Future Leaders Communiqué Volume 3 Issue 4 October 2018
Download PDF: FL Communiqué October 2018
Case: Medicine – It’s a risky business!
Comments from our peers
Sometimes less is better
Navigating the coronial jurisdiction
Welcome to the January 2019 edition of the Future Leaders Communiqué. In this edition, we discuss the concept of ‘medical risk.’ An example of the many situations that arise in the healthcare system that create risk, and the challenges in managing that risk, is illustrated by the case summary presented here where a patient suffered an adverse reaction to intravenous contrast that sadly resulted in death.
Croskerry and colleagues (2009), defined medical risk as “the probability of danger, loss or injury within the health system.” As junior doctors, we order hundreds of tests each week to investigate and monitor our patients’ clinical conditions. Even the most routine of tests, such as a full blood count or a head scan, pose a degree of risk to the patient. Thus, as junior doctors, it is important that we understand these risks so that we can inform our patients and learn how to weigh up the risks versus the benefits of our decisions.
Regrettably, in this day and age, it is not just the probability of risk to the patient that influences our medical decisions, but also the risk of litigation. This has led to the practise of defensive medicine becoming embedded into the hospital culture, whereby investigations are ordered primarily with a view to safeguarding oneself from litigation. In Australia, 55% of doctors admit to practising defensive medicine, which is less than the United Kingdom (78%) and the United States (96%) (Bird, 2017). According to the Australian Medical Association, ordering unnecessary tests and using speculative treatments is estimated to cost the health care system in Australia more than $15 billion dollars a year.
Reflecting on my own experiences as a junior doctor, I am definitely guilty of ordering tests ‘just to be safe’. Particularly on night shifts when there is less access to support from senior doctors and in situations where I am lacking confidence in my own clinical judgement. I find myself more inclined to order a blood test or radiological scan so that I have an objective measure that may reassure me that I’m not missing something important.
In the case presented, the patient did not die from the condition that brought her to hospital, but rather from the management prescribed to investigate her symptoms. It highlights that even when there is a reasonable indication for a test, the critical question should be whether it is appropriate and necessary. Every test carries an associated risk and the potential to be ‘unsafe’ for the patient, but we are so used to thinking about the risk-benefits of treatment that we may overlook the fact that the investigations may also cause harm.
Our expert commentaries highlight the potential harm and costs associated with ordering unnecessary tests. They also provide tips for junior doctors about good medicolegal practice. Whether we like it or not, dealing with risk is part of our day-to-day job as doctors. It is important that we learn to approach risk systematically with a focus that is patient-centred. We need to think about the clinical indications for investigations to ensure we are ordering them with the best interests of the patient in mind, and not just as a mechanism to protect ourselves from a risk of legal consequences.