Are we all clear? Multidisciplinary care

Jul 20, 2018

Multidisciplinary care has become increasingly common as the benefits to both the patients and health professionals have made apparent. These include improved health outcomes and satisfaction for patients, and the more efficient use of resources and enhanced job satisfaction for team members. However, it also opens up the possibility for confusion around where responsibilities lie and communication between care providers and with the patient, as the following case highlights.

Cancer care confusion

The patient, who had a long-standing history of oesophageal reflux disease, had a gastroscopy which revealed a lower oesophageal adenocarcinoma. The patient was transferred to the oesophageal cancer clinic under the care of Dr White*, the treating surgeon. A multidisciplinary meeting was held to determine the appropriate treatment for the patient, with gastro-intestinal cancer specialists deciding on pre-operative chemo-radiotherapy followed by surgery.

Dr White referred the patient to radiation oncologist Dr Gray*, who contacted oncologist Dr Brown*, to arrange chemotherapy. As part of the treatment plan, the patient underwent surgery several weeks after radiation and chemotherapy.

Pathology results following surgery revealed a poorly differentiated neuro-endocrine tumour. The hospital’s pathologists suggested this should have been the original diagnosis, instead of adenocarcinoma. This new diagnosis may have negated the requirement for the surgery.

Noting that the change in diagnosis could make a difference to subsequent chemotherapy, Dr Gray contacted Dr Brown to advise him of this and to ensure he arranged a consultation with the patient. The consultation, however, was only conducted two months after the surgery.

Complaint to regulator

The patient’s family complained to the regulator of concerns regarding the treatment and care provided. They noted it took five months for the patient’s disease to be correctly diagnosed and that by then, a range of treatment had already occurred.

Following disclosure of the misdiagnosis, the family was concerned that the treating team were inconsistent and contradictory in their responses to their questions. They felt as though the treating team was trying to hide something and alleged the misdiagnosis may have resulted in an inappropriate treatment regime.

Changed diagnosis

In providing an explanation for the change in diagnosis, a number of factors were cited by the doctors. The initial specimen appeared to have been a mixed tumour, which often have a mixed pathology. The treating team remarked chemo-radiotherapy treatment resulted in the tumour changing. Based on the original pathology report, the team thought the patient’s diagnosis was reasonable on the evidence available at the time. They also noted the subsequent diagnosis was an exceptionally rare tumour.

Dr Brown advised the patient and family that the surgical pathology indicated a good response to pre-operative chemo-radiation treatment, which would still have been appropriate if the disease was correctly diagnosed in the first instance.

In his response, Dr Gray stated there had been a long discussion with the patient about the change in diagnosis. He educated the patient about the change, and that this was in no way intended to hide the fact that there had been a change in pathologic diagnosis. Rather, it was an attempt to explain how information is dealt with in clinical medicine, and that the division in histologic diagnoses can sometimes be subtle.

In conclusion, the complaints body found that the knowledge, skill and care provided was to an expected level. The care team did not present any risk to public health and safety, and no further action was required.

The doctors were satisfied that their treatment and care of the patient was not compromised as a result of this complaint and have continued to see the patient.

Key considerations

Ultimately, doing everything correct medically does not protect a doctor from complaints. Inconsistent messages from the treating team caused concern for the patient’s family which, combined with the request for more information, triggered the complaint. Therefore it’s important to ensure the patient and their family understand what is being communicated to them.

Where the complaint is from a family member about a relative’s treatment, often issues and concerns arise because they rely on information from their ill relative. This may not always reflect everything that has occurred, so a key part of the response is explaining the situation, while considering whether the family member is entitled to health information about their relative due to privacy constraints.

To ensure privacy and confidentiality, consideration always has to be given as to what consent has been provided and what, if any, of the information should be released to the complainant. When a third party makes a complaint, Avant requests the regulator to produce an authority to release personal information, which is signed by the patient, or a notice to produce.

Case comment

Dr Ushma Narsai, MBBCh, FRACGP, Senior Medical Advisor and Claims Manager, NSW, Avant

Throughout the investigation, we liaised with the complaints body on behalf of our members, submitted their responses and provided a debriefing when the assessment was received.

In a case involving numerous doctors across different specialties, there are many perspectives to consider along with a large amount of clinical information. Consequently, we allocated two medical advisors to support our members. When providing statements to complaints bodies, it is important to focus on the elements that we know they look for. In helping our members respond, we ensured the facts were clearly laid out, that the concerns of the family were acknowledged and reflections on the issues by the doctors were communicated.

As one of the doctors commented “This complaint represents a problem of communication, and a high level of concern by loving family members, with different specialists explaining the problem of a complex diagnosis and management from their own perspective, using different terminology, which the family find confusing and inconsistent”.

We helped our members in clarifying the key issues of the complaint and in particular, responding only to those issues that relate to the care each doctor provided, and not commenting on care provided by other doctors. When multiple members are involved in the same complaint, it is not about ‘telling the same story’ but working with the members to reflect on how their actions may have contributed to issues raised in the complaint, and having these explained to the complainant.

Support and useful resources

If you are the subject of a complaint or have concerns about multidisciplinary care contact Avant’s Medico-Legal Advisory Service on 1800 128 268 for expert advice, available 24/7 in emergencies.

Read our article ‘Medical records – the essentials’ and our factsheet ‘What to do when the news is bad’ for recording and communication tips. 

This article was originally published in Connect issue no. 10.

*All names and some details in the case studies have been changed.

 

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