professionalism in medicine - bolton gp...
TRANSCRIPT
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Professionalism in Medicine
7 February 2017
Dr Greg Dollman
Medical Adviser
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Who said… ?
Patients need good doctors. Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity and within the law. Good doctors work in partnership with patients and respect their rights to privacy and dignity. They treat each patient as an individual. They do their best to make sure all patients receive good care and treatment that will support them to live as well as possible, whatever their illness or disability.
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Name an (in)famous doctor
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What is professionalism?
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Intended learning objectives
Explore what medical professionalism is as a concept
Review the recent history of professionalism in medicine
Consider the GMC’s view on professionalism
Discuss cases which bring professionalism into play
Challenge your current beliefs/practice
Consider what this evolving concept means to you
How do you best manage the grey?
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The patient–doctor partnership is the fundamental unit of clinical practice.
The patient–doctor partnership is the fundamental unit of clinical practice.
multiple and varied
a work in progress
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In early 2015, the GMC noted…
“growing concerns within the medical profession about doctors’ role in a modern health service.”
“Although the values underpinning professionalism may remain constant, the context in which those values are played out is always changing.”
“Many doctors feel the current environment is the most challenging of their careers.”
“That relates not only to the pressures of day-to-day practice, but also to increased patient expectations and the often conflicting demands of employer and patients. And this has to be set against the backdrop of almost unprecedented upheaval in the NHS in England, with major reforms coinciding with one of the severest financial squeezes in its history. The long-running contract dispute in England can be seen as symptomatic of these growing concerns.”
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A brief history …
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“… comprises a set of values, behaviours and relationships that underpin the trust the public has in doctors.”
“… lies at the heart of being a good doctor. The values that doctors embrace set a standard for what patients expect from their medical practitioners.”
RCP, Doctors in Society, 2005
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“… is realised through a partnership between patient and doctor, one based on mutual respect, individual responsibility, and appropriate accountability.”
integrity continuous improvement
altruism
excellence compassion
working in partnership
RCP, Doctors in Society, 2005
“… is hampered by the political and cultural environment of health, which many doctors consider disabling. The conditions of medical practice are critical determinants for the future of professionalism..”
RCP, Doctors in Society, 2005
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Mastery
Autonomy
Privilege
Competence
Self-regulation
Art
Public good
Excellence
Judgement
Commitment
Altruism
Appropriate accountability
Continuous improvement
Compassion
Partnership
Integrity
A change in mind-set and vocabulary…
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What was the response?
What was the response?
GMC included “Professionalism in action” into GMP 2005
In 2007, the Government issued further suggestions following Shipman Inquiry
In 2008, the King’s Fund reviewed the RCP report, in Understanding Doctors: Harnessing Professionalism
In March 2009, the NCAS conference took as its theme ‘Professionalism – dilemmas and lapses’.
CQC set up 2009
NHSLA 2009 – saying sorry is not an admission of liability (from Compensation Act)
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NCAS 2009 – conference and guidance
“Professionalism – dilemmas and lapses”
“There are many definitions of professionalism but the broad categories or domains generally include:
• competence
• interpersonal relationships and emotional function
• maintenance of boundaries
• consistency of practice and reliability
• reflection and learning
• commitment to service”
What happened next?
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“The report of the Francis Inquiry into the failings at Mid Staffordshire NHS Foundation Trust shook the medical profession.”
“The Francis report makes it clear that medical professionalism is at a critical juncture. Core medical values – values that underpin the trust patients and society have in doctors – are under intense pressure.”
BMA, Examining professionalism, 2013
“refers … to that set of values and principles that guide the actions of doctors as they seek to deliver the best available health care to patients.”
BMA, Examining professionalism, 2013
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This is now a hot topic …
Patient groups
“We want our doctors to be honest, properly skilled, fully up to date, to inform us, to take account of our preferences and to treat us with dignity and respect.
Equally we want to be confident that the medical profession is making sure that these standards of good practice are observed by all doctors, everywhere.
We want our doctors to have the capacity to accept that we are all prone to error, to have insight and to accept and learn from constructive criticism.”
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Advancing Medical Professionalism to Improve Health Care
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What does the GMC say?
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1. Patients need good doctors. Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity and within the law.
Professionalism in action
2. Good doctors work in partnership with patients and respect their rights to privacy and dignity. They treat each patient as an individual. They do their best to make sure all patients receive good care and treatment that will support them to live as well as possible, whatever their illness or disability.
Professionalism in action
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3. Good medical practice describes what is expected of all doctors registered with the General Medical Council. It is your responsibility to be familiar with Good medical practice and the explanatory guidance which supports it, and to follow the guidance they contain.
Professionalism in action
4 You must use your judgement in applying the principles to the various situations you will face as a doctor, whether or not you hold a licence to practise, whatever field of medicine you work in, and whether or not you routinely see patients. You must be prepared to explain and justify your decisions and actions.
Professionalism in action
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6. To maintain your licence to practise, you must demonstrate, through the revalidation process, that you work in line with the principles and values set out in this guidance. Serious or persistent failure to follow this guidance will put your registration at risk.
Professionalism in action
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The compassionate doctor
The resilient doctor
The doctor’s dilemma
The collaborative doctor
Putting safety and quality improvement first
The doctor as scholar
The compassionate doctor
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The resilient doctor
GMC: “Doctors under pressure need resilience, not mental toughness.”
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The resilient doctor cont…
Factors aiding resilience:
Intellectual interest
Self awareness and self reflection
Time management
Continuing professional development
Supportive working environment
Mentors
The doctor’s dilemma
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Professional/ethical duty
Legal duty
regulation 20 of The Health and Social Care Act 2008 Regulations 2014
Applies not to individuals but to organisations
Including all care providers registered with the CQC from 1 April 2015
CQC guidance expects an organisation's staff to act in accordance with this obligation
Duty of candour
The collaborative doctor
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Putting safety and quality improvement first
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The doctor as a scholar
Good systems of appraisal are one of the foundation stones for sustainable medical professionalism.
Appraisal is not to assess performance, rather is part of the career development process for every doctor.
Appraisals
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“Appraisal should include data on clinical performance, training and education, audit, concerns raised and serious clinical complaints, application of relevant clinical guidelines, relationships with patients and colleagues, teaching and research activities, and personal and organisational effectiveness.”
Appraisals
Concerns that the focus has moved to tick-boxes and achieving targets rather than patient needs
Appraisals
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http://www.mddus.com/media/2440/fyi18_jan17.pdf
Maintaining professional boundaries
“You must not use your professional position to pursue a sexual or improper emotional relationship with a patient or someone close to them.”
“Social media can blur the boundaries between a doctor’s personal and professional lives and may change the nature of the relationship between a doctor and a patient.”
“Wherever possible you must avoid prescribing for yourself or anyone with whom you have a close personal relationship.”
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Medical professionalism matters conclusion: the way forward
The Medical professionalism matters series was held in the
face of a number of challenges in the healthcare system. While
doctors expressed considerable unease during the course of
these events, the overriding message remained one of
optimism and humility. They spoke time and time again of the
privilege of being a member of the profession, their fascination
with their work and their potential to make a real difference to
people’s lives.
Case scenarios
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Your patient with terminal pancreatic cancer wants to die at home. Her family feel that she will get better care in a hospice.
How would you proceed?
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A 27 year old patient visits the practice intermittently, worried about her health. She spends a lot of time reading up about medical conditions on the internet, and she presents with vague symptoms which she attributes to unusual conditions. Today, she complains about a headache and is worried that she has a brain tumour. You find no warning features after a thorough history and examination. Your patient would like a brain scan, and becomes very upset when you explain that this seems unnecessary today.
What would you do next?
You are the senior partner, and you employ a new salaried doctor. A complex complaint is made to the practice, and involves mainly the salaried doctor as well as other practitioners. After the complaint, you notice that the salaried doctor is staying latest in the practice every day, is there first thing in the morning, looks tired and has given off the impression of being anxious about various patients who she appears to have managed well.
How do you approach this matter?
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Your patient has a condition which means he may not be able to drive. The patients tells you he has notified the DVLA, who say he can continue to drive. The patient withholds consent for you to inform the DVLA of your concerns. You feel it unlikely the DVLA would say over the phone that it is appropriate for him to drive. You are concerned the patient is not telling the truth.
What could you do?
Your patient loses her baby at 38 weeks. She does not appear to be suffering with post-natal depression, but is clearly struggling to cope. She blames one of the doctors in the practice, although all agree that no one could have prevented this. The patient refuses to see that doctor when offered an appointment with them, and no one else is available. The patient shouts at the reception staff. The staff report feeling very uncomfortable, and ask for the patient to be removed from the list.
What do you do in this situation?
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You, as the senior doctor, receive a complaint from a patient who was not offered a chaperone. No clinical incident ensued. The patient said she had to ask for a chaperone, and although the doctor did eventually seek assistance he seemed unwilling to do so.
How would you proceed?
You discover, after a few weeks of on-calls at your new Practice, that one of the salaried doctors has dismissed the symptoms of a number of patients whom you admitted to hospital. You believe that he has made several clinical errors. You are concerned, and wonder what to do.
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Hello Dr Ismail I just saw your profile, and see that you play cricket. I wonder if your team is looking for a spinner. I’m keen to get back into the game, and would love to join you sometime. Thanks Mike
Mike Thomson
Your uncle arrives at your house at 22h00, in transit from America. He is due to fly to Botswana at 07h00 for a two week camping holiday. You ask if he has been to a travel clinic. He hasn’t, and asks if you would prescribe him a few Ciprofloxacin tablets and malaria prophylaxis.
What would you do?
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Learning objectives met?
Explore what medical professionalism is and what it means.
Review the history leading to this concept becoming a hot topic.
Consider the GMC’s view on professionalism.
Discuss cases which bring professionalism into play.
Action Points
Be aware of GMC guidance and how to access it
Work with colleagues in MDTs to best serve your patients
Seek guidance when unsure
Report concerns earlier rather than later
Seek medical help for yourself if needed
Maintain boundaries – social media, patients, treating self/friends
Call MDDUS for advice and assistance anytime
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Conclusion
Any questions?
What do you think?
I welcome your feedback…
Useful links
GMC guidance
http://www.gmc-uk.org/guidance/
Good medical practice
http://www.gmc-uk.org/static/documents/content/Good_medical_practice_-_English_0914.pdf
Good doctors
https://www.gooddoctors.org.uk/
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Useful links
MDDUS
http://www.mddus.com/resources/
http://www.mddus.com/risk-management/
Useful links
Social media
http://www.gmc-uk.org/Doctors__use_of_social_media.pdf_51448306.pdf
Confidentiality
http://www.gmc-uk.org/static/documents/content/Confidentiality_-_english.pdf
Prescribing
http://www.gmc-uk.org/static/documents/content/Prescribing_guidance.pdf
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Useful links
Boundaries
http://www.gmc-uk.org/static/documents/content/Maintaining_a_professional_boundary_between_you_and_your_patient.pdf
http://www.gmc-uk.org/static/documents/content/Maintaining_boundaries_Intimate_examinations_and_chaperones.pdf
http://www.gmc-uk.org/static/documents/content/Maintaining_boundaries_Sexual_behaviour_and_your_duty_to_report_colleagues.pdf