Time for a check-up

By Martin Johnston

Photo / Thinkstock
Photo / Thinkstock

Patients are suffering and even dying because our system of monitoring doctors is too slack and too cosy, says a former medical watchdog. Martin Johnston reports

Janice* trusted her doctor to know what to do. She was 62 and had been his patient for more than 20 years.

Her GP was a part-timer in his 70s, working at a multi-doctor suburban Auckland clinic. Like many others he had (perfectly legally) never gained a post-graduate qualification in general practice.

When Janice began suffering pain in her abdomen and had problems passing urine, he at first diagnosed irritation of the urethra and prescribed medication. Janice, who was obese and had many other health conditions, consulted him repeatedly in 2002. After five months, he referred her for an ultrasound scan and she was found to have a pelvic mass the size of a 24-week pregnancy. A CT scan later found she had cancer of the uterus.

Things got worse. Janice had a heart attack, her right leg had to be amputated because of blood flow problems and she suffered a stroke. Her cancer was so advanced it couldn't be treated.

She was discharged home from hospital and died a few weeks later, nine months after she first sought help for the abdominal and urinary problems.

"It was a really painful time," Janice's niece, Sharon, recalled this week.

"I was living at home at the time and I remember her going to the doctor on many occasions with complaints. Then, over a space of a few months, she had to have her leg amputated and had cancer. It all turned into a bit of a nightmare. We didn't feel the doctor gave her a very good professional opinion, and we feel he failed to give a proper diagnosis.

"The reports said the outcome wouldn't have been different [if correctly diagnosed earlier] but as a family, we think maybe she could have been saved.

"We were shocked. She had been going to this doctor for many years. You put your trust in your doctor and in the health profession that you are getting the best care possible. I think sometimes things slip."

Former Health and Disability Commissioner Ron Paterson, now an Auckland University law professor, says in his forthcoming book, The Good Doctor, that although Janice's case didn't attract media attention and did not lead to a public scandal, it has stuck in his mind from his decade as the country's leading health watchdog.

His 2005 investigation criticised Janice's doctor for failing to adequately investigate her symptoms and recommended the Medical Council review the competence of "Dr B".

The doctor's medical centre colleagues had told Paterson they did not know what steps clinics usually took to ensure practitioners were competent, "other than informal inquiry with their peers and casual overview of their notes at work.

"[Dr B] has been in practice for 50 years without a complaint. He is a humble and careful man with a deep concern for his patients. ... We did not 'audit' his notes. It did not occur to us to take steps to satisfy ourselves that he was competent ... this is the job of the regulatory authorities."

Paterson - now free to speak his mind on such matters - says there was no evidence the Medical Council had taken any steps to check Dr B's ongoing competence before Janice's case, "nor that it had any rigorous system in place to do so".

He expects Janice would have assumed that her doctor needed a medical "warrant of fitness", that his colleagues would have kept an eye on him, and that the Medical Council would require him to meet strict practising standards.

"She was wrong. Her trust was misplaced," he says in the book, to be launched next week.

Checking the competence of doctors is not in the commissioner's brief, but Paterson saw the results of incompetence, enough to want to push for improvements. He emphasises that most doctors are "good" or at least "good enough". However, he cites international researchers' estimates that up to 5 per cent of doctors are practising poorly and 1 to 2 per cent may pose a threat to patient safety.

In New Zealand's pool of around 14,000 registered doctors, that suggests roughly 200 may pose similar risks as Dr B.

"It became clear to me," Paterson writes, "that despite supposed safeguards, some incompetent practitioners were able to continue in practice and harm patients. More worryingly, I observed the apparent unwillingness or inability of regulators to take any decisive action to improve the situation."

A doctors' medical degree, or equivalent exams for immigrants if their qualification isn't recognised in New Zealand, provides the initial competence checks on entry to the profession. Many progress to become specialists or GPs by an "apprenticeship" as a registrar and passing more exams - another competence check - run by various colleges, such as the Royal Australasian College of Surgeons.

The Medical Council is at the heart of this and although it has wide scope to deal with doctors accused of incompetence by other health authorities, it oversees what Paterson considers only a very light-handed system of ongoing checks on competence.

As well as being registered - the profession's entry point - doctors must obtain an annual practising certificate from the council. This includes declaring they have completed their college "re-certification programme" or 50 hours of "continuing professional development", which involves reading medical journals, attending conferences, peer review and clinical audit such as a pathologist's accuracy in diagnosing abnormalities in tissue samples.

Paterson says that from the list of things re-certification programmes are allowed to include, most are "notably light on exams, review and inspection". And he told the Weekend Herald that continuing professional development systems, "although worthwhile, don't really give the assurance that the public is looking for".

Hospitals' "credentialling" of their doctors may detect incompetence, but these systems are neither uniform nor consistently applied.

"I think that I and many people in New Zealand felt that in our Health Practitioners Competence Assurance Act we had this world-leading legislation that enabled us to - the title gives the game away - to ensure that practitioners are competent. But when you actually start to look in detail at the way it's working, in fact it doesn't give that assurance."

Paterson calls for colleges and the council to replace current re-certification with systems that incorporate aspects of North American and British developments, including:

* feedback from a doctor's patients;

* eventually some type of clinical skills test (although exams are currently "a bridge too far"); and

* either targeted screening of at-risk doctors such as those of advanced age, or occasional performance assessment of all doctors.He is also critical of the clinical auditing done for re-certification. He argues for public league tables that go far beyond the Government's six health targets comparing district health boards. He wants robust data made public on the quality of care provided, first by hospitals and primary care teams, and then, within a decade, by individual doctors.

"A 40 per cent reduction in risk-adjusted mortality has been reported in the United States and [Britain] following the introduction of public reporting of results, and this has been achieved without denying surgery to high-risk patients."

A companion theme in the book is that change is stifled by factors like the alleged timidity of the Medical Council in the face of under-fire doctors' legal challenges and the council's "cosiness" with the profession - Paterson notes two of its heads in the past decade have also led the Medical Association. Curiously he doesn't name them: they are Drs John Adams and Tony Baird.

Paterson calls for an end to both the statutory majority of doctors over lay people on the council, and to the profession being allowed to elect half of the doctors.

A review of the council in 2010 by a British health regulator also criticised the doctor majority, suggesting it undermined public confidence. The review noted council research showing only 9 per cent of the public thought doctors in general were "very trustworthy", although 43 per cent said their own doctor was.

It recommended greater openness and accountability at the council, a view echoed by Paterson, who wants the council made subject to the Official Information Act.

Adams, the current council chairman, and Medical Association chairman Dr Paul Ockelford reject the "cosiness" claim. "We believe strongly in the integrity of those who are on the council," Ockelford says.

Adams defends the membership balance, saying the council needed the medical and sector knowledge of its eight doctors to carry out all its functions. The elected members' job was, like the other members, to protect the public; they were not representatives of the profession.

He says the re-certification processes appropriately balance external regulation and internal professionalism and he explains the council is making big changes - acknowledged by Paterson - for many so-called "general registrants", where the system wasn't working.

Dr B was in this group. He had general registration, not specialist or "vocational" registration.

There are about 3000 general registrants who receive adequate oversight as specialists-in-training or through hospital credentialling or college re-certification programmes. But the remaining 2000 - including those in general practice, accident and medical centres and some in hospitals - have practised in a "loophole" of weaker re-certification.

The beefed-up checks, which began last month, introduce a three-yearly clinical knowledge test, patient and colleague feedback, and five-yearly practice reviews including direct observations of their work.

Adams says some colleges already use the latter, notably the obstetricians and gynaecologists, but the council won't make these regular practice reviews mandatory as this would tip the balance too far to external regulation.

Ockelford says there is no evidence practice visits make for safer doctors or capture poor performers. And he is cool on Paterson's clinician league tables, although supportive of institutional comparisons.

"We would see collegiality and professionalism as the keys to ensuring that doctors do practise most effectively."

Collegiality, or shared responsibility, is on the mind of Janice's niece too. "Maybe if a medical clinic which had multiple doctors, like the one she went to, swapped notes and discussed cases maybe she would have been sent for more tests and a diagnosis could have been achieved earlier," Sharon says.

"I think this would have definitely helped. Doctors need to be on top of their game. If they have a situation where they are at a loss, then surely more heads are better than one?"

* Names of the patient and her niece have been changed at their request.

How it works overseas

Former Health and Disability Commissioner Ron Paterson suggests New Zealand draw on developments by medical regulators overseas to improve systems for checking that doctors remain competent throughout their careers. Here are some examples he cites:

Quebec, Canada

"Red-flag" doctors considered at risk of performing poorly are identified by a screening process and receive a professional inspection visit.Serious deficiencies can lead to practising restrictions and a remedial programme."At risk" includes those still practising more than 35 years after gaining their medical degree; doctors whose prescribing and billing data are outside the norm; specialists who do no hospital work; international medical graduates with restricted licences; and doctors subject to complaints and concerns.

United States

The American Board of Internal Medicine has an exam as part of its re-certification programme.The exam focuses on clinical problem-solving and diagnosis.

Britain

The General Medical Council is planning a new system in which doctors will have to prove every five years that they are up to date and fit to practise.This will include feedback from patients and colleagues.Any council doubts about "re-validation" of a doctor will lead to further checks which may result in loss of his or her licence.

- NZ Herald

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