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I'm a radiologist and writing helps me make sense of the world.

"My method is to take the utmost trouble to find the right thing to say, and then to say it with the utmost levity" -George Bernard Shaw

Tuesday 29 January 2019

How to Stay Out of Trouble

There are two versions of this blog. The short version and the long version.

Here is the short version. You can’t. Complaints will occur irrespective of skill, knowledge, caring, communication and assiduousness. Complaints will occur irrespective of harm caused, liability or mitigating circumstances.

This short version isn’t a great read to be honest. But it is the truth albeit an unpalatable truth. At this point the main message has been made; feel free to move on. But the longer version below is worth a read, mainly as I have some solutions for those keen on avoiding trouble.

I should probably point out some conflicts of interest. I’ve missed cancers, pulmonary emboli, fractures and all manner of findings. I’ve also overcalled normal scans as abnormal. I’ve offered to eat my pants if I was wrong (and should have - I was). I’ve made registrars cry (accidentally). I’ve offended colleagues (mainly accidentally). I’ve been sanctioned by the medical director. I’ve been involved in complaints and lawsuits. But I’ve not been in court or referred to the GMC. Yet. 

I know I’m not alone. It isn’t that I’m reckless, negligent or have criminal intent. Well, not every day. Osler wrote “Errors in judgement must occur in the practice of an art which consists largely of balancing probabilities”, pretty much describing what radiologists do. Thus the longer you are in practice, the more errors you’ll make. Inevitably some errors will be clinically significant. Which puts you at risk of trouble. The difficulty is there is no practical answer to the question of what separates a simple error from malpractice. In reality, it is probably 90% luck and 10% the skill of your defence lawyer.

The author on hearing about yet another mistake
The good news is that serious trouble is rare in the UK. Radiology claims account for only 2% of NHS litigation, under 3000 claims since 1995. And being referred to the General Medical Council is rarer still. I made a Freedom of Information Act request which revealed that roughly 24 radiologists are referred to them annually, of which only an average of one a year have sanctions. So it isn’t as bad as you think.

But the terror of GMC investigation has a weighty cost to the individuals. Doctors referred have a 22x risk of suicide, equating to 4-5% risk of death - riskier than an AAA repair. The recent trend of scapegoating is very worrying. Doctors have been charged with Gross Negligence Manslaughter when there were clearly system errors. And simultaneously NHS Whistleblowers are still systematically persecuted. 

These conflicts have put the fear of God into many Fellows of our dear College. It has lead to the concept of ‘Schrödinger’s Radiologist’. This is a radiologist who is simultaneously not working because of unsafe conditions but also working because they have a duty towards patient care.

Naturally you’ll be wanting to such avoid serious trouble. I present you with four simple ways to do this. 
  • Don’t Be A Jerk. The one thing that unifies radiologists getting into serious trouble (i.e. sacked or struck off) is their unreasonable behaviour. GMC Hearings are on the public record and they frequently entail odious behaviour over money. Just remember that you can only eat one breakfast’. Quality of life pretty much flattens out above £70k. 
  • Don’t Drop Your Colleagues In It. If you make a mistake, document everything with scrupulous honesty. Explain, admit, apologise. But don’t criticise others. It is hard enough in the modern NHS without the threat of unwarranted knives in the back. It is easier to criticise a good radiologist than to be one, usually because of the destructive power of hindsight bias.
  • Stay Safe The Easy Way. We know radiologists make more mistakes when rushing, overworked, tired, in pain, stressed, interrupted, hungry, thirsty and towards the end of the day. If you act on each one in turn, you can make your department more error-proof by design. Improved systems of work, better ergonomics and more reasonable workload distribution are all achievable.
  • Smile. Happier radiologists are more productive, healthier and less prone to stress and burnout. Rude and grumpy radiologists are less happy and have an impact on others. Research shows that if you are rude to someone, they lose time worrying, reduce the quality of their work, reduce time at work and take it out on others. Put simply, rude radiologists are a recipe for poor care.
Put these four simple notions into practice and not only will you sleep better at night but your colleagues will too. And you never know, your patients might just benefit too

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