Indirect communication between colleagues has serious consequences

Sep 22, 2016

Communication problems contribute to a significant number of complaints against doctors. In a recent case, indirect communication between a physician and a surgeon over a patient’s postoperative care, not only led to the patient undergoing emergency surgery, but disciplinary action for the doctors involved.

Clinical background

A general surgeon, Dr White*, performed a laparotomy and adhesionlysis on a patient. During the procedure, he perforated the duodenum and repaired two small perforations. Dr White inspected all other parts of the small and large bowel after all the adhesions were divided and no further perforations were detected.

The patient’s condition progressively declined over the next few days. Dr White noted in the medical records that he believed the patient had developed peritonitis secondary to a small bowel leak. He ordered an urgent CT scan of the patient’s abdomen. The results were recorded as ‘Post-laparotomy for adhesions. Post-op ileus? Bowel leak.’

Physician consulted for second opinion

The next day, Dr White noted that the patient’s peritonitis was resolving, but the patient’s relative requested a second opinion. Dr White consulted Dr MacPherson*, a consultant physician to assist with the patient’s postoperative care. That day, Dr MacPherson reviewed the patient and ordered Lasix (frusemide) and blood tests. The patient’s white cell count was 9.7 and their c-reactive protein was 456 mg per litre.

Dr MacPherson ordered further blood tests the next day. These showed the patient had a white blood cell count of 19.8 and a c-reactive protein (CRP) result of 460mg per litre. These results were far in excess of the normal range of 3.5 to 10, and less than 10mg per litre, respectively. The pathology report included an observational finding of neutrophilia and monocytosis suggesting a bacterial infection or inflammation. The neutrophils showed toxic changes.

A perfect storm

Dr MacPherson noted the patient’s symptoms and results, and instructed the nursing staff to bring these to Dr White’s attention. Around midday, Dr White called the ward and was told the patient was stable. He was not informed of their high blood count.

That night, Dr MacPherson was urgently contacted by nursing staff as the patient had developed rapid atrial fibrillation. While he did not see the patient personally, Dr MacPherson prescribed an anti-arrhythmic drug and the patient reverted to a normal rhythm.

The next day the patient was transferred to another hospital for emergency surgery for peritonitis. The surgeon found a further perforation and repaired it. The operation also revealed 4.5 litres of small bowel content in the abdominal cavity which was suctioned out.

Direct communication may have resulted in earlier intervention

While it was determined that the patient’s care was the primary responsibility of Dr White, experts found Dr MacPherson had administered appropriate treatment to the patient within the remit of a consultant physician.

Experts agreed that it had not been necessary for him to treat the patient for rapid atrial fibrillation personally, as it would not have made a difference to the patient’s condition. The experts considered that Dr MacPherson had not acted inappropriately in failing to contact Dr White directly that night. This was based on the grounds that Dr MacPherson would have assumed that Dr White would review the patient the next day.

However, the experts indicated that “direct communication” between the two doctors on the day in question, may have resulted in an “earlier, more aggressive intervention” in the patient’s care. It was suggested that direct contact may have been another option open to Dr MacPherson.

Dr MacPherson conceded that on the day in question, he was aware the patient had unresolving peritonitis and a small bowel leak. He admitted that he should have brought the patient’s symptoms and CT scan and blood test results to Dr White’s attention. He conceded that this failure contributed to a delay in the patient’s treatment by the health care team, and had compromised their health. He accepted that this amounted to unsatisfactory professional conduct.

Tribunal cautions physician

Ultimately, the tribunal cautioned Dr MacPherson for unsatisfactory professional conduct and ordered him to complete a course in professional communication.

Surgeon reprimanded for unsatisfactory professional conduct

Dr White admitted that he made a clinical error in not returning the patient to theatre on the day in question, and failed to actively maintain and monitor the patient’s health and care prior to their transfer for emergency surgery. This included personally reviewing and requesting their test results. He admitted that this placed Dr MacPherson in a position where he maintained responsibility for the care of the patient, which was inappropriate.

The tribunal reprimanded Dr White for unsatisfactory professional conduct. Conditions were imposed on his registration, including that he participate in a mentoring program and a surgical management course.

Key lessons

This case brings the importance of clear and direct communication between doctors and health care teams to the fore. Avoid the issues outlined in the case above with this guidance:

  • Ensure systems are in place to track and follow up on the patient’s condition or test results. This is essential when a health care team is involved in the patient’s care in order to avoid human errors.
  • If you are concerned about a patient’s condition or test results, always record the findings in the patient’s medical record and communicate this directly with the treating doctor.
  • If there are ‘red flags’, for example, where the CRP or white blood cell count are very high, a physician should ensure that appropriate surgical action is taken.
  • Clearly establish each doctor’s role to ensure that misunderstandings about responsibilities are minimised.
  • If a second opinion is needed, it should ideally be obtained from one of your colleagues in your own speciality.

*The doctors’ names have been changed to protect their privacy.

Need advice?

If you need advice on a workplace issue, call the Avant Medico-legal Advisory Service on 1800 128 268.

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