The patient concealed his sexual life history, and the hospital was sentenced to full responsibility after he cut the uterus by mistake. Why?

Medical history is one of the most important basis for diagnosing a disease. However, if a patient conceals the medical history and subsequent misdiagnosis and mistreatment occur, what should the doctor do if a medical dispute arises?

In 2015, a hospital in Shandong encountered such a case.

The patient was diagnosed as "choriocarcinoma" by the hospital and needed to be removed for treatment. However, postoperative pathology showed that the patient's illness was due to "placental implantation, cornual pregnancy"-the hospital had made the wrong cut.

The patient took the hospital to court. The hospital stated that this situation occurred because the patient concealed his sexual life history during the consultation process, so it "ruled out the possibility of pregnancy and led to a misdiagnosis."

The hospital said that a similar case in which patients concealed their medical history occurred in Taiwan, China in 2008.

A child less than 2 years old was admitted to the hospital because of "coughing, spitting up, breathing difficulties, and convulsions". The cause of this is unknown. During the period, the child suffered from respiratory depression many times.

It was not until a week later that the doctor discovered that the culprit was a peanut choking into the respiratory tract. Although the foreign body was removed smoothly, the child suffered from repeated hypoxia due to respiratory depression and paralysis of the whole body.

The family members of the patient appealed that "the hospital did not find the cause of the disease in time." The hospital stated that "they had repeatedly asked whether the child had eaten hard objects, but the family members always denied it."

The verdicts of these two similar cases at first glance were completely opposite.

In the Shandong case, the court did not accept the hospital’s opinion on "patients concealing the medical history" and ruled that the hospital bears full responsibility; in the Taiwan case, the court found that the patient’s family did indeed have concealed behavior and ruled the hospital not responsible.

Similar cases, opposite judgments?

The biggest difference between the two cases is whether the hospital provides evidence for "patients concealing their medical history."

In the Taiwan case, according to the medical records, the family members of the child told the doctor when they were admitted to the hospital that they had sucked milk from the respiratory tract during CPR. After the hospitalization, the medical records showed that the doctor had asked the family twice whether the child was eating The family members did not mention foods such as nuts and apples."

However, in the Shandong case, there was no record of the patient’s “denying a sexual life history” in the hospital data, and the patient himself did not admit that he had denied it. Therefore, even though the hospital in question refused to accept the judgment after the first instance and appealed again, the court still upheld the original judgment in the second instance.

It is worth noting that the procedures for the courts in Mainland China to prove that patients subjectively conceal their medical history may be more complicated than those in Taiwan: The hospital must provide the court with the patient’s medical history data of the patient’s visit to this hospital, as well as other evidence as before The medical records are used to prove that the patient has indeed concealed the medical history from him before the medical treatment.

Take a case in a hospital in Guangdong as an example.

The patient died of diabetic ketoacidosis, and the hospital claimed that the patient had “concealed the history of diabetes”. However, apart from the medical records in the hospital’s medical records that “the patient denies the history of major diseases such as diabetes”, there is no evidence to prove that the patient knew he had diabetes before, so the court did not accept the hospital’s statement that “patients conceal the history of diabetes” .

Screenshot of Judging Document Network

In addition to lack of evidence, the hospital in the Shandong case also made an important mistake.

If women of childbearing age experience abnormal vaginal bleeding, doctors should first consider whether it is caused by pregnancy. In the Shandong case, the doctor failed to rule out the possibility of pregnancy through auxiliary examinations such as hCG, which directly led to errors in the diagnosis and treatment process.

In contrast, in the Taiwan case, because different diseases may show similar symptoms, and children at this age are usually supervised by parents, doctors do not regard choking in foreign bodies as the primary cause if the family denies inhaling solid foreign bodies. , But to give higher priority to the treatment of more common clinical diseases such as pneumonia, and to exclude various possibilities through corresponding examinations. Therefore, the court held that the hospital was not responsible.

How can doctors avoid risks?

In 2018, JAMA published a survey of 4,510 American patients. Most patients (70%) said that they “have the experience of concealing medical-related information from doctors”.

It is not difficult to see that concealment of medical history is extremely difficult to avoid clinically. How can doctors avoid risks?

Lawyer Liu Zhongzhi from Lu Man Jiangsu Tongdari Law Firm suggested that the most important evidence is medical records.

The medical records written during the diagnosis and treatment process will be a shield for doctors to protect themselves in medical disputes. Whether the shield is strong or not depends on whether the medical records filled out by the doctor are in full compliance with the norms.

In addition to detailed inquiries about the medical history of patients and family members, doctors also need to record them faithfully.

According to the "Basic Standards for Medical Record Writing" promulgated by the Ministry of Health in 2010, inpatient medical records should include 10 main points: patient general information, chief complaint, current medical history, past history, personal history, physical examination, specialist status, auxiliary examination, preliminary diagnosis, physician signature.

During the consultation process, the current medical history "other diseases that are not closely related to this disease but still need to be treated", past history and personal history are usually provided by the patient and family members. The medical record should be fully included and cannot be omitted .

If you encounter special circumstances, you need to modify the medical record afterwards. The doctor must not modify the medical record without authorization. Instead, he should report to the relevant hospital department (such as the medical office) for approval and keep supporting evidence for filing. It can be seen that the revision of the doctor’s signature and date is required for revision.

In addition, lawyer Liu Zhongzhi suggested that in order to prevent patients and their families from denying oral medical history afterwards, the hospital can add a link to confirm and sign the patient's medical history.

A doctor who had worked in the Infectious Diseases Department of Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine told Dingxiangyuan that the hospital had taken this measure.

Within one day of the patient’s admission, the bedside doctor will print out the completed medical record and hand it over to the patient and family members for confirmation. If there is any objection, it shall be amended until there is no objection, and the patient or family member shall sign on the admission record, mark the medical history and indicate the date.

End of major medical history of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

In addition, Lawyer Liu Zhongzhi stated that with the gradual popularization of electronic devices, the evidence that can be submitted to the court will not be limited to medical records, but also include audiovisual materials that have passed legality review and left behind by audio and video recordings.

Duty of care and professional judgment

Just like the previous Shandong case, it is important to have records, and it is equally important to ensure that the diagnosis and treatment comply with regulations.

In other words, once there is a fault, the doctor needs to bear a corresponding proportion of the compensation liability for the corresponding medical fault. Even if there is evidence that patients conceal their medical history, it can only partially relieve the hospital's responsibility.

According to the law, there is no fault in the diagnosis and treatment behavior, which means that the doctor has properly performed the duty of care and the duty of notification. When patients conceal their medical history, it is easy for doctors to fail to fulfill their "duty of care."

The so-called "duty of care" requires doctors to do two things: not only to foresee the possible consequences of their own medical behaviors, but also to fully understand and estimate the possible dangerous ways and degrees of danger that medical behaviors may produce, and to avoid them. Take appropriate measures when danger occurs.

In the Taiwan case, doctors used multiple examinations to rule out suspected diseases. Although the diagnosis was delayed due to family members' concealment, the court still held that the hospital had fully fulfilled its duty of care and that there was no fault in the medical behavior, so it did not have to bear any responsibility.

During the diagnosis and treatment process, there is unequal knowledge between doctors and patients. The gap in professional knowledge may lead to different understandings of medical history between doctors and patients. In addition, patients often take the initiative due to various factors such as economic reasons and shame. Choose to hide the medical history.

Once the doctor accepts the medical history concealed by the patient, it is easy to cause the diagnosis to deviate or even go wrong.

Lawyer Liu Zhongzhi stated that the relevant conditions obtained by asking patients in detail can only be used as part of the basis and reference for the doctor's diagnosis. In the process of diagnosis and treatment, doctors should rely on their professional judgment.

For example, through physical examinations, auxiliary examinations, etc., clues can be found to obtain the basis for diagnosis; once suspicious or abnormal clues are found, doctors should be vigilant and pay attention, follow relevant diagnosis and treatment specifications, improve corresponding examinations, and make necessary differential diagnosis of patient symptoms.