Examination of Witnesses (Question 640-659)
DR JO
BIBBY, DR
OLGA KOSTOPOULOU
AND CAPTAIN
GUY HIRST
5 FEBRUARY 2009
Q640 Dr Naysmith: Yes.
Dr Bibby: Clearly there has been
a concerted effort across the infection agenda, but we would want
to see that same concerted effort around some of the things you
have been hearing this morning about medication errors, for instance,
or errors in surgery and so on. When the Department has a priority
and puts full weight behind it you can see it has an impact, but
patient safety is much bigger than infection and we need to make
sure there is the same co-ordinated effort across all the areas
of patient safety.
Q641 Stephen Hesford: In your memorandum
there is a quote: "The failure of the National Patient Safety
Forum to make significant progress in driving forward the patient
safety agenda has been disappointing". Why do you say that?
Dr Bibby: Hopefully it comes across
that we are an organisation that is very passionate about patient
safety and we were very pleased with the formation of the Forum
because that clearly sends out a signal of the importance the
Department attaches to that. At the time of writing our submission
we felt that the Forum was being useful in bringing together some
of the different interests around patient safety. In a sense,
it is not a delivery mechanism and we need to make sure there
are very clear delivery mechanisms around the patient safety agenda.
Since submitting our evidence there has been a new Head of Patient
Safety appointed at the Department of Health and that will certainly
help with some of the co-ordination issues. There have also been
some changes to the way in which the Forum is working which will
make it more effective as an information sharing and shaping forum.
As I say, there needs to be some very clear sense of what the
delivery mechanism is around the patient safety agenda.
Chairman: We are now moving on to look
at diagnostic errors in primary care.
Q642 Dr Stoate: Dr Kostopoulou, as
the Committee well knows I am a GP who still does some general
practice so I am well aware of the issues facing general practice,
but I want to explore the patient safety culture within primary
care and start with your memorandum which says that there is a
problem with diagnostic error amongst GPs but they are often not
aware of it. How would you define "diagnostic error"
in primary care?
Dr Kostopoulou: How would I define
it?
Q643 Dr Stoate: Yes.
Dr Kostopoulou: It is difficult
to define, which is why it has been so elusive and under-researched.
We only get to find out about it when patients sue or when doctors
become aware of a patient deteriorating or patients come back.
This does not happen very often though because, as you are aware,
some GPs work in large practices, patients may go to see different
doctors or they may get lost in the secondary care system. Feedback
is missing and the problem is that without feedback we do not
learn. We cannot change the healthcare system in the way primary
and secondary care are organised to give doctors more feedback,
but we can construct more structured training environments where
feedback is immediate and provided on a large number of cases
if we want to improve learning, for example.
Q644 Dr Stoate: For example, if you
have got a delayed diagnosis, if somebody comes in with symptoms
of an everyday nature, as Professor Esmail was saying earlier,
undifferentiated, and it does take a while for the GP to have
gone through the diagnostic sieve, to await new developments,
to use time as a tool in diagnosis, is that a diagnostic error
or is that simply the nature of general practice?
Dr Kostopoulou: That is very true.
Some things will not be diagnosable and we are not really talking
about those things where no GP would really be able to diagnose
that. We are talking about things that can be diagnosed and can
be caught early and GPs may not consider something that is slightly
less common but more serious, or they may miss some red flags
if they are there. There are ways of getting them to become more
aware of those situations, possibly through education and training,
so we can "de-bias" the way people think. Because GPs
serve a population with a lower rate of serious disease they tend
to think it is the most common thing, and they are usually right,
and once you consider that this is the diagnosis and it explains
most of the symptoms you may just stop there and not explore other
possibilities.
Q645 Dr Stoate: Does that tell you
anything about the culture of safety in general practice or does
it just tell you a bit about how GPs are trained?
Dr Kostopoulou: It is not necessarily
the culture of safety. GPs have adapted to the population they
serve and also to the healthcare system. Do not forget that we
have got time limits on consultations. If you need to finish a
consultation within ten minutes you are more likely to think of
the most obvious or most common diagnosis, you have got less time
to explore other possibilities. Also, the healthcare system puts
pressure on GPs to reduce "unnecessary" investigations
or "unnecessary" referrals. Even if a GP may consider
there is something more serious, they may wait, they may want
to be convinced and collect more evidence before they decide to
refer. This is an interaction of the system where they work, the
difficulty of the population they serve and the cases that they
see. They do have a difficult job to do.
Q646 Dr Taylor: Sure, but that does
not tell us anything about the safety culture because that is
what I am trying to get at. We all know the problems of diagnosis,
and we will come on to training in a minute, but does that tell
us anything about the culture in general practice? Do you think
there is a real problem that GPs are not taking patient safety
significantly seriously?
Dr Kostopoulou: There may be.
I cannot say that there is or there is not. Because they have
to work under such difficult conditions it is possible they forget
patient safety in some cases. We know that they do not report
diagnostic errors, but I am not sure whether other kinds of doctors
report their own diagnostic errors, so it might not be a GP problem.
Q647 Dr Taylor: Do you see a solution
to this?
Dr Kostopoulou: Yes, and I have
already mentioned a couple of things. I am a big believer in catching
things early, so medical education and training. Also, supporting
GPs while they work through better designed systems, electronic
systems, the electronic record and decision support. These are
long-term and we need to put a lot of effort into research on
how to do these things properly.
Q648 Dr Taylor: How would you change
the education and training of GPs in particular to try and put
this right? What changes would you make?
Dr Kostopoulou: Simple things,
like what I called "de-bias" earlier. Simple things
like, "Why might my diagnosis be wrong? Are there any features
here that I have not managed to explain or I have ignored?"
These are little things that will open up our minds to other information
that we may not be paying attention to. These are things that
could be taught much earlier at medical school. I do not think
students are taught at medical schools how to diagnose formally,
how to form differential diagnoses, how to test diagnoses. They
need to know about probability, for example, about the diagnostic
value of information and also that diagnosis is a psychological
process and what are the common pitfalls.
Q649 Dr Stoate: Do you think that
has changed over the years because I remember all that being taught
when I was a medical student? Has that changed?
Dr Kostopoulou: Students learn
typical features of diseases, but as a doctor you probably know
you do not often see patients presenting typically. As a doctor
you need to differentiate competing diagnoses, so what you need
to know is not the list of features of each diagnosis but what
features help you differentiate between easily confusable diseases.
Q650 Dr Stoate: You think that is
not taught sufficiently well?
Dr Kostopoulou: No, there is no
formal teaching on diagnosis and clinical reasoning, nothing like
this.
Q651 Dr Stoate: That is obviously
an issue which we need to look at. If I can just briefly pick
up on your statement that you want to see more automation and
more electronic support effectively. Do you see any drawbacks
to that type of usage of expert systems?
Dr Kostopoulou: The most obvious
drawback is the expert system suggesting the wrong diagnosis.
We need to make sure they are more reliable than their users.
Also, they may increase referral rates or investigation rates,
but I am not sure how bad that is. Can I just go back to the training.
We have not explored at all training students or doctors with
simulated patients, that is computerised scenarios that will give
them immediate feedback, large numbers of them carefully structured.
At the end of the day we train our pilots and we train our surgeons
on simulations, so why can we not train our doctors to learn diagnosis
on simulations. That is completely unexplored in medical education.
Q652 Dr Stoate: That is also very
interesting. If a GP is practising unsafely or making consistent
errors, how much is that an issue for the GMC or other professional
body to be responsible for?
Dr Kostopoulou: There may be very
bad GPs; I do not think there are very many. I am talking mostly
about the average GP, how most GPs practise. If we want to improve
safety we need to look at how most GPs practise. The GMC has a
role in setting standards for medical education, for example.
Q653 Dr Stoate: You would involve
them much more in setting the curriculum and training?
Dr Kostopoulou: I think so, yes.
Q654 Dr Stoate: How does the "fair
blame" culture apply to general practice?
Dr Kostopoulou: It is not really
something I am involved in, there are probably other people much
more knowledgeable who can talk about that. I worry sometimes.
We know that there is an increase in the rate of litigation against
GPs so it might be that they are becoming more reluctant to discuss
their errors. That might be a problem. In terms of a "fair
blame" culture, I am not sure.
Dr Stoate: Thank you very much.
Dr Taylor: Very quickly on that. I am
horrified when you say there is no teaching on diagnosis because,
as Howard and I both remember, the diagnostic process was history,
exam, differential diagnosis and investigation.
Dr Stoate: Clinical Method.
Dr Taylor: Clinical Method, surely that
is still taught.
Dr Stoate: We remember it cover-to-cover
even after all this time, do we not?
Dr Taylor: Inspection, palpation, percussion,
auscultation.
Chairman: We get these reminiscences
regularly.
Q655 Dr Taylor: Surely that is still
taught?
Dr Kostopoulou: The problem is
that when students start practising this goes out of the window.
Q656 Dr Stoate: I am shocked!
Dr Kostopoulou: You are doctors,
you know that you do not go over a list of things. You employ
shortcuts, you do not go over a whole list and do these things
systematically. That is how people become experienced and faster
at doing these things.
Q657 Dr Taylor: And they miss out
some of the very important things.
Dr Kostopoulou: Inevitably.
Chairman: Can I thank the historical
wing of the Health Select Committee for that intervention!
Dr Stoate: It is called experience.
Q658 Chairman: I am an ex-member
of the General Medical Council as of last month and it is often
said that people come out of training quite well and then go into
work with an individual to get the experience that is vital for
them and pick up the habits of the individual and have to drop
off some of the things they have learned in school. Would you
go along with that?
Dr Kostopoulou: Yes, I do. That
is why I think there needs to be continuous training as a type
of professional development for practising doctors.
Q659 Chairman: Do you see revalidation
as a part of that doctor's journey?
Dr Kostopoulou: Yes, why not.
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