Patient Safety - Health Committee Contents

Examination of Witnesses (Question 640-659)



  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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