30 March 2008

The Price of Competence - The Ocker Doc

"The price one pays for pursuing any profession or calling is an intimate knowledge of its ugly side."
James Baldwin, US author (1924 - 1987)

Her name was something like Thea Tribes. She died last week.

Thea came to me over two years ago with a cervix cancer. Big thing - the cancer that is. She was a pretty petite girl with a young family. It was not surprising that the cancer was big when you consider the the preceding 12 months. Thea had seen her family doctor with vaginal bleeding. She was sent to see a obgyn. He said it was 'dysfunctional uterine bleeding' - a common enough hormone-related problem of the womb lining which results in episodic, non-period bleeding - and she needed a D&C (a scrap out of the womb lining). She was booked for theatre and got a start some 7 months later. But the obgyn got sick ... so no D&C. Thea saw the obgyn again and was re-booked. And she saw the obgyn a third time.

Finally 12 months after the first visit, Thea made it to the OR with the obgyn. As is normal, the patient is put to sleep and the obgyn begins with a pelvic examination. Now according to Thea, and she was believable ...... THIS WAS THE FIRST TIME A PELVIC EXAMINATION WAS UNDERTAKEN BY ANY OF HER DOCTORS.

Of course with that one simple examination, the penny dropped and the diagnosis was made. After a year left untouched, now it wasn't small. Other tests including MRI and PET scans showed the big cervix cancer as well as lymph nodes halfway up the tummy. Probably incurable. Almost certainly incurable.

Then it was my turn to try to turn this mess into something positive. But not surprisingly, I wasn't up to the task. She managed about 2 years of pretty reasonable quality of life while her little girl grew up, but the last 6 months have not been any walk in the park with increasingly difficult problems. Life had become no fun. She needed more medications - steroids for swelling, anticlotting agents for clots, platelet infusions for lack of platelets. And then the day before yesterday, it became too much.

She died with her family.

At our first consultation she asked me why these other doctors hadn't examined her and whether they were incompetent. I know the examination wasn't done, but I don't know if they are incompetent. I told her that she needed to concentrate on her treatment and her family then, and that she had my support if she wanted to do something later.

Competence is a strange concept. The media thinks that it means being perfect and never making a mistake. Obviously no doctor will be competent if that is the definition - certainly I wouldn't be competent.

The competent doctor tries to be better when they are shown to be deficient, and they try not to make a mistake again. Certainly if you have made such a grave mistake as not doing a standard examination in this case, what does the competent doctor do? Apologize? Say sorry? (the patient may have died anyway but her cure rate was reduced) Alter their practice?