Monday, 15 January 2007

Medico-Legal Medicine: the Musts of Medicine

The following blog, is soley my opinion from what I have read in respect of medicolegal cases in the UK and I hope it is enlightening.

Medicolegal cases in the UK are on the rise, and the payouts for medical negligence are reaching mammoth amounts.

Why is taking a history and performing a detailed physical examination important?

Well, it protects the patient and the physician alike.

Taking a thorough history shows that the physician was trying his or her best to find the problem. It also identifies areas that the physician forgot to ask. Hence, having an armory of stock questions to cover all the possible life-threatening problems protects the patients, as the diagnosis will be made quickly, and this protects the physician as a result.

This is the purpose for the Review of Systems Questions. I always describe it as a 'safety net' as it will catch those problems that the patient or the doctor forgot to touch on in the earlier part of the interview. In doing so, problems that were previously unidentified come to the foreground, some of which might be serious e.g. prostate cancer, and the physician will be complemented for finding the problem that others have missed, rather than miss it and be scorned for failure.

Performing a rectal examination is a MUST do part of the abdominal examination as a way to identify the rectal cancer or prostate problem. It must always be performed in cases of anaemia, diarrhoea (it might be overflow diarrhoea from an obstructing cancer), constipation, change of bowel habit, fresh rectal bleeding, weight loss, jaundice (rectal tumour with mets to liver), groin lymphadenopathy (rectal tumours can spread to the groin as well!!), unusual utero-vaginal bleeding in case of the neoplastic fistula to bowel.... If you avoid the Rectal test, the patient fails to get diagnosed and the physician gets wrongly labeled as negligent by the lawyers!

Examining the external genitalia is ALSO part of the abdominal examination with a chaperone of course!

Pyrexia of unknown origin in a man, the physician MUST examine the testicles because testicular tumours can cause fever (and spread to the lungs), and the lump of the testicle may have gone unseen by the male patient.

Also, patients with congestive cardiac disease, liver disease, nephrotic syndrome or severe low protein states can develop genital swelling to the extent that their urethra cannot be identified and they may develop urinary obstruction. Failing to inspect the genitalia can be disastrous leading to suprapubic catheterisation, that might have been avoidable if diagnosed earlier, and again, the physician might be labeled as negligent.

Writing all the physical examination down and the vital signs is extremely important as it is your only proof that you did the job correctly.

Failing to write down the heart rate, blood pressure, temperature, respiratory rate and SpO2 and sometimes even the capillary blood sugar might be taken as negligence by a court.

For example, a patient who is severely unwell and who has shock vitals on admission and who subsequently dies due to their illness is not uncommon. However, if the doctor fails to write down the full set of vitals can be be accused of not treating the patient correctly even if they did their best.

Here is a good example:

Lawyer ' So, this patient had severe breathlessness in your ER department right?'

Doctor ' Yes, that is right.'

Lawyer ' So, where is your record of the respiratory rate and SpO2?'

Doctor ' I am sure I wrote it down'

Lawyer ' Where. There is no electronic record of it!'

Doctor ' But...'

Lawyer ' Is it not true, that the reason there is no respiratory rate and SpO2, is that the patient was already dead!'

Doctor 'No....'

Lawyer ' Well, doctor, we have no proof. You never wrote it down. The patient died in your ER department. How do we know that the patient was alive?!'

The above is a made-up example of just how important the vitals can be.

Vitals are important as they tell the senior doctors of how severe the patient's condition is and how quickly they need to act and where the patient should be located e.g. a normal ward or the ICU department !

Always documenting the important positive findings and the negative findings shows that the physician actually checked rather than saying everything was normal. My 'Everything' and the inexperienced junior doctor's 'Everything' are completely different, and what a junior may miss a senior would hopefully identify.

Hence, writing everything 'normal' without qualifying why it is normal is incomplete and not good enough for notes that might one day end up in the hands of lawyers who may not care about your career at all...just about winning their case and of course, getting paid!

Timing and dating notes and signing the entry (by signature or electronically) shows that the physician did attend their patient, for example, before their unexpected sudden death on the ward, which shows anyone looking, that the problem may have not been readily identifiable or that some other problem arose. It also shows that the physician did not neglect their patient.

Writing a summary and differential set of diagnoses also shows that the physician had made a diagnosis and that treatment was then initiated for the problems identified. Failing to make a diagnosis at all might be construed as incompetence by lawyers, but making a differential diagnosis shows that the physician thought of many problems rather than nothing being documented at all.

So, you may have been thinking that patient notes are there just to tell other doctors and the nurses what is going on with the patient. Think again!

Patient notes if kept poorly maybe the thorn in the doctor's side despite them being an excellent doctor, whereas perfect notes may show that the doctor did a superb job for the patient and that the end result was unavoidable.

Although the litigation in Japan is not as high as in Western countries, it should always be borne in mind that it will increase in time and that when you put 'pen to paper' or 'fingers to the keyboard', you may need to defend it in court one day and sometimes, many years later, when you can't even rememer the patient you saw at the beginning of the busy clinic this morning.

I hope this gives you something to ponder about.

All the best!


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