The silent pulpit
Prologue: The essential nature of science is to quest to find the truth. Successive additions to a stock of tested truths are where scientific progress lies. The practice of medicine is essentially conformation to medical science. But is there really a way to put this to test in every given situation be it a lab test or a patient given situation.Or Is there a mechanism to confirm that the best is being done in every clinical situation given the best of resources. Albeit as giant strides are being made in medicine & with the application of QMS in every crevice in health care,does medicine stand on the high pulpit of infallibility?
Error disclosure in healthcare.
The truth has been misunderstood, difficult to deal with & is elusive at times. In the process of seeking the truth science has perpetually run into several stumbling blocks ranging from cassock clad clergymen to conceited persona from the scientific community itself. For instance the reticence Virchow to accept the germ theory of disease & fervent rejection of the laws of the universe by the catholic church bear testimony to this ‘I/We can’t be wrong’ attitude.These are instances where in credibility is based on face value & assumption but not inductive justification.
To subscribe to a practice which might seem perfectly reasonable now, or to conform to what is the norm now need not be essentially correct. Many a time a valid change in medicine comes after being faced with stiff opposition. Ignac Semmelweis being labeled a maniac when he proposed that hand washing could save women from puerperal sepsis is but one example of empirical evidence throttling scientific reason.
In an era where we have unlimited access to data & with our computational capabilities ever stronger than in any time in human history, the tendency to rationalize everything thing exists. The very nature to delve into logical explanations for everything ranges from probing the reason for a lab result becoming suddenly abnormal or a patient suddenly lapsing to coma is itself a fallacy. In many ways loosely accessible information about healthcare has given birth to the ‘google’ patient & has but complicated the way patients are being handled & responded to. Omnipresent data forces upon health care professionals a tendency to avoid trouble & be defensive before treating or reporting. This also applies to personnel who don the ‘technical’ or ‘quality’ robes. With an ever increasing need to do everything right the first time around & burgeoning expectations from the patient,practitioners of medicine are forced to view every patient as a potential pitfall.
We also should bear in mind that we are perennially offered with the opportunity of being healthy & have never had such limitless access to healthcare in medical history. However attaining the goal of hale & hearty cornucopia should but fill us with doubt rather than mirth. We constantly are faced with the tumult & uncertainty pertaining to what we know & what we don’t know. The following situations can be agonizingly delicate especially when they are related to expectations of healthcare & truth disclosure.
- I know, you Know
- I don’t know, you Know
- I know ,you don’t know
- I don’t know,you don’t know
Given these four situations in the patient – practitioner (lab medicine included) relationship, the first scenario is ideal with due consideration to patient rights. But it is worth noting that the possibility of the other 3 situations existing cannot be dismissed from the outcome in a clinical narrative. Whilst we practice evidence based medicine how can we be sure of the diagnosis/es,or the truth behind the values we get in the best of laboratories after applying the best of QC practices.
Moreover the truth holds true only for ‘what’ questions & not for ‘why’ questions.
The chance of ensuring infallibility relies on processes. However it is known that the best of processes can fail (like all security checks don't evade bomb explosions, plane crashes,etc).The same applies to healthcare as well. Clinical excellence does not translate to healthy bliss.This does not undermine the importance of keeping a robust process in place.Focus on that tiny fraction of error that we could have sneaked past person or process could also be avoided. Like an inadequately mixing a sample or not cleaning a puddle leading to a fall.Hence the onus is on preventive action that could have checked the error from happening in the first place.
Holier than thou !
Lab medicine has come a far way from being a branch which housed live rabbits a century ago. Current laboratory practice in the organized sector is incomplete without the application of QMS,QA processes & stringent accreditation guidelines. Hospital accreditation guidelines when compared with lab (ISO 15189) guidelines are but copiously watered versions. For instance the yardstick applied for the comparison of the quality of radiology reporting when compared with the evidence required for documenting histopathology reporting quality would put a wry smile on the face of most lab practitioners.
Even more silhouetted are the mechanisms of gauging competency in the closeted air conditioned recesses of healthcare. Evidence for the same in places such as operating theatre,delivery rooms,ICU’s etc are not in par with the lab medicine. When confronted by consent forms in dull print & litigable language in times of vicissitude, patients can only but hope on the scrub clad saviors. The high reputation & the many accolades that a clinician might carry along with the documented evidence need not bear much resemblance to what transpires as clinical outcome.
Epilogue:
All perceptions are a mix of the accurate & inaccurate. Though we practice science what we are faced with in practice at first is perception of a situation. The same could be a bleeding artery or a hemolyzed blood sample or a value reported by an analyser.There is a tiny fraction of error that creeps even when the best of processes are in place. The choice of error disclosure & expert concealment lie in our very hands. Moreover the subject of error disclosure is faintly touched upon as it has a bearing on individual,as well as organizational reputation. Practitioners of healthcare walk a thin line & are often faced by the classic Hamlet situation.