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Legal aspects of clinical practice in reproductive medicine. Retrospective judgement of medical decisions: is the 'linear' model appropriate?

Retrospective judgement of medical decisions is a major component in medical education and quality control as well as in litigation. As the latter gathers momentum worldwide, a central concern of the medical profession should be to sort out the inherent weaknesses of retrospective assessment. One obvious difficulty is the limited opportunity for accurate record keeping as clinical events evolve. Also, the best medical records may fail to reflect the clinical situation in its entirety. Furthermore, there may be differing and even contradictory recollections of events by the patients and staff involved. Finally, the emotional and cognitive state of patients and caregivers may have a bearing on the later interpretation of events. Obstetricians experience too often the frustration of being judged retrospectively. In order to broaden the understanding about this problem, we would like to draw attention to an aspect which has not commanded much attention in the field, i.e. the fact that obstetricians are often involved in the simultaneous treatment of several cases, a reality which is ignored in retrospective judgement because these judgements tend to view each case as an isolated ‘linear’ series of consecutive events. It is not unusual for a delivery room, which handles 300– 400 deliveries a month, to have between three and five women in labour simultaneously. The usual setting leaves the delivery room with only a skeleton staff for ~16 out of 24 h. With a Caesarean section rate of 10–20%, one sometimes observes a night call during which two or three Caesareans are performed with maybe another two operative deliveries. Facing this often stressful ‘overload’ situation, the senior obstetrician on call is required to closely monitor, and be personally involved with, decisions on more than one case. The need to skip from one track of dynamic considerations