PERIPHERALIA

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Decision-making in general practice is a complicated affair 
and seems to be one of those skills that get more difficult 
as one gains more experience and knowledge. After some 
years in practice, several adverse advents have almost always 
happened which may “colour” one’s judgement.

As time goes by, a general practitioner starts to take many 
more peripheral factors into consideration when making 
diagnoses and decisions. Some of the strongest influences 
on our decision-making may be previous adverse events and 
experiences. These are the mistakes we made in treatments 
and the operations that went wrong. 

We are also strongly influenced in the way we practice when 
a complaint has been made against us. The doctor naturally 
becomes extra cautious when a similar illness or situation 
arises again. The patient either gets over-investigated 
or referred unnecessarily to avoid an intervention that 
might lead to the same complication, otherwise known as 
practising Reassurance Medicine.

As litigation increases, we also move more and more into this 
avoidance behaviour called Negative Defensive Medicine. 
After reading about the cases of malpractice against doctors, 
I believe we all have sleepless nights on the basis of “there-
but-for-the-grace-of-God-go-I.” I find myself becoming extra 
careful in both my prescribing habits and the procedures  
I perform.  

In a recent case, a breast lump was missed by a general 
practitioner. The reason was that he had previously 
been unjustly accused of inappropriately touching a 
patient during an examination. Following this incident 
he had, understandably, become cautious with intimate 
examinations. This resulted in him missing a breast lump as 
he had not re-examined a patient, who had already been 
screened by a nurse. 

Long ago, one of my partners asked me to show him how 
to operate on a Meibomian cyst in the upper eyelid of one 
of his patients. I set up the eye tray with the Meibomian 
clamp and fine curette and put anaesthetic eye drops in the 
patient’s eye. I then injected a small amount of local around 
the cyst. After this, I asked the patient to open her eye and 
to my horror the eye was completely white. I had injected 

the local through the eyelid into the eyeball and underneath 
the cornea. She had not felt it because I had put the local 
drops into the eye at the beginning. I was appalled at the 
sight of this completely white opaque eye staring at me.  
I had blinded her.

With a shaking hand, I phoned my favourite ophthalmic 
surgeon who reassured me that no harm would come from 
the local anaesthetic. He asked me to send her over to his 
office. She recovered in a day and had no adverse effects. 

One of the most common adverse reactions in general 
practice is an allergic reaction to an injection. A few years 
ago, I gave a patient an injection of Diclofenac in my room. 
He then promptly dropped like a stone, unconscious, to 
the floor. It was a syncopal attack and after a few minutes 
he recovered. He actually recovered much quicker than his 
shaken doctor whose pulse rate remained fairly high for the 
rest of the morning, although the tightness and the choking 
feeling in my chest subsided after about an hour. I then 
found myself somewhat reluctant to give injections for the 
following few weeks.  

Another case I was involved in also occurred a few years ago 
when a patient in our clinic was sent to our procedure room 
for a stress ECG for a routine insurance medical. He was a 
fit thirty-nine-year-old marathon runner and after a minute 
or two of running he had a heart attack on the treadmill. 
Although we have full resuscitative equipment with a crash 
cart and defibrillator as well as trained nurses in our rooms, 
we all found ourselves rather reluctant to do stress tests for 
a while.

Adverse events and reactions have an extraordinary effect 
on our subsequent decision-making in similar cases or 
situations. These reactions may be out of proportion to the 
actual condition, but psychologically they may be difficult 
to overcome. This happens in all disciplines of medicine 
and over time our confidence usually returns, but for some 
mishaps the doctor may completely lose his nerve.

I never operated on a Meibomian cyst again.

Chris Ellis is a family physician in Pietermaritzburg, 
KwaZulu-Natal

Email: cristobalellis@gmail.com

I got burnt once (IGBO)
“Do not dwell in the past, do not dream of the future,  

Concentrate the mind on the present moment.” 
Dalai Lama