Code of Conduct vs Code of Silence
Last week’s column in this series elicited two types of emotionally charged responses. People with similar stories of real and perceived malpractice, and doctors some of who said the malpractice claim was not clear-cut on medical grounds, and pointed accusatory fingers at the lack of adequate staffing and facilities at the San Fernando General Hospital.
Among them was a public service doctor who asked the stark question based on his experience: “What does a lone duty doctor do when four people are simultaneously admitted with heart attacks?”
Or, “What do I do when the family of a dying patient accuses me of malpractice when I don’t have basic life-saving equipment?”
And a patient who asks the question: “What do I do when I know my husband died under the care of doctor X and I am subsequently told by doctor Y (both in private practice) the drugs doctor X was administering hastened or even precipitated my husband’s death?”
What patients and doctors agree on is existing systems for dealing with complaints have failed dismally to the point of being non-operative. Most doctors, according to one medical source, take pride in their work. However, under the present system, the source says, the only checks and balances errant doctors face is ridicule from their peers, or an occasional letter of complaint to the Ministry of Health. Other than that they wrap around themselves a protective code of silence to maintain patient trust without which their profession would lose its credibility and accompanying monetary value.
Meanwhile, dissatisfied upset patients, or those with serious complaints end up airing their grievances to a passing nurse, a doctor in another ward or a security guard. All these positions support my renewed call for systems to the Medical Board to ensure accountability, transparency and recourse to patients.
An independent medical malpractice Board to examine complaints over medical treatment. This Board should put forward decisions that can allow legal action to take place in a reasonable time.
A medical ombudsman.
A published national data bank which would list doctors, their area of expertise, including ongoing training, a record of complaints of both breaches of codes of conduct, and a record of malpractice complaints.
The malpractice Board should be made up of at least three doctors, one nurse and two lay people. The board should be rotated on a staggered basis to avoid interference and ensure independence. A standard complaints form should be made available at all private and public health institutions and a written acknowledgment given to the complainant on submitting the form. Within a month, the complainant should be informed if he or she has a case. Within six months the complainant should have a final ruling on the matter that may be used for legal action either against doctors or the Ministry of Health. The malpractice Board should have the authority to discipline doctors in addition to ordering them to be struck off the list.
A malpractice Board would allow the patient recourse, if the doctor was at fault, and the doctor, vindication, if he was not. This Board would also show up deficiencies in both private nursing homes and public health system and could be the basis of a lobby to improve general health conditions.
In addition, the Medical Board should be exercising its responsibility to educate people on how to use public and private health effectively.
In their responses doctors have raised several points to this effect: that many patients fail to inform doctors of previous treatment; fail to take their medical summaries with them when switching doctors; don’t take their medication according to instruction, take treatments from two doctors at once with the (sometimes fatally) mistaken assumption the cure will be twice as effective; are unaware preventative care such as annual check-ups are much more effective than waiting until an ailment reaches chronic proportions and then are disappointed when their unrealistic expectations of a miracle cure isn’t realised.
The data bank on doctors should be published on a semi-annual basis.
The medical ombudsman would bring further checks and balances into the system and can be used as a measure of last resort for those who are unhappy with the decisions of the malpractice Board.
The Medical Board must play an effective role in guiding the profession towards primary and preventive care with a nationwide education programme. The Medical Board itself must be transparent and its power and responsibilities published for the benefit of doctors and patients, and their minutes should be made available.
Meanwhile, other than the malpractice issues, doctors’ standards of services need to be improved. I have taken the liberty of proposing a code of conduct based on the UK code. If one exists now, clearly the patients of this country don’t know about it because it hasn’t been published. In order for it to work, an effective monitoring and complaints systems will need to be put in place by the Board.
Doctors should:
Provide health care without discrimination as to your lifestyle, race, creed or similar factor. (eg Workers at the Cyril Ross Nursery have complained of how many young doctors were reluctant to treat HIV positive children for fear of contracting the virus.)
Respect their patients’ privacy, dignity and religious and cultural beliefs at all times. (If a male doctor examining a female patient and requires her to strip, it should be compulsory to have a nurse present. Many women have complained of sexual harassment on the doctor’s table. In one case a doctor asked a young woman to bare her breasts when she came in with a twisted ankle!)
Make it easy for everyone to use medical services, including children, elderly people or people with physical or mental disabilities.
Provide a specific appointment time and be seen within 30 minutes of that time. Exceptionally, if unable to make this appointment or be delayed inform patient, and provide another appointment if requested.
Provide information in writing about the following:
The services they provide.
Standard Price list for services and treatments (especially ongoing treatments).
List ongoing training.
Document their track record, with notes on any areas of specialty.
Opening times, how to make appointments and what patients should do if they have to cancel.
Arrangements for giving the patients the results of any medical tests.
Arrangements for obtaining repeat prescriptions.
When it is and is not appropriate to call for out-of-hours treatment;
Arrangements for dispensing drugs and medicines within the practice.
Details of the way complaints and suggestions are handled within the practice.
Explain any proposed treatment, including any risks involved in that treatment and any alternatives, clearly to their patients before they decide whether to agree to it.
Explain any proposed medication regimen, including any risks involved, how often it is to be taken, reactions with other medication (eg the elderly may take several drugs) and any alternatives (including generic drugs), clearly to patients.
Provide patients with access to their health records (ie copies, if requested), and ensure everyone working under them is clear as to their duty to keep patient records confidential.
Comply with requests for referral to a specialist acceptable to the patient, and provide referrals for a second opinion if the patient so desires. In case of any referral to a medical facility the patient has a right to know if you or any member of your immediate family has a vested (financial or other wise) interest in the facility.
If we allow the fatalism that comes with living in a small country, or the knowledge most people at a high level get by more by whom they know than what they stand for, then there is no hope for us. But if each of us starts to care about the rest of us, then there will be change, there will be growth, there will be hope.
Next week: The Patients’ Charter