論理、不要「隱惡揚善」？

論理、不要「隱惡揚善」？Talking with Patients about Other Clinicians' Errors — NEJM http://nej.md/1dW0TT0
N Engl J Med 2013; 369:1752-1757October 31, 2013

Talking with Patients about Other Clinicians’ Errors.

這期的NEJM有篇文章吸引我注意，當我們發現同事在醫療上有錯誤時，應該怎麼做？

這是一位神內的醫師收了一個腦中風的病人，發現病人之前有2張心電圖就有atrial fibrillation (Af)，而他的家庭醫師並沒有注意到。當這位神內的醫師告訴患者的家庭醫師時，那家醫醫師還推說是因為心電圖機比較老舊，訊號干擾，不是Af。而神內的醫師拿心電圖請教心內的二位醫師時，心內的醫師異口同聲的說是：Af，這時該怎麼辦？(註：這個家庭醫師之前也轉了不少的病人給這神內的醫師)

以下摘錄部份文字

You are a young neurologist practicing in a small hospital. You admit a 55-year-old woman with hypertension and type 2 diabetes mellitus who had an embolic stroke at home. On reviewing the patient's medical record, you notice that she appears to have been in atrial fibrillation during two electrocardiographic (ECG) tests during visits to the office of her primary care physician (PCP) for palpitations. Her PCP, an internist who provides many of your referrals, read both ECGs as normal and attributed her palpitations to “probable mitral-valve prolapse and anxiety.” The patient is currently in normal sinus rhythm. You show the internist the ECGs and express concern that they indicate atrial fibrillation. He politely disagrees and says you are confused by noise from his old ECG machine. However, when you ask two cardiologists to look at the ECGs, both immediately say “A-fib.” The internist requests that you transfer the patient to his service (see the video, available with the full text of this article at NEJM.org).

是的，當這情況發生時，文章中也提到醫生們多數不知道該怎麼辦，因為前輩老師們也都沒教導。然而，文章中也提到，雖然指出同事的錯誤可能會損壞同事之間的關係，但是給病人最誠實的資訊，這件事也是相當的重要的。

Patients and Families Come First

Although anxieties about damaging collegial relationships loom large in situations of potential error involving other clinicians, a patient's right to honest information shared with compassion about what happened to him or her is paramount.

接下來該怎麼做呢？這位處於尷尬位置的神內醫師，他先告訴那位家庭醫師，他將安排患者做心臟的會診，當有了心臟檢查的背書後，他再來和這家庭醫師溝通日後的處置。若是這家庭醫師仍然拒絕患者以上這心臟檢查，則神內醫師打算上報醫院高層來處理。

WHAT SHOULD THE NEUROLOGIST DO?

The neurologist in our case is in an awkward position. She is confident that the patient's internist did not diagnose atrial fibrillation, that this error probably contributed to the patient's stroke, and that disclosure to the patient is vital. The internist has rebuffed her without assuaging her concerns. The neurologist's next step should be to tell the internist she plans to request a formal cardiology consultation. With the diagnosis firmly in hand, she should communicate the findings to the internist and attempt to formulate a joint disclosure strategy. If the internist declines or objects to the cardiology consult, the neurologist should seek assistance from the institution's medical director or other senior administrative leader. The neurologist would be well served by support from a disclosure coach.

以上這流程可給大家參考。

註：洗腎的病人有Atrial fibrillation也不少，要小心，只是這麼慎重告知的，也不多。