Medical Errors & Accidents: Calling A Spade A Spade

By Dr David KL Quek

dquek@pc.jaring.my

 

“For the sake of its own credibility, the MMA should waste no time in acknowledging three basic truths about medical errors, that: errors have always happened; there has been no official indication, until now, as to how common they are in Malaysia (CAP's ground-breaking bare-all report on the matter represents the first public attempt to quantify the size of the problem); and we need to do more about errors (including welcoming vital information on the issue from the public) to reduce their occurrence and improve safety for the benefit of all Malaysians.           S.M. Mohamed Idris, President, Consumers Association of Penang.

 "Freedom requires that we learn and put into practice the three R's - Respect, Responsibility, and Restraint." -- Fr. Brian Cavanaugh

Recently, the Consumers Association of Penang has come out strongly against the MMA and its purported stand on Medical Mistakes, accusing us of our “total lack of transparency on the matter” which it feels, “reflects a clear disregard for public interests.” This alleged nonchalance is considered even “more disturbing than the medical error phenomenon itself.”

Indeed, the strong rhetoric that CAP is using underscores the concern and perhaps also the misguided opinionated approach it wishes to take, vis--vis our Association and the medical profession.

Perhaps it adopts such a confrontational style to forcefully focus on issues, which it perceives as having been obscured or underplayed by establishment-controlled practices and by big business bullies. They obviously see their role as the ultimate protector and strident voice of the weak, the marginalized and the powerless masses. They clamour that injustice, and shortcomings—which ultimately harm or belittle the consumer, the hapless victim—are often deliberately hidden and underestimated.

We do not deny that consumer associations have a major role to play in re-directing the attention of society against the excesses and the bullying mendacity of many a cruel and amoral business practice, so rampant in this winner-takes-all new age.

The powerful seems to overwhelm the powerless, which can more often than not resort to no other help save for a few concerned non-governmental organizations (NGOs). Some of these would be sufficiently motivated to take up the cudgels of activism and counter-establishment objectives to help accentuate the voice of reason. Often such NGOs succeed in forcing many a miscreant establishment to fall back and re-assess their priorities and actions. Ultimately the under-represented victims or vulnerable people at large could benefit, and we salute them for their dogged tenacity.

Sporadically and unfortunately, CAP and other consumerist associations such as FOMCA have focused their attention on us the medical profession, much to our chagrin and gut-wrenching discomfort. The glare of such unsolicited spotlight is what most professions dread. As doctors we are no different.

In truth, despite all talk of increasing transparency and universal openness, no one really desires to be so publicly scrutinized. Worse in societies such as ours where quiet and closed-door deliberation remains the preferred mode of airing of disputes, washing dirty linen in public carries a particularly distasteful flavour.

However, whatever our own personal sentiments may be, it cannot be denied that the medical profession can no longer expect the kids glove handling that it is so habitually used to having. Not too long ago, we had begun to lose the awe and demigod-like status with which we have been so nobly bestowed, because of our healing vocation.

Alas, our gradual slide into the business and corporate world has put paid all pretense that we are in it just because of our humanitarian concern for the health and welfare of our raison d’etre—our patients. True for most of us, our profession continues to evoke that hard-to-express altruism that as a schoolboy or girl, we became enamored with, and which led us into the long tortuous road of years and years of medical studies. Our public-spiritedness and lifelong vocation must necessarily still conjure up the magic of humbling and gratifying service to others who are ill, infirmed, and suffering.

Nevertheless, it cannot be denied that we are still a special profession with perhaps the strongest and most consistent moral compass, the most rigid of all ethical codes of professional conduct. We remain perhaps, the last bulwark of the crass commercialization of all the professions. Individually perhaps, we maintain a most personal touch with our clients—the patients—this unique intimate person-to-person interaction continues to be unmatched and second to none.

To be sure there will be some black sheep amongst us. To be sure there will also be those who are less able, less perfect, less competent in varying degrees. But on the whole, are we so bad, that we have to continually defend our profession?

Are we still to be castigated for being less than perfect? Perhaps we should be, because public expectations have risen by leaps and bounds. Perhaps we could be more forthcoming in our acknowledgement that some inadvertent mistakes and medical errors do take place from time to time. Perhaps some of these could have been prevented, and perhaps some lives could have been saved, or some grievous hurt avoided. Perhaps.

Perhaps too, by not offering our less-than-perfect services, there would have been more suffering, more deaths, more painful infirmities. Would there not have been more wretched ailment if we were not in existence? Would we have exterminated smallpox, and now nearly poliomyelitis, if not for the veracity and efficacy of our public health efforts, such as mass vaccination? Consider too, why lethal pockets of childhood diphtheria still crop out with such devastating heartbreak, unless some failure to implement such preventive public health measures has occurred, such as when some religious or ill-informed communities refuse these “modern” health plans, for fear of unwarranted adverse effects.

It is a terribly curious and incongruous phenomenon that only the worst aspects of modern medicine and medical care are highlighted with such irrational and petulant tones.

Consider, the HIV-AIDS plague in Africa. The whole world is lamenting the fact that the drugs for treating the ailment are too costly for the poor victims of the sub-Saharan Africans. The world’s giant pharmaceutical corporations are being accused of unfairly profiting from the anguish and pain of the sufferers, by pegging the cost of drugs too high. Perhaps. But do they know that the therapeutic use of most of these drugs is still far from evidence-based proven, and that they merely slow down the progress, and extend some lives somewhat? Do we remind ourselves that many of these drugs are not too well tolerated, and have myriad adverse effects, which require extensive and expensive monitoring? Some of these side effects can be pretty serious, some are even life-threatening.

Yet suddenly this alternative of potential drug-induced medical mishap, is acceptable and preferred because the alternative is certain painful death. Denying such interim treatment albeit imperfect would have been an unthinkable option under these circumstances. Choices therefore, are what modern health care is all about—some quite unacceptable, but others reluctantly less so.

Therefore, do we blame the harbinger of hope, and condemn it regardless? Or do we welcome the less-than salutary effects, and hope for the best outcomes? The health choice by even the most knowledgeable and the most well read, nowadays, is really not so simple. Otherwise, we can all become doctors of the Internet age, with no need to be trained or taught. In actual fact, many are now attempting to heal themselves, from the prickly tones with which they attack modern day medical practice.

However, it is not so black and white, because the art and science of medicine is simply too complex and capricious—it is neither a perfect science nor is it strictly and logically certain. Modern medical care is just more rational, more repeatable, more ratifiable than all the historical mumbo-jumbo of witch doctors, sangomas, astrologists, grandma’s remedies or even thousand-year old panaceas of folklore herbs and roots. While we may not fully comprehend all the minutiae and nuances, the underlying principles of modern medicine are consistent and replicable, with no need to resort to magical or wishful thinking.

The public must learn to be more discerning, less gullible and less easily taken in by folksy and testimonial-embellished propagandas of so-called new-age “natural” cures. They are urged to review the history and development of modern health and medicine, so as to truly understand the growth and advancement of the scientific thinking that has reshaped our humanity and man’s longevity thus far. Undoubtedly we have become too complacent and take our improved lives and health for granted.

Do we know that just about the end of the 19th century, around 1900, the average life expectancy worldwide was just 48 years? Infections were decimating many even before their childhood years were spent. Bubonic plague, cholera, tuberculosis, typhus, septic infections and malaria were the rage, inflicting unspeakable suffering and shortening of lives. Entire generations had been nearly wiped out. Until the advent of widespread hygiene and antibacterials, mankind was subject to the whims and chancy luck of the draw, on who would suffer, recover and who would die. Through trial and error, modern medicine fought back a courageous if checkered victory.

Sanitation, cleaner environment, improved water supply, improved sewerage drainage and better personal hygiene all helped to eradicate the scourges of the past. Until a better alternative was discovered and tried, many suffered from serious side effects and erroneous measures. Imagine the common use of highly toxic metals such as arsenic and mercury for many an ailment on a trial and error basis. What suffering or even disastrous consequences would have occurred unwittingly in the past?

Yet we plodded on and we improved. Yes, in the bygone era, many were sacrificed on the altar of ignorance and misconceptions and the now recognizably wrong choices in medical care. Yet, can we deny that today we have become all the better for it, and that we have profited from these unfortunate mishaps of the past?

At the present age, things have changed. Entire systems have been overhauled, and entire outmoded concepts thrown out and revamped. Our paradigms of health and medicine are constantly being changed and refined. We have progressed much. We have become so empowered with new knowledge, new understanding that we have adopted much safer and people-friendly approaches to testing and treating humans. Now we are even challenging the need to use animals for pre-testing therapeutic advances, before they can be offered to man. Anti-vivisectionist and anti-animal testing activists are now noisily blaring their vociferous protests. What alternatives do we have? Very little, as of now. But the future holds tremendous promise with the advent of proteomic/genomic biotechnological models that should prove to be less testy.

Will we ever achieve error-free, zero-defect medical practice and health care? Can the modern practice of medical care be structured after Quality Control models? Or will we be condemned to the perpetual fate of inherent errors, which can never be totally eradicated? I believe we can and should certainly aspire to attaining gradually more and more superlative quality of care and practice.

"Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction and skillful execution; it represents the wise choice of many alternatives." -– Willa A. Foster

Of course, the MMA and the medical profession should not protect doctors for the pure sake of concealing medical errors particularly when these are clearly negligent. Neither should we go to the extent of ignoring the issue of medical errors and sweeping them under the carpet. We should be very clear on this point that negligence is always frowned upon, whereas medical mistakes and/or accidents may not be. We are cognizant that these do occur, and that some may indeed be preventable. Yet we recognise that many of these so-called medical errors are often impossible to predict, much less to avoid. Many could be simply human foibles, which although inexcusable, might be better understood, for the sake of our patients.

We recognise that human beings react very individually and idiosyncratically to modern medicines or procedures. Many variables are often impossible to quantify or even assess with precision—which is not to say that modern medical care is akin to the roll of the dice, it is certainly better documented than that. Our proofs of success have been well tested for the majority of our patients and our fellow sufferers. That is why more people than not, believe in the system that curative measures work, such as anti-TB drugs, appendectomy or bypass surgery, notwithstanding the accompanying tedious and sometimes painful personal journey of recuperation.

It is true that these days, patients should become more aware and be duly informed of the potential risks of medical treatment, although whether these informed choices would stand them in better chance of surviving or escaping the ordeal, is debatable. Nevertheless, this is indeed an acceptable modern expectation.

But to second-guess that medical mistakes are occurring with rampant impunity is reckless and unfair. To extrapolate that Malaysia must be faring just as badly or worse (!), just because certain countries have reported on the risk of medical mistakes and their alleged toll on human lives and suffering, is unwise and in itself untenable. The many alleged reports, which have been released through the various health agencies or journals, have all been contested, and in many instances discredited. These alarming statistics while eye-catching have so many confounding variables and guesstimates that these mis-data simply cannot hold water.

Details are painfully absent, and although human error has been latched on to some half or one third of these so-called mistakes, close scrutiny has revealed strangely poor substantiation. Unforeseen complications of the illnesses themselves are frequently confused and confounded with drug interactions and various surgical effects. They have been lumped together as if these were predictable and carelessly thought of. The motives for such reports—while good (and painful) for the medical and health profession to chew upon—are unfortunately less clear and smack of mischief and alarmist fear-mongering.

For SM Mohd Idris to state that “all of the evidence … bode grave ills for any country that embraces the western system of medical care,” is indeed reckless and patently biased. Is the CAP president advocating that we return to an era of Talibanesque and antiquated health and medical care?

While I might be accused of overly defending the profession, it is certainly not my intention to downplay serious mistakes, which have taken place or those that will occur in the future. It is accepted that medical errors do take place, but my contention is that we don’t just have the real data, as of today. The scope as adduced from foreign alleged sources cannot be acceptable, even as a poor guess.

Perhaps it would be good to have independent ombudsmen or authorities to perform regular and sample audits, to arrive at the better statistics. Only then can we be sure. Only then can we hope to improve, by studying these errors for their possibility in preventing or avoiding them in the future.

Surely one cannot be so cynical as to believe that the medical profession is so obtuse as to knowingly inflict suffering on our patients! Inadvertent and unforeseen accidents and/or errors could happen, but many occur not because of lack of proper medical care. Incompetence and negligence on the other hand must be checked and reduced through thorough medical audits, or even medico-legal address.

But let us not shoot from the hip first and hope for some victim out there to be hit, just so because we wish to have target practice. The medical profession is not and will not become easy prey for unfair and unjust predators whatever their motives.

Our tradition and honour deserves more respect than it is accorded these days, and doctors can help preserve this, by being even more caring, more careful and more circumspect in their dealings with patients.

Let us remember that we are healers who should first and foremost cause no harm at all, or if unavoidable sometimes for the ultimate benefit of the patient, inflict as little suffering as possible. It is well to remember that sometimes to heal or save a person, it may hurt a little… The choice in many instances is clear, a little pain and live, or perish through pusillanimous inaction. To offer alarmist public critique is, needless to say, a grave travesty of justice.

SM Mohd Idris has quoted Napoleon Bonaparte as saying: "You medical people will have more lives to answer for in the other world than even we generals.''

My retort to this is that most medical doctors have more live patients who have been gratefully saved than the generals or the alarmists who frightened the public away from good medicine and proper health care…

 

"Life is no brief candle to me. It is a sort of splendid torch which I have got a hold of for the moment, and I want to make it burn as brightly as possible before handing it on to future generations." -- George Bernard Shaw

March 2001

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