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July 28, 2014

Far from ‘ultra’ sound advice

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Dr Ruairi Hanley argues that doctors are more likely to get a right answer than the notion of ‘patient instinct’ promoted in the recent coverage of misdiagnosed miscarriages


I was driving to work when news broke of the latest misdiagnosis crisis on national radio. As I listened to the initial reports, my immediate reaction was to mutter, ‘Please, Jesus, don’t let it be the Lourdes!’
Within seconds, it became clear this particular prayer was in vain. Ireland’s most controversial hospital was once again in the headlines for all the wrong reasons.
While I have the utmost sympathy for those mothers affected by these incidents, I am extremely disappointed at much of what has been written on this issue to date. I believe I have never read more drivel in my life than some of the commentary on the ultrasound scandal.
Let us begin with a few facts. There are roughly 80,000 pregnancies a year in this country, and perhaps 10 to 15 per cent of these end in miscarriage. This is very distressing and tragic for the patients involved, but it is usually a completely unavoidable medical event.
We should also recognise that ultrasound scans do not enjoy 100 per cent accuracy. Even if they managed 99 per cent (a very optimistic figure), there would still be potentially 800 inaccurate pregnancy related diagnoses a year.
Unfortunately, it would appear that sections of our media believe that medical technology should have achieved perfection, similar to that employed in the sick bay on the Starship Enterprise. Such a level of irrational expectation does not lend itself to balanced analysis.
We also live in a society where an acceptable margin of unavoidable human error is treated as a ludicrous concept, rejected in favour of the public crucifixion of the unfortunate individual who has made a genuine mistake.
Now that the popular press has had a few days to stop being completely hysterical, maybe they can try to grasp the following reality. It will never, ever be possible to eliminate misdiagnosed miscarriage. It is inevitable — even in the world’s greatest health systems — that some women will be told that they are no longer pregnant when in fact they are. (Once again, I wish to emphasise that these patients and their families deserve our every support and sympathy.)
Of course, it is possible to minimise the risks of these events occurring. Ensuring that equipment is up to date, learning lessons from previous errors, maintaining training standards and implementing evidence-based protocols are the best methods of achieving this outcome. Even then, there will always be mistakes made.
Media outrage
Unfortunately, in Ireland we prefer to reject such science-based rationalism and improvement in favour of media-based outrage competitions, which achieve nothing more than stress, suspicion and fear for patients. A good example of this thinking has been seen in recent articles urging women to ‘trust their instincts, not their doctors’. In my opinion, this is the type of idiotic statement that will do nothing to improve the situation.
The science of medicine, including obstetrical medicine, is ideally governed by evidence-based practice backed up by research and clinical excellence. Such an approach cannot be abandoned in favour of subjective ‘hunches’.
Based on trust
The relationship between doctor and patient is one that is fundamentally based on trust. This means that the individual accepts that the medical advice they receive has their best interests at heart, and is based on a high standard of training and expertise.
Patients are entitled to expect that their doctor is competent, and if they are not they should be sacked. It is for this reason that we have the Medical Council. They are also entitled to seek a second opinion if dissatisfied with their care. I have no difficulty supporting these basic patient rights.
However, what I cannot accept is a culture where patients tell doctors how to practice medicine on the basis of their ‘gut feelings’, or on something they have read on the internet.
The harsh reality is that patient instincts and self-diagnosis are usually wrong. This is not their fault, as they have not spent decades learning how to interpret physical symptoms and signs.
Usually, reassurance and an accurate diagnosis will ensure that the vast majority receive effective medical treatment. A minority will continue to ‘trust their instincts’ and, as a result, will undergo unnecessary investigation, stress and worry.
Patient’s hunch
Of course, in a tiny number of cases it will emerge that the patient’s hunch was correct and the doctor was wrong. These are thankfully rare scenarios that can potentially have tragic consequences.
Such extremely unusual stories also sell newspapers, whereas far the more common incidents where patients die because they ignored medical advice will never ever appear in print. I fully accept that we must acknowledge when we make errors and apologise for them fully. In return, we should expect that the public be informed of how high our standards are and how infrequently mistakes are made.
The truth is that doctors are right most of the time and if patients trust and listen to us, in the vast majority of cases, they will have positive outcomes.
The medical profession is not infallible, but it is a hell of a lot more likely to get the right answer than the notion of slavish adherence to patient instinct. Unfortunately, this is rarely acknowledged by our popular press who would apparently prefer to portray obstetricians as incompetent potential baby killers. One columnist in a tabloid newspaper went so far as to suggest that misdiagnoses would not happen as frequently if there were more women gynaecologists.
Closet misogynists
I believe such analysis is truly beneath contempt. Not only does it imply that obstetricians are emotionally retarded closet misogynists, it also ignores the fact that female members of the profession are just as likely to make clinical errors as their male counterparts.
These supposedly heartless men have also made Ireland one of the safest places in the world for a woman to have a baby, an undeniable fact overlooked by some commentators — presumably because it is inconsistent with their fundamental anti-medical prejudice.
Thankfully, there has been one positive development from all these events. In a rare good decision, Minister for Health Mary Harney refused to hold a public inquiry into the ‘scandal’. Such an investigation would have achieved nothing more than a massively increased workload for our obstetrical departments. It might have appeased some doctor-hating newspaper columnists, but it would have done nothing to improve standards of care.
Therefore, I will conclude this week with four words I never thought I would write. Well done, Mary Harney.