one reason why most surgeons are advised to get “tail” coverage on their malpractice insurance, so that they are protected from medical negligence suits brought against them after their retirement. There is no such protection for patients who might want to guard against the possibility of permanent pain and disability as a result of some accident or malpractice while under the knife. As for those in health care who might be sufficiently alarmed by unsafe clinical practices or surgical incompetence to bring it to the attention of higher authorities, there is usually only hostility.

The case of Canberra rehabilitation doctor Gerard McLaren, who was ostracised and attacked by colleagues as a “filthy rat” after raising allegations about the competence of a Canberra neurosurgeon during the 1990s, is yet another reminder of the considerable risks attached to whistleblowing and of the apparent inability of the medical profession to take all necessary steps to minimise “adverse outcomes”, negligence and malpractice. All surgical procedures involve risk to the patient, just as all surgeons, at some stage of their careers, have made mistakes, and while human frailty is a universally acknowledged truth, the medical profession (along with a great many others) has had considerable difficulty in the past acknowledging and dealing openly with mistakes.

One of the (understandable) reasons for this is that no one, particularly a doctor, wants to deprive a colleague of his or her livelihood by shopping them for incompetence. Nurses, of course, can theoretically blow the whistle on badly performing doctors, but the deference with which doctors have always been treated by patients and support staff alike make this a rare occurrence. And it is even less likely that administrators would want to bring the reputation of their hospital into disrepute by admitting to the existence of those physicians whose technique is slapdash or who simply apply the wrong solutions.

Word about doctors soon gets about on the medical grapevine. Those patients and their families ignorant of problems at Woden Valley Hospital, later the Canberra Hospital, and who accepted recommendations to undergo surgery there, might feel they were placed in an unacceptably risky situation by Canberra’s health-care system.

As many doctors will agree, neurosurgery is a highly specialised field, and one of the most sophisticated of the surgical specialities. Operating on the brain and spine means a greater probability of adverse outcomes than in other branches of surgery. Knowing this, all neurosurgeons and doctors will take time to explain the risks of surgery to their patients.

Most good surgeons will encourage their patients to ask questions too, but all too often the system prefers not to invite scepticism from patients. It certainly offers little, if any, consolation or redress to those it fails through negligence. That so few doctors have been persuaded to put down their scalpel, either by the courts or the medical profession itself, shows the difficulty of bringing a negligent doctor to account.

That it is virtually impossible for a member of the public to question the performance of a surgeon makes it even more imperative that surgeons and hospital administrators ensure that errors and mistakes are minimised. Accountability systems that allow surgeons to analyse their mistakes, via self-criticism and feedback from colleagues, are the usual methods employed to ensure doctors minimise their mistakes while sharpening up their techniques and results. But if morbidity and mortality meetings or peer review mechanisms were unable to prevent the episodes at Woden Valley Hospital revealed by McLaren, then the public has reason to ask what other measures have been put in place to guard against a repeat of these mistakes in the future.

One of the possible reasons for the failure of internal accountability mechanisms at Woden Valley Hospital is Canberra’s small size and its relative isolation. Candid criticism of a doctor’s surgical performance is not easy when the number of neurosurgeons in town can be counted on one hand. This is in part a consequence of the fact that Canberra, for all its attractions, is not an attractive destination for specialists and surgeons. Canberra Hospital’s new status as a teaching facility ought to be raising standards, but a public well able to seek sophisticated surgery in Sydney or Melbourne will want reassurance not only that standards can bear comparison, but that quality control does. One means could be making the performance statistics of surgeons and hospitals public, and indeed comparing and ranking them with hospitals from all over the country. Such comparisons would be odious to many in the profession, but done carefully they would be a valuable tool in raising the performance of surgeons around Australia.
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