Getting It So Wrong

I read something the other day that I found quite challenging in a personal sense primarily because someone close to me has been battling breast cancer. The question I am posing is this: Should a Doctor whose misdiagnosis causes the death of a patient, be named and shamed?

This ethical and moral question was prompted by a case in New Zealand where a doctor was forced to apologise to the family of a woman who died from breast cancer because he “forgot” to tell his patient she had the disease.

Here’s the backstory. The woman was successfully treated for cancer in 2003. In November 2009, six years later, she presents herself at a clinic complaining of pain in her left shoulder. Now at this point the alarm bells should have been ringing in any event. Breast cancer can make a comeback and the timeframe for it happening is usually within five or six years.

Her treating Doctor was well aware that she was a cancer survivor. He referred her for an x-ray and the specialist radiologist said it revealed a tendon tear that appeared “highly suggestive of metastasis”, or the spread of cancerous lesions.

As this point the alarm bells should have stopped ringing and treatment begun immediately but that didn’t happen.

The GP saw the woman again several days later. He told her about the tendon tear and gave her a steroid injection, which the woman said was “excruciating”.

But crucially he did not mention the cancer link nor did he refer her to a cancer specialist.

She was told to return in a month if the pain persisted, which she did once in December and again in January before the doctor finally referred her to an orthopaedic surgeon.

The woman was correctly diagnosed with recurring breast cancer in February 2010, after she had changed doctors. Despite several years of aggressive treatment, the woman died.

The case became the subject of a complaint to the New Zealand Health And Disability Commissioner.

The doctor told the inquiry he either overlooked or completely forgot about the radiologist’s comment in relation to a suspicious lesion.

The Health and Disability Commissioner criticised the GP for failing to read his own notes, ask the right questions, or reflect on his patient’s medical history when assessing her.

He said Doctors owe patients a duty of care in handling test results, including advising patients of the need to follow up on those results.

The GP has been referred to the Director of Proceedings for possible legal action.

Clearly neither the patient, nor the Doctor nor the clinic or its location has been identified. I can completely understand not identifying the patient now that she has passed away out of respect for her family.

But the Doctor, I’m not so sure. If we are going to be talking about duty of care, what about the duty owed to all the other women with a history of cancer or symptoms of the disease or even the same symptoms as the woman who died?  They might visit that same Doctor and run the risk of a misdiagnosis. If they knew his name they could make the choice to either see him or go somewhere else.

Or is he entitled to the protection that the medical profession offers Doctors like him who make a mistake? We all make mistakes. Has he paid enough of a price already? Well has he?

 

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