Saturday, 23 July 2011

Patient Safety

We have been told (by the General Medical Council) how doctors' revalidation will improve patient safety, back in October 2010.

The sagely Jobbing Doctor muses over whether nurses' revalidation/governance will tighten up, querying what the fallout will be, here.

It truly isn't a cynical comment, it's simply an observation, that I really can't see how revalidation will make any difference to patient safety. Post-Shipman we've had rigorous annual appraisals, taking literally days to do each time. And Consultant peers looking at our cases for Case Based Discussions. And Peer Groups (which should have happened anyway) actually happening, looking at our learning objectives and what we're doing/what we've done. I really can't say patient safety's any different.

Realistically, how would you spot someone like Shipman? We frequently have very different outcomes with different clinicians. A real example from my training : one surgeon wants low mortality rates and only operates on those who will have good outcomes, leaving most to no active treatment/palliative care, so those with moderately advanced cancer are denied surgery and go on to die. But those he operates on do very well and his perioperative death rate was incredibly low, since he only operated on those with early cancers and decent health. Another surgeon would try his hand at even the most desparate cases, figuring that death was inevitable and pretty immediate if he didn't. Many (indeed most) of his patients did very well, but some of course died soon after surgery. His perisurgical death rate was stratospherically higher. But understandaly so. He was still the better surgeon (and arguably the better clinician). Mortality rates alone are just numbers, we need context and understanding of the patient population, the interventions, others involved in care, comparative data with others, understanding of norms and bell curves and variability, it's not simple to speak with a doctor and dichotomously allocate them in to a "safe" box or "murdering" box.

What it boils down to is, usually, over a coffee, hoping to trip up the bad apples through slipping in a question such as, "Well Bob that about covers things. Oh, by the way, d'you have any urges or are you planning on murdering large cohorts of your patient population, within the next year?"

It's as good as governance systems would seem to be . . .

4 comments:

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Julie said...

The system already had ways of spotting rogue doctors and it was one of them - the requirement for cremation forms to be countersigned - that caught out Shipman. I'm not sure that revalidation is going to add anything to ordinary vigilance apart from piles of paperwork.

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