Debate: We feel insecure when doctors make mistakes

By Allan Flyvbjerg, Dean of the Faculty of Health, Aarhus University

Most of us can remember at least the outline of the unfortunate cases from the healthcare sector that have featured in the media over the past few decades. We have seen psychiatrists that have blatantly misdiagnosed their patients for years; surgeons who have carried out repeated fatal operations; and those medical doctors who have had their authorisation revoked in one Scandinavian country, only to resume practicing medicine in another. On top of this there have been a few unfortunate cases with a dishonest brain researcher and with heart researchers who have regarded research funding as their own personal pocket money.

Fortunately, the fact that almost everyone can remember something about these individual cases is actual a healthy sign, because these are relatively isolated examples. Here in Denmark we are used to seeing a medical profession that is honest and incorruptible and which lives up to the ideals of the Hippocratic oath. For us, receiving competent treatment when we visit the doctor is the most natural thing in the world, regardless of whether a doctor is employed at a hospital, in general practice or in the private sector.

The headlines in the media when doctors make mistakes, cheat or commit a crime are the result of the Danish population’s feeling of security. These headlines really tarnish the reputation of the medical profession, but also touch on something essential in society. It is the very essence of a loss of trust when we lose faith in the healthcare professionals that we literally entrust our life to. When a negative case arises, it sends a shock through the collective. But fortunately everything points to Danes still feeling secure about their healthcare service. And that is something we must fight to preserve.

This sense of security is an unconditional good for the individual citizen, in particular when we are ill and need to be able to rely on the people who must help us. But we also have to fight for this sense of security because it benefits us socially and economically. When citizens believe in the doctor who treats them, far less resources are spent on second opinions, doctor shopping and defensive medicine. The United States is an alarming example of a healthcare system that is characterised by insecurity from both patients and doctors, and which is therefore extremely expensive in relation to the healthcare services that are actually delivered.

As an ordinary citizen you can rightly ask a simple question: Who is responsible for ensuring that we avoid these regrettable cases where doctors end up in the role of the villain? 

The Danish Medical Association has adopted two sets of rules for its members. One ethical and the other collegial. Both sets of rules expand the Hippocratic oath and are also, like the Hippocratic oath, not legally binding. However, the provisions which are set out in the Danish Authorisation Act are legally binding. Danish government agencies and institutions act in accordance with these when carrying out supervision and dealing with complaints.

However, the question is how can we ensure that the universities, the Danish Medical Association, practitioners in the healthcare sector and the government agencies and institutions comply with the intentions of the regulations and maintain the sense of security and trust in doctors.

Reliable, responsible and competent medical graduates are first and foremost fostered at the universities. We need to train and educate graduates of medicine with a high academic and theoretical level, which is supplemented with clinical experience from clinical training during the degree programme. So once the Hippocratic oath has been pledged, the graduate should therefore be fully qualified to function as a junior doctor during the clinical basic studies that follow immediately after the degree programme.

The universities must also teach junior doctors the special culture that ensures they are aware of their responsibilities and that they constantly take ethics, patient safety and quality into account in their work as doctors.

We are able to provide the best possible education at both the universities and later at the hospitals, where medical doctors qualify for their specialist training.

But it is seemingly impossible to prevent people with deviant behaviour, criminal tendencies or psychopathic traits slipping through the net. Nor is it possible to completely avoid doctors who are weakened by illness or some form of abuse failing to recognise their inability to carry out the duties entrusted to them. Such cases must therefore be halted by a governing body.

It is no secret that many people believe the former Danish Health and Medicines Authority could and should have intervened in a number of the worst cases which received media attention, and should have done so long before these cases developed so far. A number of problematic doctors were allowed to continuing practicing for too long, even though the authority had been warned. It is therefore pleasing to see that the political system has decided to act and taken the step of establishing the Danish Patient Safety Authority, which has the sole task of quickly and professionally strengthening the supervision of doctors and other healthcare professionals.

However, if we are to look at how we can reduce the number of negative cases in the healthcare sector, it is crucial to underline that the Danish Patient Safety Authority will only react if they receive a report on a healthcare professional who constitutes a threat to patient safety. In other words, the authority will not begin to investigate individual healthcare professionals on its own initiative. The general responsibility for the operation and quality of the healthcare sector rests with the sector’s operators. For the public hospitals this is the Danish regions, while for the private sector it is the owners. The operators are responsible for taking action if poor quality work is carried out, and they are also responsible for ensuring that the employees possess the correct competences to carry out their tasks.

How do we create a culture in the healthcare sector that makes it legitimate to draw attention to a doctor who behaves in a way that can endanger patients? And how do we get management in the hospitals, municipalities, general practice and private hospitals to react quickly, transparently and professionally when suspicion is raised? Unfortunately, the unfortunate cases we have seen show that the ethical guidelines and collegial rules that medical doctors are subject to apparently do not suffice in these cases.

One option is to find inspiration in the system for the responsible conduct of research that the universities in Copenhagen and Aarhus introduced in the wake of the Milena Penkowa case. The universities have appointed special advisers to act as an independent body similar to the Danish Ombudsman system.

These special advisers can be consulted informally by researchers and others connected to the research environments if there is any suspicion of cheating, negligence or other irregularities. The special advisers independently assess the case, and if it is a question of differences of opinion, as is often the case in university research environments, then they can e.g. use mediation to diffuse the situation. If there is actually dishonesty involved the case must be brought before the appropriate bodies using the usual channels. 

The special university advisers do not replace the Danish Committees on Scientific Dishonesty. Rather, they are a supplement for avoiding cases which could otherwise drag on for years, create bad blood and drain research environments for talented researchers. The special advisers act as a helping hand to those who need an independent but competent look at the case before it is rejected for being devoid of content, or alternatively must be brought before the appropriate authority or reported to the police.

There is a parallel to the healthcare sector. A neutral and easily accessible special adviser to the healthcare professionals who hesitate to pass on their knowledge or who have doubts about a doctor's competence or lack thereof. We have spent many years discussing medical ethics and putting documentation requirements in place to prevent doctors from making mistakes. These have generally been useful initiatives. But we still need to crack the code as to why a few doctors – despite pledging the Hippocratic oath – as well as codes of conduct and supervision, make fatal mistakes and get away with them time after time. Without colleagues, employees, and management intervening or perhaps only doing so once the mistakes have become particularly serious and costly.

Putting a colleague under suspicion is a serious matter. It is natural to hesitate and wait and see, but this is also apparently part of the explanation of why such cases become so unfortunate. A whistleblower scheme with special advisers who can listen, ask questions and help clarify both the content and context of the case could be the missing link here.

Universities, supervisory authorities and others carry out the important task of protecting the trust and sense of security which fundamentally characterise the Danish healthcare system. It is not about having fewer of these unfortunate cases in the headlines, but about whether people can expect safe and prudent medical treatment – regardless of where in the healthcare sector they receive treatment.

The article was originally published in the Danish newspaper Weekendavisen on 8 April 2016.