Via KevinMD there's a link to a blog by an OB doc named Dr Tuteur. Dr Tuteur discusses a dinner party conversation this past New Year's Eve she had with friends about a doctor's responsibility to inform a patient of an error made in his/her care by a previous doctor. The example they use is: Patient with advanced lung cancer seeing an oncologist. Oncologist notices that a CXR from a few years ago demonstrates the tumor at an early stage. The patient now has has unsalvageable metastatic disease. Question: ought the oncologist inform the patient that an error had been made, that the cancer was missed by the referring primary care physician and the radiologist?
First of all, if it's New Year's Eve and you find yourself at a dinner party where the dominant topic of discussion is medical ethics, it's probably safe to assume that you've made some sort of horrible mistake in choosing your dinner companions and you ought to explore all possible modes of escape from said gathering. I mean, it's New Year's Eve right? Let's drink some champagne and rant about the Browns and tell a few funny stories.
But an issue like this is generally handled in an overly simplified fashion. It's a nice little thought experiment and well reasoned arguments can be made for telling versus not telling but the reality of such situations is usually much more nuanced and complex. To aver that one ought to always inform a patient of a past error is dangerously rigid and dogmatic. Likewise, to maintain that you would never reveal such information to a patient only serves to create the impression that physicians just look out for each other and are not a patient's advocate.
It's not a black and white moral conundrum. How do we define "error" and "mistake" in relation to "negligence"? Whose responsibility/obligation is it to inform the patient? What purpose is served by full disclosure? Is it always in the patient's best interest to know everything that has transpired? Will there consequences for those doctors who choose not to inform on their colleagues?
Consider the following more realistic examples:
1. You see a patient referred by your cash cow OB/Gyn with regards to a palpable breast mass. Upon review of last year's mammogram it appears that someone neglected to inform the patient that BiRADs IV calcifications were noted in the area where there is now a palpable mass. The mammogram had been ordered by the OB/Gyn. You've worked with the OB/Gyn for ten years and you've never had a situation where you questioned his management of a patient's care. He is universally recognized as an excellent physician and is well respected by the community. Moreover, he sends you at least 10-15 cases a month. What do you do?
2. You see a consult in the ICU for gallstone pancreatitis. The patient is in multiple organ failure and the CT scan suggests pancreatic necrosis. Upon reviewing the electronic medical record, you observe that the patient had been admitted multiple times over the past three years to the hospital by the internist for minor attacks of cholelithiasis and gallstone pancreatitis. A surgical evluation had never been requested. The internist has just finished a very emotional family meeting where he informed the wife and children of the patient's dire prognosis. Internist's eyes are swollen and red cracked. She has been the physician for everyone in this family for 15 years. Are you morally obligated to inform the family at this very delicate time that their trusted doc screwed up? Or ought you to show some tact and send them an anonymous letter in the mail three months later along with an attachment listing area malpractice attorneys?
3. You're the ID consultant seeing a patient with perianal sepsis. Cultures from the I&D site are growing MRSA. The general surgeon managing the case just has the patient on Unasyn. The cultures have been available in the chart for 4 days. You were consulted because the patient had persistent erythema and a leukocytosis. Do you simply make the necessary antibiotic adjustments? Or inform the patient that the general surgeon neglected to respond in an appropriate fashion to culture results that were freely available days ago?