KEY POINTS:
Two decades after the Cartwright inquiry, have doctor/patient relations improved? Phil Taylor and health reporter Martin Johnston examine the inquiry's effects on our health system
COMMUNICATION REPLACES PATERNALISM
Informed consent. Those words resounded loudest from the Cartwright inquiry - the strongest of public statements that doctors could not assume they knew best and leave patients in the dark.
It's 20 years since the release of Dame Silvia Cartwright's report into the treatment of cervical cancer patients at National Women's Hospital; more than 40 years since Professor Herbert Green undertook the "Unfortunate Experiment".
Six years after Cartwright's report, the Office of the Health and Disability Commissioner was set up. Two years later, a Code of Rights came into effect. Rights five to eight together aim to guarantee patients are able to make informed decisions, covering the right to effective communication, to be fully informed, give informed consent and have the right to have a support person present.
But rules and regulations don't guarantee perfect practice. It emerged that Greenlane Hospital had taken body parts, including some from five babies, without family consent from 1990 to 2000, the hospital's revelation coming a week after the Ministry of Health's assurance that informed consent had been sought for all body parts kept for teaching or research since the 1988 Cartwright report.
But a culture change has occurred, hurried along by the Cartwright inquiry but also driven by a decline in the influence of paternalism and the growing influence of the ethical principal of self determination "that a competent patient, not her doctor, should decide whether to accept or reject proposed medical treatment," says commissioner Ron Paterson, "and with it the corollary that she must have adequate information on which to base her decision".
The code requires doctors not just outline the risks of a procedure but also the alternatives, and to do so in a language the patient can understand. It is recognised by the medical councils, the universities and by bodies such as the Australian-based Cognitive Institute, and used by district health boards and the ACC to improve staff communication skills. "Communication is recognised as a core skill, it's part of being a competent doctor," says Paterson.
He believes, however, that doctors still perform poorly at informing patients about alternatives. "It is human nature to talk about the procedure that the particular doctor likes to follow. Where we fall down most, is in not saying 'but there are other views on this', or 'another option might be to monitor the situation', or 'others find this helpful'."
The failure of doctors to do this is a common theme of complaints to Paterson's office. "The thing that surprises is doctors, surgeons and anaesthetists think that informed consent is about disclosure of risks and about getting a signature."
There was a lot of "catastrophising" after the inquiry about how informed consent would bog down doctors in paperwork and time-consuming explanations of infinitesimal risks. Some doctors quoted studies that indicated half of all patients don't remember the information. But, says Paterson, that's not the point. "You do it because you respect the autonomy of the patient - it's their body. But, secondly, you do it because it's part of the relationship of trust and of partnership between patient and doctor. And that's not just PC language, there is research to show that patients have better outcomes if they are a partner in the process and they understand their options."
Professor John Campbell, chairman of the Medical Council, believes there has been real change towards partnership:adapting has been easier for younger doctors due to emphasis on communication during training but the vast majority of doctors are communicating well. "I think there are only a few - and I think the doctors who figured in the Cartwright inquiry would fall into this group - who failed to adapt to the changing times."
But Lynda Williams, of Women's Health Action, says the modern environment is ripe for the vested interests of pharmaceutical companies and the Ministry of Health to erode informed consent through marketing and selective information. When the Ministry decides a vaccination campaign is warranted, for example, it sets coverage targets which, argues Williams, can result in information inclined to favour vaccination.
Payments to health providers for each vaccination given can also create a vested interest. Williams says a practice nurse recently told her of being instructed by a GP to "encourage" parents to have their babies inoculated with the meningitis vaccine because of these payments.
- PHIL TAYLOR
REHABILITATION REPLACES RETRIBUTION
When patients take their doctor to task over medical mistakes, their overriding aim is "to make sure this doesn't happen to anyone else".
I can't think of a medical misadventure case I have covered where this has not been so. Some want vengeance; some want compensation. But everyone wants to find some sort of meaning for the harm they have suffered. An explanation and apology can help to find meaning, while for some it comes from "making a stand" through a complaint and disciplinary proceedings.
With this in mind, it is at first surprising that the number of disciplinary hearings for doctors has dived from around 40 a year in the 1980s, to 10 in 2004 and seven in 2005.
This while complaints have tripled in number as patients have discovered a new assertiveness as healthcare "consumers". The apparent gap has been filled by competence reviews and re-education programmes, arguably a better way, in many cases, of preventing a mistake being repeated.
This "learning not lynching" approach was an innovation that came with the revolution in medical discipline following the far-reaching Cartwright Report. The 1988 report followed a seven-month inquiry headed by Judge (now Dame) Silvia Cartwright into the cervical pre-cancer trial at National Women's Hospital in Auckland.
In the "Unfortunate Experiment", some women were not given the conventional treatments - hysterectomy or cone biopsy - for cervical intraepithelial neoplasia (CIN). Subsequent research has shown those women have had a much higher rate of invasive cancer and death than women treated conventionally.
Solicitor-General David Collins QC and assistant crown counsel Charlotte Brown presented the discipline and competence statistics to an Auckland University conference yesterday to mark 20 years since the Cartwright Report was released.
"The Cartwright Report threw into sharp relief the need for public scrutiny of medical practitioners, and for the public's involvement in the processes by which they are censured," they say in their conference paper.
They trace the pedigree of today's health discipline and competence assurance system - covering doctors and all other registered health practitioners - to the Cartwright Report and its recommendation to create a role of health commissioner.
It took seven years, but in the mid-1990s, Parliament responded by setting up the machinery of the Health and Disability Commissioner's office, and in tandem rewriting the Medical Practitioners Act.
A code of health and disability consumers' rights was written, covering informed consent, effective communication, dignity and independence. The commissioner became the gatekeeper for complaints, could investigate complaints and issue adverse findings, and could make recommendations like referring health workers to the director of proceedings for possible disciplinary action or to the relevant regulatory authority (such as the Medical Council) for a competence review.
Collins, a former chairman of the Health Practitioners Disciplinary Tribunal, says the commissioner and medical practitioner legislation in 1995 "produced a sea-change, where sub-optimal medical practice could be addressed through rehabilitation measures. This led to a dramatic decrease in disciplinary hearings."
It also did away with the secretive processes, disliked by doctors and the public for differing reasons, of the old order, and gave discipline to the Medical Practitioners Disciplinary Tribunal and competence reviews to the Medical Council. Previously, discipline was handled by the council and associated bodies, leaving the medical profession open to the charge that it was prosecutor, judge and beneficiary.
The new systems, says Collins, focus on "trying to salvage and rehabilitate and reserve the punitive measures for the truly bad behaviour".
"We have moved from dealing with doctors who have made a one-off mistake by way of discipline, to trying to educate them, nurturing them and ensuring their processes, and they, change - rather than simply throwing the book at them and then expecting them to pick up the pieces afterwards and become good practitioners as a consequence."
The Medical Association's chairman, Dr Peter Foley, says the current set-up contributes to improving the quality of health care. "Greater transparency and greater honesty is providing patients with much greater safety and reassurance."
- MARTIN JOHNSTON
