­Martha’s rule: an undeniable right to a second medical opinion

The reason that Martha’s rule has an unstoppable momentum is that everyone who has worked in healthcare knows that each one of us has made mistakes. Some of those errors live on in our memories longer than others. The ones that linger are those where we know we might have done something different, and probably thought of doing something different, but didn’t; where we hesitated because of a lack of confidence in our clinical ability or rushed to intervene through hubris; where we dreaded the humiliating response we might get from a senior colleague; or where we didn’t pay enough attention to a patient because of how busy or fatigued we were.

We rightly consider error in clinical practice to be a system failure, but our individual decisions and actions contribute to that systemic response. That’s why the principle of Martha’s rule—which empowers people to request a review of their or their family member’s care—is undeniable and right.

In a system that perpetuates the power of doctors, that reinforces the belief that “doctor knows best,” what’s really required from health professionals is a daily dose of humility that recognises our fallibility. Martha’s rule, by redressing some of the power imbalance—an imbalance that doctors themselves experience when ill (doi:10.1136/bmj.p2278)—is likely to make the system more robust and safer (doi:10.1136/bmj.p2319).12 It has the potential to protect both patients and professionals.

For more than 20 years The BMJ has argued for an end to patriarchy and for it to be replaced by patient partnership and shared decision making (doi:10.1136/bmj.316.7125.85).3 These concepts are advanced. Improvement is ongoing. The evidence is supportive. But that progress is fragile. The covid-19 pandemic reminded us that, when the system is under stress, patient partnership is easily overlooked and good intentions are quickly forgotten.

Health systems across the world remain under stress, struggling to achieve a new normal that delivers better patient care. Pockets and periods of stress have always been present in health systems, when clinical teams or individuals have failed to perform to expected standards. It’s at these moments in particular that we require a fresh perspective from a team member or colleague. It is something that doctors already request: a process of review through second opinions, grand rounds, and multidisciplinary meetings.

Empowering patients to seek a second opinion for in-hospital care at the time of a workforce crisis will be complex. Martha’s rule must therefore be introduced with full consideration of the implications for staff and with structures in place for evaluation and evidence gathering. Systems for patients or carers to instigate a second opinion already exist in places (doi:10.1136/bmj.p2331), and the evidence is encouraging, albeit preliminary (doi:10.1136/bmj.p2221).45 The health professions are broadly supportive. Informal behaviours should now become standard practice. Medical error cannot be eradicated, but it’s our duty, and within our power, to embrace constructive ways to reduce it.