Benjamin Daniels - Further Confessions of a GP

I was dreading seeing Ted again when he came into see me after his diagnosis. However, when I apologised for not picking up his illness earlier, he laughed. ‘Dr Daniels, it was me who smoked all them cigarettes for all those years. I can’t blame you for me getting this disease. I was dreading coming in to see you as I thought you’d be cross with me for not taking your advice to give up the fags sooner. I was expecting you to say “I told you so”, not “I’m sorry”!’

I tried to explain my culpability: ‘But if I had sent you for a chest X-ray sooner, the cancer might have been curable.’

Ted gave me a generous smile. ‘Don’t blame yourself, Doctor. I don’t.’ With that, he left. Despite his generous forgiveness, every time I saw Ted I was awash with guilt.

There is a bad joke about doctors being able to bury their mistakes. This wasn’t the case with Ted. I saw him at work, but I also bumped into him in the supermarket with his wife. I even spotted him at the football with his grandson. It was as if he was everywhere I looked, and each time we met, his obvious deterioration was a reminder of my error. Even now that he has died, Ted’s wife comes to see me regularly. She remains oddly trusting of my medical opinion and completely unaware of the massive guilt that bubbles to the surface of my consciousness with her every visit.

The fear of making a mistake is indeed a terrible part of being a doctor, but on reflection actually making a mistake is truly the worst part of the job.

I’m not the only GP to have made a mistake; compensation payouts for medical negligence are going up, not just the number of cases but in the cost of the payouts. As a way of combating this, it has been suggested by the government that doctors should be named and shamed by publishing our mistakes and performance data online. The idea is that this will allow patients to choose their GP based on his or her track record, and that the resulting possibility of losing ‘customers’ (patients) will motivate us to improve.

It might also be suggested that the best way for GPs to reduce the chances of missing a serious diagnosis is for GPs to have a very low threshold for referring patients on for specialist care. The problem with this is that we are also under massive pressure to keep our referral figures down. The NHS is able to keep costs down in part because GPs successfully triage the ‘worried well’ away from busy hospitals and costly specialists. High levels of referrals are expensive and push up waiting time. Often those referred are already better by the time they see the specialist or could be equally well treated by their GP. There may well come a time when those doctors who are over-eager to send their patients to hospital will be penalised for using up too many resources.

GPs are under pressure from all sides, but at the same time there are some slip-ups for which we have to step up and take responsibility. I made a mistake with Ted and it is one for which I will hold up my hands up. If the current proposals go ahead, would my patients have the right to know about that previous blunder? Would they register with another doctor as a result? In an attempt at redemption I now ask all my smoking patients if they have a cough. If they have even the slightest throat tickle, they get sent for a chest X-ray. My practice has changed because I am scared that a future patient might come to harm due to my misjudgment. I’m not convinced that the added forfeit of damaging performance stats would really make that much difference.

I am ready to own up and take responsibility for my mistakes, but wouldn’t we all agree that the real key is trying to prevent errors being made in the future? Rather than spending money on dredging up my past in order to rank me in a series of performance data statistics, perhaps it would be better to look for more positive ways to prevent future slip-ups. In our practice we have found talking openly about our errors helps. If a patient had a serious condition that was missed, all the staff look through the notes together to try to work out what we could do differently next time. If there is a field of medicine we feel our knowledge levels are lacking in, we encourage each other to get up to date on the latest research.

There were 300 million GP consultations in England in 2011 and just over 7,000 complaints made to the General Medical Council. That works out at around one serious complaint for every 42,000 consultations. Most GPs are good at their job and this is reflected in the ongoing high levels of trust in our profession. When mistakes are made we need to take responsibility for them, but we should also be encouraged to learn from them in an open and supportive environment. It really doesn’t seem to me that name and shame proposals are offering this. I would also suggest that they don’t really tackle the issue of persistently poor GPs either. If a doctor can’t learn from their errors and makes the same mistake time after time then surely something more serious needs to be done than simply publicly denouncing them on a government website?

‘I think I’m losing my baby,’ wailed the lady sitting in front of me.

Karen was not one of my regular patients and had only registered with our surgery that week. She explained to me that she was 25 weeks pregnant and that up until now her pregnancy had been completely normal.

‘Every day for the last six weeks I’ve felt my baby move, but I’ve felt nothing since last night,’ she anxiously told me.

‘I’m sure he’s fine in there, he’s probably just having a lie-in,’ I chirped optimistically. ‘We’ll have a little listen.’

I was fairly convinced Karen was just having first-time pregnancy jitters and I was looking forward to reassuring her with that lovely sound of a baby’s heartbeat. With Karen up on the couch, I squeezed some gel onto her tummy and moved my Doppler probe around listening for the baby’s heartbeat.

We both remained silent as we listened for the trace of life. Every so often, between the white noise of interference I could make out a pulse, but it was the slow whooshing sound of Karen’s own arteries pulsating rather than the much faster clicking sound of a baby’s heartbeat. We endured an awful 10 minutes of searching, but however much I tweaked and moved the probe, I couldn’t hear the reassuring beat that would let us know her baby was alive. I finally gave up and Karen got off the couch.

‘Look, Karen, it might just be my Doppler machine or perhaps your baby’s lying at a funny angle or something. I’m going to call the obstetric doctor at the hospital and ask them to see you this afternoon. They’ll do a proper scan and find out what’s going on.’

Just as I picked up my phone to call the hospital, I heard a wail from Karen.

‘Oh my god, Doctor, I think I’m going into labour!’

Karen started screaming in pain and I dialled 999.

The paramedics were with us within minutes.

As she panted and groaned, I helped Karen into the ambulance, tears of fear and pain running down her face. As soon as she was safely on her way to hospital, I called the obstetric registrar to warn him of Karen’s imminent arrival.

I carried on with my surgery that afternoon, but all the while I was thinking about Karen and wondering what was happening to her. Going into labour at 25 weeks is much too early and although I’ve heard of the odd baby surviving when born that premature, the odds really aren’t great. The fact that I couldn’t hear the baby’s heartbeat on my probe made me feel even more despairing of the poor little mite’s chances. Miscarriages before 12 weeks are common and heartbreaking, but losing a pregnancy after 25 long weeks must be absolutely horrendous.