Parents' quality of care rating correlates strongly with quality of health worker-parent communication. Main concerns are info given direct to child + care coordination. Involving patient in decision making process leads to fewer symptoms, reduced pain, and higher rates of satisfation.
On average a patient gets 23 seconds to voice their concerns; in most cases the doctor will interrupt before they finish speaking. The patient wants to know:
The more efficiently they get the answers to this the quicker the consultation.
Barriers include irrational ideas which patients may be reluctant to voice; over-interpreting information; lack of assertiveness. Usefulness (cf cost) of aids such as training, lists etc is related to patient variables such as age and gender, and the reason for the consultation and hence its content (diagnosis, prognosis, check up) and context (for example, first consultation with new doctor).
Roter found intensity (that is, the amount of information conveyed within a certain time) was positively associated with satisfaction, and Buller and Buller found that increased time spent talking was inversely related to patient satisfaction. The implication is that quality is more important than quantity and that this will arise when patients communicate their agenda clearly and doctors respond appropriately. Most of the evidence suggests that encouraging patients to ask questions does not inevitably increase consultation time, and where this becomes an expected part of the consultation process it can be more efficient and more satisfactory to both patients and doctors.
Patients' opening monologue is often interrupted but spontaneous duration is only 30sec in primary care, and 90sec in consultant clinic. Fear of wittering on is probably unfounded...
1 in 1000, over 100 throws, gives a once ever risk of 10%. 99% certain? Do it 50 times, you have a 40% chance of getting it wrong at least once. (Actually quite a complicated calculation! Needs a binomial calculator>)
How big is a billion? There are 2.5 billion seconds in 80 years.
To deal with unrealistic perceptions of risk: (Science media centre)
See also Peter Sandman's website.
Kahneman and Tversky's Prospect Theory - highly important in economics, Nobel Prize in 2002. Concerns apparent anomalies and contradictions in human behavior. People when offered a choice formulated in one way might display risk-aversion but when offered essentially the same choice formulated in a different way might display risk-seeking behavior (framing effect). For example, as Kahneman says, people may drive across town to save $5 on a $15 calculator but not drive across town to save $5 on a $125 coat.
People's attitudes toward risks concerning gains may be quite different from their attitudes toward risks concerning losses. For example, when given a choice between getting $1000 with certainty or having a 50% chance of getting $2500 they may well choose the certain $1000 even though mathematically it "makes sense" to go for the other option which averages $1250 (risk-aversion). But the same people when confronted with a certain loss of $1000 versus a 50% chance of no loss or a $2500 loss do often choose the risky alternative.
Peter Bernstein asked people to estimate the probability of dying from various causes. If you add up the risks they come to much more than the estimate people give for the overall chance of a natural death. Also, people worry more about unnatural dangers and not enough about natural dangers.
Prospect theory also replaces the notion of utility with value. Whereas utility is usually defined only in terms of net wealth, value is defined in terms of gains and losses (deviations from a reference point). The value function has a different shape for gains and losses. For losses it is convex and relatively steep, for gains it is concave and not quite so steep. In practice, to get people to adopt something, focus on the gain. To get them to reject something, focus on what they might lose. See Changingminds.org.
Perceptions of risks are built up over time, informed by personal experience, social networks, behavioural norms and media reporting. Fear of disease, trust in technology and desire to take responsibility for health are all important. The framing of risks both numerically and linguistically, and the value individuals place on the gains and losses perceived have an effect on the choices that they make, which has considerable ethical implications for how information is provided. Descriptive terms (rare, common, etc) carry different meanings for different people, so use actual numbers. Relative risks and percentages are confusing and misleading; talking in terms of numbers of people helps, using the same denominator. Visual aids and comparison with normal life probabilities can help. Both positive and negative approaches should be used eg risk of dying vs risk of surviving - remember placebo effect!
| Getting three balls in the UK national lottery | 1 in 11 |
| Dying on the road over 50 years of driving | 1 in 85 |
| Needing emergency treatment in the next year after being injured by a can, bottle, or jar | 1 in 1000 |
| Death by an accident at home | 1 in 7100 |
| Death by murder | 1 in 100 000 |
| Being hit in your home by a crashing aeroplane | 1 in 250 000 |
| Death by rail accident | 1 in 500 000 |
| Getting six balls in the UK national lottery | 1 in 2 796 763 |
| Being struck by lightning | 1 in 10 000 000 |
It is essential to develop a trusting relationship, which involves interest in more than purely medical issues, willingness to cooperate, and playing up competence (by counteracting patient self criticism, and playing down their own knowledge).
Recommendations are often dependent on the balance of benefits and harms, which depends on the individual's values. For strong recommendations, there may be barriers such as readiness to change and self-efficacy. For preference sensitive options, decision aids help: describing options, clarifying options, giving balanced examples, coaching in decision making.
Some patients are reassured by normal test results, some are wholly unreassured. Simple pretest discussion (re exercise testing) made a significant improvement to levels of reassurance, and this was maintained. Indeed, symptoms were less after the test too. Size of effect impressive, considering that the intervention was not tailored. Benefit of post-test discussion similar? BMJ 2007:334;325
What would you do, doctor? Confirms asymmetry in medical knowledge. Often a sign of vulnerability and uncertainty. Certainly a sign of trust. But actually an ambiguous question: what would you do if you were in their shoes? Or what do you think is the best for them? Latter needs to incorporate their own values and beliefs. Howard Brody suggests that you think out loud, weighing up the options. Whereas declining to answer is a form of abandonment.
Why do patients delay presentation? Probably a more important question than how well they are managed after they arrive!? Need educated about multidisciplinary roles (don't have to necessarily see the doctor), primary care needs more coordination (in case they don't see the doctor), and it should be customised to match patient preferences (in case they want to see the same doctor - most don't mind). Attendance at A&E in a Canadian study by people with existing health concerns was increased by specific "What to do if things get worse" instruction by GP...
There is an interaction between patient and doctor about how much participation the patient wants/is allowed. Patient determined participation might be quite subtle - reflects normative expectations about their right to participate; depends on how much effort they perceive it to require and how much they are prepared to exert to satisfy those expectations. So don't be fooled by an apparently passive position. Also recognise that some may not wish to be involved due to vulnerability or apathy, but even then the choice may represent a deliberate act of detachment, or even defiance, in the face of perceived social or personal exclusion.
Basically comes down to personal characteristics (often socio-economic) about ability/willingness to cope with responsibility for autonomous decisions; the severity and chronicity of the condition; and trust in the doctor. Social Science & Medicine Volume 64, Issue 6 , 1297-1310
Parents express the need to receive more than just factual information from neonatologists: they also require support and engagement from caregivers to manage the uncertainty. This brings into question the traditional concept of neutral informed consent and suggests the necessity of a shared decision-making model to ensure that the decision to resuscitate extremely premature babies, at the limits of viability, becomes a truly ethical task.
Health literacy is the capacity to obtain and process health information. Patients with lower health literacy have poorer health status, higher rates of hospital admission, are less likely to adhere to prescribed treatments, experience more drug errors, and make less use of preventive services.
NHS management tends to reduce both doctor and patient to objects - makes it easier to control and research where everything is standardized. Also serves the market in that they become interchangeable. Doctors become mere technicians; patients become customers requiring a specific service. No attention is paid to maintaining a therapeutic relationship. These trends seem to be driving patients to seek therapeutic relationships elsewhere eg with practitioners of complementary medicine. Ironically, the demand is such that there is pressure for such alternatives to be funded publicly!
Ideally, technological (as researched and proven by RCTs) and subjective therapeutic power should be combined and maximised such that the intersubjective can be used systematically to maximise the effectiveness of scientific technologies of proven benefit. Lancet Volume 369, March 2007, 886-888
In a trial with a placebo analgesic, 1 group were told the drugÂ’s price was $2.5 per tablet, the other group were told the drug had been discounted to 10 cents. Those given the full price tablet were significantly more likely to report a reduction in pain scores, and reported a greater reduction in pain scores. Suggests that people equate cost with quality and effectiveness. JAMA 2008;299:1016
Elements include:
Influence vs Manipulation - techniques are the same, only the motivation of the individual differs!
Note behavioural style (assertive vs friendly vs logical). Note also whether person is internally vs externally referencing ie are they making judgements on basis of gut feelings or own initiative, cf using outcome data or other validation.
Tricky questions:
Facilitator cf Chair - disinterested, no opinion of own, keeps process of meeting active, constructive. Whereas Chair's job is to monitor content for relevancy.
Minutes - agree in advance how much detail. Action points only may be sufficient.
Rotate Chair between topics/meetings - allows a Chairperson with a particular interest in an agenda item to participate more fully, also allows others to practise the skill, and avoids controlling vested interests.
Regular meetings are dangerous! Consume time, no specific purpose - "discuss" is not an outcome, cf solve a problem, make a plan, collect ideas/info, decide a course of action. Ideally put outcomes and time into agenda (group can agree to extend if appropriate).
Seating arrangement fits with style of facilitator/chair - Hierarchical (standing at the front) cf cooperative (sitting at the front) cf autonomous (sitting alongside).
Dealing with problems:
Action points:
= Matching research with policy.
All starts from the premise that putting research into practice is as much social as technical. Cf uptake of clinical guidelines (Ethnographic study of knowledge management in primary care. BMJ 2004;329:1013-7) "Knowledge depends for its circulation on interpersonal networks, and will only diffuse if these social features are taken into account and barriers overcome." (Greenhalgh) cf pharmaceutical industry using local opinion leaders to influence patterns of drug prescribing.
Jonathon Lomas BMJ 2007;334:129-132
Use local grants/charities to get started in research.
Clinical fellowship vs project grant: Short term, little dept recognition. Project grants go to established depts, you need a high impact application, preliminary data esp presentations/abstracts, sexy images needed. Evidence of joint working helps eg academics with 5 stars on research assessment exercise. For fellowship, highlight your career goals, generic vs specific skills to be gained.
NHS funding for research avaialbe - Culyer criteria. Include written protocol, independent peer review (def?), takes account of NHS priorities. National Research Register held by DoH. All projects must be registered with R&D office. Data protection - anonymous unless patient consents. Safe guard data at all times.
Equator-network.org is about enhancing quality of health research. Easy access to reporting standards eg CONSORT for RCTs, QUORUM (now PRISMA) for systematic reviews, and STROBE for observational epidemiological studies.
Cohort or case control. Cohort can be prospective (better) or retrospective.
Jadad scale for assessing quality of a trial. Or use CONSORT statement.
A style of research in which researchers work explicitly with and for people rather than undertake research on them. The design is continually negotiated with participants; there may not be a clear demarcation between researcher and researched. Findings are continually fed back to participants for validation and to inform decisions about the next stage of the study. Generalization of results may not always be easy: the work must be described in its rich contextual detail. The onus is on the researcher to make his or her own values and beliefs explicit in the account of the research eg by including self reflective field notes.
(BMJ 320; 178)
A step beyond QALYs, examine user values, which extend beyond health outcomes to waiting time, location, type of provider etc. Allow investgation of the trade-offs between such process and health outcome attributes. But do users behave in reality as they say they would do in the experiment?
Should contain all info needed to replicate study. Keep intro colloquial, not turgid. Use table if boring (no vertical lines!). Don't over format- journal will customize. But figures need to be camera ready. (legend separate). Discussion- summarize, importance, contributiou, context, pick up themes from intro, concluding paragraph to echo abstract. Thanks.
Realist review – looks at assumed mechanisms for success/failure (explicit or implicit), gathers evidence from primary sources about process of implementation, to see whether those assumed mechanisms were directly tested or not.
Composite or surrogate outcomes – often used to boost sales despite non patient related outcomes. Composite outcomes can help avoid arbitrary selection of a primary outcome when several different candidate outcomes are available, and help analysis because in time to event analysis power is driven by number of events rather than number of patients. Esp where licensing is based on a composite outcome, need to check whether individual outcomes eg death actually proven.
The Hawthorne Effect is when a control group shows improved outcome as a result of being part of a study, and presumably, higher awareness.
The discrepancy between Odds Ratio and Relative Risk depends on the size of the initial risk, and the size of the odds ratio: biggest discrepancy is with high risk and high ratio, but in any case the conclusion is the same, that the risk is significant!
Should be specified in original protocol, rather than done post-hoc. Else like firing a shot gun then drawing targets around the holes. Test for interaction can detect a difference in effect between subgroups. If one subgroup has a significant result but not the others, does not necessarily mean genuine effect across the whole group - may just be effect of lower sample size on statistic. Difficult to prove, as it relies on non-sigificant P values and clinical judgment of similarity, but as a general rule, the main result is probably valid across all subgroups unless good evidence to the contrary.
P values measure the strength of the evidence against the null hypothesis; the smaller the value, the stronger the evidence. An arbitrary division of results, into significant or non-significant is therefore crass: precise p values should always be given, and possibly clinically important differences in small studies that are non-significant should not be ignored. Equally, the p value is not the probability that the null hypothesis is true: firstly, most of our theories turn out not to be true, so a lot of the "significant"findings will still turn out to be false. Secondly, most of our studies are underpowered, so a lot of the real differences will be missed anyway!
Suggest: stop describing differences as significant or not. Make confidence intervals 90% and interpret according to clinical importance of effect. Subgroup analysis should be accompanied by evidence for interaction (ie that effects really differ between subgroups) and claims should be tempered. Studies should seek to maximize sample size and measurement accuracy (which have logarithmic effects).
(BMJ 322:226)
More clinically relevant than the Odds Ratio because takes into account background prevalence. But to convert between them is complex! Use Nomogram at CEBM.net. Easiest way to remember it is that it is the inverse of the Absolute Rate Reduction ie the difference between the rate seen with the intervention and the rate seen without (= the background prevalence).
Number Needed to Harm is the same except that it applies to Absolute Rate Increases.
PIN-ER-t =(population impact number of eliminating a risk factor over a period of time), which is defined as the potential number of disease events prevented in a population over the next t years by eliminating a risk factor,2 allows numbers to be communicated in a more friendly way to demonstrate to both decision makers and the general public the impact of risk factors for a disease in a population
Different from sensitivity and specificity, although related. Definition = Ratio of the probability of the patient having the disease with a positive vs a negative test; more than 10 is highly likely. = sensitivity/(1-specificity). Can be calculated for different values of the same test (unlike sensitivity), and is part of Bayes theorem, where you multiply the pretest probability by the likelihood ratio to get the posttest probability. (Complex calculation because you need to convert relative risks to odds ratios, but can be done with Fagan's nomogram). Compare Positive Predictive Value, which assesses only the general population prevalence.
Highly sensitive tests can be used to rule a diagnosis out (SnNout - Sensitive, Negative, diagnosis out), similary specific tests (SpPin - Specific, Positive, In). But beware - should really use likelihood ratios, as test sens/spec may not relate to same population, may be exaggerated by spectrum bias (excluding mild/borderline cases), and may have wide confidence limits.
Coefficient of determination (R22) - This index estimates the amount of variability in test results that is explained by a regression rule. An R2 value of zero means that correlations between predicted and observed values of a test are entirely due to chance, no different than a coin toss. At the opposite extreme, R2 = 1 means that the regression predicts the observed value of the test perfectly.
Only valid if normal distribution, not always true eg weight.
| 0.67 | 25th |
| 1.28 | 10th |
| 1.88 | 3rd |
| 2 | 2.3rd |
| 2.67 | 0.4th |
| 3 | 0.14th |
Correlation means that 2 ways of measuring something have a consistent pattern. In other words, when plotted on a graph, how close to a straight line the points are. Agreement means the degree to which 2 measurements give exactly the same result - ie how close to the straight line of equality they are; not necessarily the same thing.
Pearson's correlation coefficient tells you how close to a straight line the points are. However, it can be misleadingly small when there is a relationship between the variables but it is a non-linear one. Spearman Rank correlation coefficienct may be better (non-parametric).
Bland Altman plot = is a way of looking at 2 different measuring techniques, to see if a new method is as good as the gold standard. Is a plot of the mean of the 2 measurements, vs their difference. Should not form pattern (which would suggest bias). Can also be used to assess repeatability (and since the mean difference should be zero, a coefficient of repeatability can be calculated).
The intraclass correlation coefficient (ICC) is one measure of reliability eg agreement between measurements taken by different people or labs. It is basically a one way test of variance. The paired t-test can be used to evaluate the overall ratings or bias of the two raters, while their variances can be assessed with Pitman's test.
Should be viewed as an observational study of the evidence: A protocol should be decided in advance with hyptheses and subgroups. Unpublished studies should be included – the Cochrane Controlled Trials Register is probably the best single source. Use a standardized record form, 2 independent observers (blinded if possible to author, journal and institution), rate the quality of the study. The outcomes should be presented in graphical format in standard deviations or odds ratios. Conclusions are drawn according to a fixed effects or random effects model. Heterogeneity tests are rarely significant but can at least point to deviations from the general pattern which can then be explored further.
Analysis of Heterogeneity ie variability between studies is useful because it becomes suspicious if there is a wide variation. You can assess viusally, or by examining I2 (Higgins), a quantity which describes the porportion of variation in point estimates due to heterogeneity rather than sampling error. You can then do a statistical test of homnogeneity, to determine the strenth of evidence that the heterogeneity was genuine.
Bias is similar - a funnel plot where you print effect size ranked by study precision gives a visual guide but you need reasonable study numbers.
Sensitivity analysis is done to see whether small changes in how a study or systematic review was done impacts on the results, important where certain decisions or assumptions about the data and the methods used are made possibly arbitrarily.
Cronbach alpha is a test of correlation between questionnaire items. Consider also inter/intra observability. (Test/restest represents intra).
Power calculation depends on clinically relevant/detectable effect (those 2 conflict) and degree of natural variation, or prevalence.
As demonstrated by Prof Roy Meadow at the Sally Clark trial, you can only multiply 2 risks together (for 2 events) if you can safely assume that each event is completely independent of the other. If something happens once, then it would not be surprising for there to be factors and circumstances that persist, making the risk of a repeat event much higher.
Of course, the underlying question is inappropriate. The question is "Which is the most likely explanation for the events seen? 2 cot deaths, 1 cot death and murder, 2 murders or indeed some other cause in either case? This requires the likelihoods of competing explanations to be compared.
EBM is basically Ask, Acquire, Appraise, Apply and Assess. See Literature for more EBM stuff.
Another EBM mnemonic, this one for critical appraisal.
Prioritise topics depending on importance, uncertainty, or resource consumption. Construct a model to illustrate links between the intervention and outcomes. Use this model to search for evidence. Identify stakeholders to ensure adequate discussion and representation. Cochrane controlled trials register includes trials outside the usual databases. Categorise evidence according to reliability (metaanalysis, RCT etc), then grade recommendations accordingly. External review then specify date for updating systematic review.
BMJ 1999;318:593
Clinical guidelines are appropriate when practitioners are unclear about appropriate practice and when evidence can provide an answer. In all other settings, they invite problems: inappropriate interpretation of poor quality evidence, recommendations influenced by people/cost/convenience, poor individualization of patients, perceived reliability eg audit, patient expectations, negligence.
Things that maximise success:
For the few conditions that cause the bulk of clinical work we should be looking at every facet of clinical care.
=Grading of Recommendations Assessment, Development and Evaluation system. Adopted by WHO, Cochrane etc for rating quality of evidence and strength of recommendations. A bit arbitrary, putting categories on something continuous but advantages of simplicity and transparency outweigh. Important because otherwise enthusiasm for new things (eg HRT) can become disproportionate to anticipated benefits (and unexpected harms).
Grades for quality of evidence are High (further research unlikely to change), Moderate (further research likely to impact on confidence in estimate of effect), Low (further research very likely to impact), Very low (any estimate is very uncertain). High quality usually related to RCTs, but can be downgraded if inconsistent, or study limitations, or imprecision. Similarly, case-control studies start with a low quality rating but can be upgraded if magnitude of effect is very large or clear dose-response relationship. “Expert Opinion” is a confusing one – surely the evidence is strong or the evidence is weak? Strength of recommendation (Strong or Weak – some panels prefer conditional or discretionary rather than weak!) does not directly follow strength of evidence: if the balance of desirable and undesirable is very close (eg warfarin for DVT), if there is uncertainty about whether it represents a wise use of resources etc. Aspirin in chickenpox – only weak evidence of association with Reyes, but clearly should be avoided.
Grades for recommendations are just strong or weak. A strong recommendation would imply that most patients should be offered that treatment, and that most will benefit. A weak recommendation implies that individual circumstances and preferences might influence whether or not to have that treatment. A decision aid might be useful. Depends on balance of benefits and risks, quality of the evidence, variability of individual values or preferences, cost. Strongly recommended treatments might nonetheless have only minor advantages, which would affect patient uptake; plus, prevalence and equity issues might affect policy. Strong/weak may not be the best descriptive terms: a system of ++++ or ABC is advised for quality of evidence, a system of up/down arrows +/- question marks else G1 vs G2 is advised for strength of recommendation.
Should be explicit how resolution is achieved when consensus is not reached. GRADE has a grid where individuals are asked (anonymously) to judge benefits vs disadvantages, and this is then mapped against strength of recommendation. If there is majority agreement on direction of recommendation, then it passes without further time wasting. Prevents endless rounds of argument.
See also Drug Marketing below.
The idea that you need more than just valid content to promote your ideas. Typically involves:
See BMA guidance on a range of ethical issues.
The "D" case - do doctors have a duty towards parents, ie are they liable to prosecution if they make an inaccurate claim about abuse? No, says House of Lords, primary duty is to the child. With respect to parents, they must be able to show that they acted after careful consideration of history and examination, pending further investigations; and that such actions were done "in good faith". There is no right to privacy - there is only the right to respect for privacy ie interference must be justified, proportionate and necessary. Such justification should be explained to parents, and they must be allowed to participate in decision making as much as possible. The human rights act exists to promote safety of the vulnerable, not to hinder it by protecting possible abusers (Court of Appeal).
Confidentiality is a balance of public interests and individual privacy, not a right. Compulsory disclosure is necessary to protect others, to the police (sometimes), notifiable and highly infectious diseases (note that there are legal provisions for maintaining confidentiality in the tracing of sexual contacts), fitness to drive. You must weight your duty to your patient with your duty to society: the Egdell case (serious mental disorder posing great risk to others) – but threshold is set high. NHS code of practice refers to "serious crime or abuse/serious harm to others". Consider consultation with senior colleague and defence organization first, and keep notes to show that you have considered all the options and consequences. It is not a crime for a doctor not to inform the police of evidence about a crime. There is a statutory duty for all members of the public to report activity that may relate to terrorism, and to give details that might identify people involved in road traffic accidents (but this would not usually involve clinical information – such information would require a court order or the patient’s consent). Doctors (unlike lawyers) must submit to court instructions.
Research using patient data must also be done by informed consent. If data is fully anonymized then the Data protection act does not apply. Data can also be pseudo-anonymized, where a key connecting identities to a unique identifier is kept totally separate. Research without informed consent is possible if obtaining consent is very difficult, involves a disproportionate cost, or would invalidate the research by introducing insuperable bias! Must also be shown that the data cannot be obtained any other way and that the risk of harm is minimal (a case of the potential value to society being considered more important than the risk of harm to individuals). Caldicott Guardian will be able to help.
Young people under 16yr are due an obligation of confidentiality if Gillick competent ie possessing sufficient maturity and intelligence of comprehend the nature and purpose of what is being discussed or proposed. Spelling out this obligation to young people enhances the willingness of teenagers to disclose important information. Rare exceptions are where parental involvement is in the child's best interests - but the doctor would have to be prepared to justify such a disclosure as being necessary to avoid a demonstrable risk of harm to the child. For child protection, disclosure is obligatory but assumed to be in the child's interests - such cases are worth discussing with Defence body.
Caldicott principles govern information sharing:
The Caldicott guardian is the nominated person to ensure these principles are adhered to. Usually board level, as they need to be able to inform strategy. Part of broader information governance, as laid out by various laws including Data protection, freedom of information, human rights act etc and including information security and assurance.
Joshua Greene asked participants how they would respond in two situations. In the first, they are watching five people in a trolley rolling down a railway track towards a cliff edge. They can save the five by throwing the lever of a set of points to divert the trolleyÑbut doing so will kill a person standing on this second track. Although one life will be sacrificed, five will be saved, and most people say they would throw the lever. In the second scenario, the individuals imagine themselves standing next to an exceptionally fat man on a footbridge over the track. This time they can stop the runaway trolley by pushing their companion on to the track in front of it. Here too, one man will die, but five will be saved. In this case, however, most people say they would not take action. What is the philosophical difference? Maybe none - but by putting the two situations to his participants while they underwent functional MRI, Greene showed that contemplating the footbridge dilemma prompted more activity in areas of the brain associated with emotion than did the points scenario.
Greene's findings challenge the view that moral judgments must be based entirely on reason. Indeed, he believes that emotion is a legitimate and inescapable part of moral decision-making.
Macbeth effect described by Canadian researchers whereby act of washing hands after being asked to describe an unethical act changes individuals' propensity to offer voluntary help. Lancet
A word used a lot but whose definition is problematic! Immanuel Kant - a quality belonging to all sentient human beings because of their capacity for rationality and moral freedom. This dignity carried with it the obligation that human beings be treated with respect - as reflected in the Kantian dictum that people should be regarded as ends in themselves and never just as means. This kind of dignity is intrinsic, and a consequence of it is the idea of equity and hence human rights.
But social dignity is to do with recognition by others, or at least a self-image that one has moral intentions towards others. It can be conferred or taken away. And when it is threatened, society as whole suffers because the value of humnan life has been lessened.
But it relies on the general acceptance that individuals are intrisically worth something ("epistemological contingency"). If some are thought less worthy than others, then there is potentially a conflict between the idea of dignity protecting against insult and exploitation, and the idea of dignity as enhancing autonomy and opportunity.
Social Science & Medicine Volume 64, Issue 2 , January 2007, Pages 292-302
UK's Nuffield Council on Bioethics report Critical care decisions in fetal and neonatal medicine: ethical issues gives some guidance on the basis of outcomes. When born after 24–25 weeks' gestation, the baby should usually be offered full intensive care, concludes the Working Party (most will survive, most will have no/mild disability). At 23–24 weeks', the parents' wishes should take precedence (at best a quarter will survive to discharge, and half of them will have moderate/severe disability). At 22–23 weeks', resuscitation should not be attempted unless the parents insist and the clinicians feel the case is exceptional. Leaves a grey area at 25/40!
Neuberger criteria: competence, information, understanding, voluntariness. All dubious! Proxy consent by parents can create conflict of interest eg handicapped child. Authorization a better concept (presumes right of child to take part in research)? Non-therapeutic research is not strictly legal, but usually accepted if minimal risk ie not significantly increased risk compared with standard care. Right of research enshrined in possibility of benefit outweighing possible risks. Alternative is therapeutic orphans, treated without good evidence of benefit. Failure to conduct research led to prophylactic sulphonamide disaster in 1950s (increased kernicterus). Research without consent not strictly legal but possibly acceptable for emergency situations, but retrospective consent should be sought (not really consent at all, of course) else assent (simplified consent) with later ratification, in stages if necessary.
New GMC guidance on consent (2008) - places it in context of process of discussion and decision-making. There is no "once size fits all" method. Starts with information being provided, in different formats. References advocacy services. Does not set threshold values for discussing risks: sensible, given how complex the communication of risk can be (see above). Acknowledges that some patients do not wish to go into detail about their condition. While doctors must respect their patients' wishes, there is a minimum level of information that a patient is likely to need in order to give valid consent. Adults with Incapacity Act (Scotland 2000) and Mental Capacity Act (England 2005) establish mechanisms for incapacitated adults. Provides practical advice on assessing capacity.
Reasons for refusal in EURICON study: perceived risks/distress; distrust of research/researchers; dislike of the tone of approach of the doctor; shock and inability to decide; inconvenience of follow up. Hence communication skills essential. Information sheet should be given but should not be relied upon. As a minimum, parents must know that the treatment is being given as part of a trial, that their child may be receiving an experimental or unproven treatment, that they are free to say no and to opt for standard treatment. Check list should be provided. Involvement of independent committee should be highlighted. Feedback to parents should be encouraged.
Inability to give consent eg children, unconscious, learning difficulties does not mean research should not be done – indeed that would deprive patients and others of potential benefit. But should only be done if unable to do same study with patients who can give consent; risks should be minimal (for non-therapeutic research that means equivalent to everyday life or minimally invasive therapeutic interventions; assent should be sought from appropriate advocates eg relatives, who should be provided with the same information which would have been given to a competent patient; research should be explained after its completion to participants who have regained their competence subsequently (NOT retrospective consent, mind you).
Use of medical records without consent is a moral wrong – should be balanced against potential benefit. Patients should be informed of this potential use of their records and reassured about confidentiality. Only do if consent not praticable; research is of sufficient merit and has potential benefit; identifiers should be removed where possible; contact with patients is not anticipated; permission should be gained from responsible clinician.
How to get consent – Parents should feel they are being cared for, as well as their child. They should feel that they are being involved in the discussion of care. They should feel that they are being asked for their permission to enter the baby into a trial, not to defend the best interests of the baby. Parents hate the idea of their baby being a guinea pig, so emphasize background to study: importance, plausibility, etc. Acknowledge the pressure being put on parents to absorb and understand all the information. Invite questions and interruptions, reiterate key points. Accept that research has negative connotations. Randomization is difficult to understand (and if they do, computer allocation is seen as more appropriate than tossing a coin or drawing from a hat!)! Don’t say what you would do. Beware strange comments/questions – suggest misunderstanding. Reinforce that whatever the decision, the best proven care will be given. Don’t rush.
Written consent - the law only requires written consent for a very few things, eg IVF, organ donation! But you must record the fact that you have gained consent in medical records. And it may just make everything easier to get it written anyway.
For births registered in Scotland, a father acquires parental responsibility if he was married to the mother at the time of the child's conception or subsequently. In Scotland, an unmarried father will acquire parental responsibility if he is recorded on the child's birth certificate and the child was born on or after 4 May 2006. In England, this right was introduced earlier (births from December 2003). If not on the birth certificate, an unmarried father must obtain a court registered parental responsibility agreement or order.
Interestingly, parents do not lose parental responsibility even if they divorce, have no custody rights and make no financial contribution! Foster parents usually do not have parental responsibility - that remains with the local authority and the birth parents. The parental rights of a child born under a surrogacy arrangement remain with the surrogate until the new parents complete adoption procedures or else obtain a court parental order (under the HFE Act).
As far as the child is competent, decision making should rest with the child, and any decisions eg access to medical notes should be considered in the light of the child's best interests.
Parents are allowed to authorize 3rd parties eg child minders, Grandparents to take over particular responsibilities. In terms of the Childrens Act, what is reasonable to safeguard/promote the child's welfare is permitted to such carers. If on the other hand the parent is likely to object to a treatment decision, only emergency actions are acceptable pending contact with the parents directly.
The landmark Gillick ruling was that "parental rights were recognised by the law only as long as they were needed for the protection of the child and such rights yielded to the child's right to make his own decisions when he reached a sufficient understanding and intelligence to be capable of making up his own mind". Subsequent rulings have retreated a little from that position, especially when it comes to children refusing treatment. In Scotland, the Age of Legal Capacity (Scotland) Act 1991 gives explicit rights to the child, whereas no such law for under 16s exists in England and Wales. The Human Rights Act enshrines the tension between parents' right to "private and family life" and the autonomy of children.
Suicides, medical mishap, drowning, suffocation/overlaying, infectious disease incl food poisoning, foster or cared for or CP register (or previously) child, where parent complains that medical treatment contributed, must be reported to fiscal (and possibly police). Does not automatically lead to Fatal accident Inquiry. Fiscal can order autopsy, hospital report, expert opinion. Precognose = interview. Fiscal represents public interest, not victim, at FAI. Can have legal representation, do not have to answer questIons.
Council for International Organisation of Medical Sciences guidelines call for universal principles of ethical research, not universal standards of medical care. Interventions must be appropriate for the country where the research is conducted, and no research subjects may be denied care that would otherwise be available for them. This justifies trials of short course AZT vs placebo in pregnancy. Offering US standards of health care to research participants could be seen as undue inducement. Altering the study question to satisfy medical and ethical imperialism is exposing people to potential risks of research that is unlikely to answer the study question, so is unethical.
Drug companies in the UK spend £850 million per year on marketing in primary care, or about £2500 per GP. In the US there is 1 drug rep to 15 doctors – cf teacher to student ratios in schools and universities. Ask reps about STEP: safety, tolerability, effectiveness and price. Tolerability is best assessed by looking at drop out rates between the drug and its best competitor (or whatever you would normally use); effectiveness should be judged against its best competitor. Price should include monitoring and extra visits to doctor.
No Free Lunch - take the pledge. Health Skepticism (coined by Pierre Garai, 1963) – stop blaming drug companies, responsibility lies with doctor to be resistant to the lure of the fashionable and new.
A systematic review of quality of pharmaceutical advertising in medical journals found that less than 67% of claims were supported by RCT or systematic reveiw, and that less than 28% of claims were unambiguous clinical claims. Most supporting evidence comes from convenience samples, not representative populations, and most risk reductions are reported relatively not absolutely. PLOS One 2009 PMCID: PMC2709919
Australian competition and consumer commission has since 2006 required drug companies to submit reports detailing events for doctors.
Direct to consumer advertising only legal in US and NZ but EU is now considering. Systematic review confirms that it influences consumer demand as well as prescribing practices, but little evidence of health benefits. Institute of Medicine has called for 2 year moratorium on new drugs to avoid Vioxx type incidents. EU Medicines Evaluation Agency comes under Enterprise and Industry rather than Health and Consumer Protection, hence conflict of interest. Role for industry improving patient access to information? But how to distinguish promotional material and unbiased evidence?
Elsevier, publisher of The Lancet , was found to have colluded with Merck to produce a fake journal, the Australasian Journal of Bone and Joint Medicine (AJBJM) to promote rofecoxib and other Merck products. This kind of "ghost publication" is widespread, what with ghost authoring (where an article is written by someone other than the person whose name appears at the top of the article) and other forms of pseudo-journals. Bioethics 2009 PMID: 19222451
Rationing in NHS has previously been camouflaged behind clinical judgement. Does ignorance on the part of patients have utility, by sparing them distress? Only if they never find out… Plus it goes against autonomy. Life is easier of course: public more likely to accept rationing by doctors than by managers, but only if they believe each patient is treated individually rather than decisions being made according to more general value judgments eg cost effectiveness, quality of life. Some have argued that there are no clear principles for rationing – but surely there is equal access to health care based on equal need ie avoiding/minimizing disability. Health care should be allocated to local population on basis of the most accurate needs assessments of which we are capable. Specific illness types should not be discriminated against: rationing should take place within rather than between different areas of healthcare need. Triage is accepted as a means of prioritizing waiting times: same principles apply. Unless citizens are given at least the potential for influence on policies that effect their lives, their moral developent will be damaged and they will not have the same personal stake in either learning about or conforming to the rules of their society ie democracy (JS Mill). Increased democratic feedback may increase effectiveness of public policies by helping them be more reflective.
RCPCH give 4 categories where Do not resuscitate orders are appropriate: brain dead, permanent vegetative state, no chance/purpose, unbearable. It is generally accepted that the DNR concept is unpleasantly negative, so the preferred approach is Resuscitation Planning. Medical Director should be involved, urgently if needed, if such plans are overturned or judged inappropriate.
David Glass case - went to the European court of Human Rights. Severe learning difficulties, multiple episodes of life threatening respiratory illness, fight broke out between Mum and staff after morphine given. Resuscitated by mum, still alive. Points:
Mum won the case, and indeed her clinical judgement was more accurate. It rarely happens however that judges find in favour of parents - presumably because they find it difficult to make the decisions themselves. The family should be offered time to obtain a second opinion, but failing that the courts, for all their faults, have to be used unless a clinical ethics team exists!
Parents hate to feel abandoned. There should never be a "switch" to a different kind of care; there should simply be recognition of what interventions are successful in their goals and which are not (the goals may need to be clarified). As such, there may be a mix of curative and palliative treatments. pmid 18319382
GMC guidance "Treatment and care towards the end of life: good practice in decision making" emphasizes issues of capacity, partnership with child and parents. Makes the point that fear of causing upset is not a justified reason for withholding information, and that unfounded assumptions about the impact of disability on a child should not be the basis for judgements. Seek a second opinion if unsure of treatment options or prognosis; encourage families to makes use of advocacy. Decisions about withholding of nutrition/hydration should always involve a second opinion. In the event of disagreement with a family, recommends a second opinion, case conference or ethics consultation before approaching the courts.
Nutrition and hydration are considered medical treatment (Airedale NHS trust vs Bland, 1993). But seen by general public as part of humane treatment! Withdrawal must be seen (by families and health care team) as part of a process of end of life care.
GPs have the discretion to register failed asylum seekers for routine primary care, although they are not obliged to do so.
In secondary care failed asylum seekers are entitled to free care only when it is "immediately necessary" - this is a matter of medical judgment and therefore medical discretion.
No legal obligation in UK to act opportunistically, but GMC would expect unless real personal danger. In some countries eg France, Germany there is a legal requirement. The law would usually accept that in emergency situations, conventional standards may not be obtainable. Where you are acting outside your competence or under the influence of alcohol, you should try to explain this to the patient before you treat them. Make notes, retrospectively if necessary.
Doctors (cardiac surgeons, anyway) tend to favour maximizing opportunity and potential (ie full cure) and count years in the future as being almost as important as near future. Parents tend to concentrate more on the here and now, and may place more emphasis on safety and security than on opportunity and potential.
Making a diagnosis: we tend to categorize signs and symptoms, based either on experience of individual cases or else a pattern. Errors tend to creep in when the evidence is misread, especially visual clues, or misinterpreted, so it is important to reformulate and not become psychologically committed to a particular hypothesis.
Bayes theorem applies, in that there is a pretest probability (usually rare conditions are overemphasized) then evidence presented, the strength of which gives a likelihood ratio.
Don't just do something, stand there! Ineffective interventions are perpetuated by the desire to appear efficacious.
Mihaly Csikszentmihalyi - being completely involved in an activity for its own sake. Each action/thought flows inevitably from the previous one. Good for solo working, dangerous in group working where important that everyone engaged, co-operative, attentive. To encourage:
One of IOM quality dimensions, was originally named Patient control! Elliot Freidson (sociologist) describes Professions as being an anomaly, where the public grants authority to judge own quality, as part of social contract in return for altruism etc. Is this contract still valid?
One definitions would be: "Exactly the help I need and want, exactly when and how I need and want it". But actually, what help/care do you really, really want? On one level, safe, effective care. But on another level, to be treated with compassion.
Usual objections to such ideals are societal resource limitations (but when informed, patients often use less), exhaustion of staff (but arguably suppression of emotion/empathy through institution more exhausting). Plus, external resources eg family can be coopted. "Every patient is the only patient" Don Berwick, IHI
Subjects were led to believe that they were helping supervise a study which required them to give a test subject electrical shocks. In reality the other person was an actor and no shocks were given. The study showed that 65% of the subjects continued administering ever more powerful electrical shocks - even though the actor was screaming in pain and later on pretended to pass out. The subjects were never pressured - if they protested they were simply told in a calm voice that "The experiment requires that you continue" or "You have no other choice, you must go on.".
Their conclusion was that: "Ordinary people, simply doing their jobs, and without any particular hostility on their part, can become agents in a terrible destructive process. Moreover, even when the destructive effects of their work become patently clear, and they are asked to carry out actions incompatible with fundamental standards of morality, relatively few people have the resources needed to resist authority."
US Macy report on education: lectures don't work, CME should be more problem based. Improvements come from audit, feedback, outreach and reminders. Health professionals should not accept drug money - product promotion or doctor welfare rather than patient benefit (professionalism).
When you compare medical school to how CME works for doctors - latter is fragmented and poorly regulated. Indicators for educational outcomes are rarely used. Doctors are not skilled in self assessment of educationl needs Doctors more reluctant than other professionals to shift to small group work.
PMETB (Postgraduate Medical Education and Training Board) was set up by the government after the Shipman enquiry to ensure adequate standards in the health profession, seen as different from the GMC (General Medical Council) who are a doctor led organization more concerned with ensuring professionalism and protecting reputation. However, PMETB is to merge with the GMC post 2010, at which time the GMC will take on the duty of licensing doctors in clinical practice.
The Health Care Assessment and Training foundation programme uses 4 tools:
Rating is done online via HCAT website, using their rating scales. Feedback should identify strengths and areas for development.
“Guided discovery learning” is similar but involves initial didactic teaching, provision of learning outcomes and study guides. A study guide should specify learning outcomes, help sutdents to set their own objectives and plan their learning, identifies appropriate learning resources and advises on their use, and provides opportunities for students to assess their own competence.
Research shows that doctors learn most when they are motivated enough to identify their own learning needs and meet those needs at their own pace. That means turning workplace experiences into achievable learning objectives. Use input from peers and seniors to identify needs: a personÂ’s ability to assess their own performance is limited. Identifying what you then want to achieve is usually straightforward, but finding out how youÂ’re getting on requires feedback, and specific feedback at that. With clinical questions we tend not seek evidence based answers - either due to lack of available information or excessive amounts of it. "Foraging" tools are needed; see Literature.
Adults are motivated by learning that :
Maastricht seven jump sequence:
For students, anchor prototypes - consider 2 differential diagnoses together.
Role modelling is important but not many good role models out there! Note importance of personal qualities eg compassion, effective interpersonal relationships, enthusiasm. Reflection in action – explaining what we do as we do it; reflection on action – discussing afterwards what happened. Institutional barriers exist eg overwork, a culture that accepts inadequate patient care or poor relationships between team members.
3 uneven sections (when it’s up and running). A question is devised one week, its search results looked at the next, and the week after sees an analysis of the best paper(s). In each session, the first five minutes are used to review the results of a search, and a paper selected. The next 40–45 minutes are used to discuss a paper, and the last 5–10 minutes are used to identify and clarify a clinical question to roll onwards. In the first few weeks, teaching papers and "planted" questions can be used to get the principles in place. It also helps if the group leader can make sure that the initial questions being asked are likely to have an answer—it can be highly dispiriting to have a three week run of "no evidence for this question". The problems you are likely to face when doing this include:
The best defences to these problems are encapsulated by Baden-Powell's motto: "Be prepared". Have to hand the idea that only about 1/9 questions will have a decent answer; and have a few questions up your sleeve to tickle people with. Push the idea of "how good is the study" rather than "how poor is the study". Keep a store of papers you'd use for teaching to fill in awkward gaps, and to broaden your understanding of other sorts of studies. (You'll probably find you get lots and lots of therapeutic questions and not very many diagnostic, prognostic, or aetiologic ones.) And to get around the problem of staff changing, try to empower the group to teach itself as it goes along.
(ArchDisChild 2004;89)
Mintzberg's roles for a manager; figurehead, leader, liaison, monitoring, disseminating, spokesperson, entrepreneur, disturbance handler, resource allocator, negotiator.
Learning organizations: characterised by :
2 important points: What makes people happy or unhappy varies wildly. Some people want co-workers around them, others want peace and quiet. Some people want clear guidelines, others want more freedom.
Secondly, people typically think of more negatives than positives. ItÂ’s easier to come up with ten things you donÂ’t like about your job than things you like. Also, the negatives tend to be more specific (referring to specific situations), where the positives are more general.
Plants are at their most fragile when they are small and just starting to grow. That's why gardeners use greenhouses. It's the same with ideas. They are easiest to destroy when they first appear. Unfortunately, most work cultures tend to stifle ideas before they can take root.
So, all new ideas should get a grace period where they are nurtured, not attacked. During this period, you can ask questions like:
Then after a while, take a critical look and see if the idea holds water.
If this greenhousing doesn't happen, it might be worth pointing out to people that this leads to:
A lot of getting people to like you is about likinq people. "Trait transfer" is subconscious association of what is being said with who is saying it eg someone who gossips is likely to be thought of as untrustworthy, someone who praises others is thought of as generous.
Sarah Warner demonstrated that workplaces with a culture of forgiveness had:
Interpersonal stress was found to mediate in the relationship between forgiveness and health/productivity outcomes. The strength of the results was the most surprising aspect of the study.
One of the most thoroughly replicated findings in the field of social psychology is that the more you reward people for doing something, the more they tend to lose interest in whatever they had to do to get the reward. In the early 90s Flink and Bogiano in Colorado took teachers and invited them to teach a given task to their students. The first group were told that they would be held accountable for raising standards (with reference to a test). The second group of teachers were told to facilitate the kids' understanding of the task. Testing the children afterwards showed markedly inferior performance for the kids who had been taught under the standards and accountability condition.
Teachers working to standards became drill sergeants, removing virtually any opportunity for the kids to participate actively in their own learning. In effect, the teachers were controlled and they responded by becoming controlling. Horizontal vs vertical standards - horizontal aim to facilitate the teaching process, vertical donÂ’t change how things are taught, they just demand that the learning be better.
Alfie Kohn
From The Chief Happiness Officer website
From The Chief Happiness Officer website
Bob's Top Twelve Tips:
Multitasking - mythical activity in which people believe they can perform 2 or more tasks at once (Hallowell, ADHD psychiatrist). Only ever doing one thing at a time, and jumping between reduces depth, reflection, emotion ie hard work. Being distracted by phone calls and emails causes IQ reduction twice that found in marijuana smokers. In flooding of new info is at cost of reflection on what is already in hand, feeds a need to always seek new material, so that then memory gets confused, attention is distracted (not just by other tasks, but by irrelevant stuff too). Something addictive about it (dopamine?).
Handling interruptions:
Time stealers:
Procrastination - usually delusion that one has no time, yet actually achieving little. Vicious circle of guilt, stress, inadequacy.
Urgent vs Important grid (Steven Covey) - we tend to give our attention mostly to the urgent+important work, yet if had given more attention to the important-urgent work, it would never have become urgent.
For beginners, an introduction tutorial. For more indepth help, try the Powerpoint FAQ site.
To change background, choose Format, Background, click on down arrow to select Fill Effects, then click on Picture tab. You can either insert or link to file, and you can apply to all or just to one. Save your design for future use by Save as Design template.
There have been reported medical errors from using Excel sheets were a typing error has inadvertently altered the contents of one of the cells. To lock the majority of cells:
To hide unneeded gridlines (makes it much tidier looking):
Refworks is an online references manager for when you are writing a paper. You can import your references from a text document, and then get a nicely formatted bibliography. Free via E-library.
A free Firefox extension that will automatically import references from webpages.
On demand is more useful than live stream, because it is permanent. Many different software options eg Adobe Captivate (expensive), TechSmith Camtasia; some free trial, some free. Services also exist to host the presentations.
Ask presenters for consent, a summary and a photo for indexing. Reassure that slides themselves will be deleted once presentation movie is complete. Where data from publications is shown, no copyright issue if referenced and not for profit. Where new data is presented, danger of duplicate publication claim - so limit to as much data would be in an abstract, or else selectively remove data, or embargo presentation for a period.
Consider backup audio recording.
For internet streaming, aim for 1Mb per minute; 800x600 should be OK unless video content.
Healthspace from CfH is opt-in except for summary care record, where it is opt-out. Independent evaluation in May said current level of development still too early for proper evaulation. Uptake very low so far (0.12%), complaints about clunky interface and frustating procedures. Patients with stigmatising conditions more positive than expected! Risk of credibility gap appearing if patients find mistakes (real or perceived) in the record. Microsoft Health Vault and Google Health available to some US patients.
Talks, presentations, lectures, and speeches involve communicating your thoughts to an audience. Ideally, you hope to instill some knew knowledge, or awareness, or even inspire a change in practice. The Heath brothers found that sticky messages have six key attributes in common:
The "rules" of Powerpoint are being increasingly challenged by new models - for examples, see Presentation Zen, TED. Many of the best presentations use virtually no text whatsoever.
Introduction
Development
Conclusion
Find out what equipment is available and ensure you are familiar with it. Keep your slides simple for talks and speeches - pictures are much more involving and stimulating than text, but the most passionate speakers do well from having no distractions.
Rehearse on your own, check your timing, record it on tape and listen to yourself. Then, rehearse in front of friendly colleagues and ask for their constructive feedback. Rehearse in the room where you will be speaking if possible, in order to get accustomed to the acoustics. Make sure you arrive relaxed and in good time.
Wai Ching Leung, BMJ 2002, 324
Rotherham Consultant resident on call rota - 3 years, all consultants work evening shifts and a Friday night. Fixed sessions cancelled for the following week, and extra leave granted, plus financial recompense for evening shifts. Middle graders do weeks of nights, so work 9 to 5 for 5 out of 6 weeks, and do regular clinics/lists. Handover very educational. Encourages better working relationship between consultants and midwives. After evening shift, night tends to be less busy and very unlikely to be called in that night. Encourages consultant interest in ward activity, eg guidelines etc.
Even if a job demands an application form, if it seems to inadequately reflect on you and your experience, you should include a CV and refer to it where appropriate.
Design is important. But excessively fancy can be counterproductive. I would advise against putting a photo in, given how easily (and subconsciously) people can begin to make judgements when presented with a face. The quality of printing must be excellent; the quality of paper and binding should reflect the post being applied for: for a consultant post, I would recommend a heavy fibre based paper eg 80g/m2 and a binder.
Your portfolio should demonstrate:
Should also prevent you pursuing irrelevant goals.
Structure it according to pillars of Good Medical Practice:
Contractual obligation for consultants. See Consultant Handbook from BMA. Aims to optimize use of skills and resources in delivering service priorities. At the same time it maps out personal and professional development, and identifies required resources. GMC revalidation stuff squeezed in here as well. Content should be structured along GMC's core headings for good medical practice, as above, plus relevant management issues esp local service priorities.
Preparation involved identifiying issues you wish to raise with the Clinical Director, and preparing a personal development plan. There should be a workload summary, usually helpful to discuss in advance what data is considered relevant. This summary identifies any changes since the previous year, and is the basis for job planning and service development. Supporting data eg routine performance measures should be shared at least 2 weeks before meeting.
Can be requested by appraiser or appraisee, as a way of obtaining further assessment eg of specialist aspects of clinical performance. Ideally done ahead of meeting, else within 1 month with review meeting thereafter.
The outcome of the appraisal should be a personal development plan, with key objectives. This should then be reviewed by Medical Director and Chief executive to ensure that key areas have been covered, for example, that training is being provided to enable a consultant to introduce a new clinical technique and to identify any employer-wide issues which might be addressed on an organisation basis. This might include clinical audit priorities.
From application form/CV identify your weak points, what needs clarification. What are your “headliners”? Be prepared to expand on anything on the page.
Talk to people to build up different perspectives on the role for which you have applied. What are the key issues? Prepare questions that illustrate enthusiasm and professionalism.
Reiterate your motivation for the role, without sounding evangelical. Ask for clarification about a tricky question before launching into the abyss. Bookend your responses – summarize what you have said, in relation to the question. Give specific examples, referring to what you did (not what “we” did).
If you don't have a substantial question to ask at the end, say that you've had the opportunity to ask questions, and that you are satisfied that this is exactly the job you are looking for!
Surprising that anxiety is not reduced. Perhaps our ritualized styles of consulting in themselves are reassuring... (BMJ 2008;337:338)
Any indication of dissatisfaction from an employee, esp if in writing (incl email) should be dealt with promptly and by someone with full working knowledge of statutory dispute resolution procedures. Take advice first, then act! Disciplinary matters, criminal or FAI cases are excluded from complaints procedure.
GMC recommends that patients who complain have a right to expect a prompt, open, constructive and honest response including an explanation and, if appropriate, an apology. Indeed, apology early may prevent escalation. An apology, as in an expression of regret, is different from admitting liability. This distinction is recognised in Compensation Act.
Patient affairs office clarifies consent by patient for actions of complainant eg MSP. Must acknowledge complaint within 3/7, and written reply must be forthcoming within 20 working days (although this may take form of holding letter, with indefinite end point). Dissatisfaction with this response usually due to a new complaint! Further investigation or meeting can be offered. Involved individuals are NOT summoned to meeting, else potential for aggression and targeted criticism. Not disciplinary so manager more appropriate, with ability to take things further through appraisal procedure.
Ombudsman has wide discretionary powers incl ability to request expert opinion (and other powers similar to courts). Published findings are in public domain, but emphasis is on qulaity/safety of public services rather than naming/shaming individuals.
Communication as common theme. Poor record keeping as impediment to investigation.
Get perspective:
Beware - complainant entitled to see complaints file incl your comments, so avoid passing blame or politicizing. Summarize clinical history. Refer to what is written in notes (may already have been seen by complainant) and to individual paragraphs in complaint letter. Your response often cut and pasted into final response. Draft response circulated for comments - often tight deadline eg 24hrs to review (as still needs final sign off by GM/Assoc Med Director).
No timescale for meeting, although delay unlikely to help process. Complainant often brings internet materials… Lawyer "friends" must accept that other individuals do not have legal representation, and that any attempt to transform case into a legal one will lead to referral to Law Society.
(Liz Price, MDDUS)
NHS redress act 2006 aims to introduce to E&W (hospitals only) a new scheme in 2008 aimed at:
So if claim is likely to be up to a maximum of £20 000, then redress system may be useful. Also free. Still requires clinician time and probably deserves expert opinion, plus NHS run so not strictly independent.
The Medical and Dental Defence Union of Scotland (MDDUS) advice on writing reports at the request of solicitors:
With regard to court attendance as a professional witness (note that there is a grey area between being a professional vs an expert witness):
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