Handling the Heat: A PLAB 2 Guide to Managing Angry Patients When Disclosing a Misdiagnosis

Summary: This scenario involves informing a patient’s family member about a missed diagnosis of a femoral fracture, initially misdiagnosed as normal on X-ray, now confirmed via CT scan. The candidate must communicate the error transparently, manage emotional responses, and outline the next steps in care.

Key Points

Breaking Bad News Protocol (SPIKES):

Setting: Establish a private, calm environment; use telephone etiquette if the interaction is over the phone.
Perception: Gauge the family’s understanding of the patient’s recent health developments.
Invitation: Offer information about new developments in the patient’s condition.
Knowledge: Explain the chronology of events factually (initial misdiagnosis, recent CT scan results).
Emotion: Acknowledge feelings and show empathy, using pauses to allow the family to respond.
Strategy & Summary: Outline the plan for follow-up care and potential treatment options (e.g., referral to orthopedics for possible surgery).

Information Verification and Communication:

Verify family member identity using patient identifiers (age, address) before discussing sensitive information.
Avoid overwhelming them with medical jargon; instead, use clear, understandable language.
Emphasize that further steps will be taken to prevent recurrence of such errors.

Important Considerations

Transparency in Error Disclosure: Clearly acknowledge the error and take responsibility.
Emotional Support: Be prepared for a range of emotional responses (anger, sadness) and show genuine empathy.
Safety Netting: Offer reassurance by explaining measures in place to avoid future errors and the family’s right to file a complaint.
Ethical Responsibility: Follow GMC guidance on openness, honesty, and professional accountability if things go wrong.

Diagnostic Approach

Chronological Explanation:
- Begin with the initial X-ray conducted for suspected fracture and describe the initial normal findings.
- State that the patient’s ongoing pain led to a repeat scan (CT), which confirmed a fracture.
Clarify Details of Mistake: Explain that upon reviewing the initial X-ray, the fracture was indeed visible but missed.
Acknowledge Responsibility: Apologize sincerely, as outlined in GMC’s guidance on openness and honesty.

Management

Immediate Steps:
- Reassure the family that an orthopedics team will assess the patient.
- Inform them of likely next steps (e.g., potential hip replacement surgery) but clarify that this will be decided by the specialist.
Follow-up Arrangements:
- Schedule a follow-up to address any additional questions.
- Provide contact information for patient liaison services (PALS) and offer assistance if they wish to make a formal complaint.

Communication Skills

Active Listening and Empathy:
- Use pauses and non-verbal cues (if in person) to validate their feelings.
- Avoid stock phrases; personalize responses to build trust.
Signposting and Clarity:
- Introduce each new topic to help the family follow the conversation structure (e.g., "I’d like to discuss the recent developments in your mother’s care").
Professional Apology and Supportive Statements: Acknowledge the error empathetically, apologize, and offer full support for their concerns.

Ethical Considerations

Duty of Candor: Be open about the mistake, ensure transparent communication, and maintain the patient’s and family’s trust.
Follow-Up Support: Ensure proper channels for complaints are available and assist them as needed in accessing them.

Additional Resources

GMC Guidance: Refer to GMC’s Good Medical Practice for principles on handling medical errors and patient communication.
Patient Liaison Information: Provide written material, if available, about PALS and similar services for additional family support.