Category Archives: Generic

Liminality

Generic, Health Literacy, Patients

Liminality in medicine is the idea that you can be between illness and wellness.

Paul Turner et al give the example of having a food allergy: people with allergies do not consider themselves fully ‘ill’ or entirely ‘well’, but something in between. They are typically “well” so long as they apply food safety skills to avoid their trigger food(s) – but a slip or mistake can lead to a reaction and potentially death from anaphylaxis.

With liminality, a young person feels set apart, or a family feels their child is different from others – this can impact on self image, social interaction, which in turn can lead to denial or other unhealthy coping strategies and adverse health outcomes.

[Sanders, Soc Sci Med 2019]

Non traditional medicine and alternative health beliefs

Communication, Ethics, Generic, Health Literacy, Patients

Non-disclosure of use of traditional, complementary and/or alternative medicine (TCAM) is found in 20 to 77% of studies. This has been attributed to an anticipated negative or dismissive response; assumption that health care professionals lack knowledge on the subject; or the HCP not asking.

HCPs who take the time to listen attentively and respectfully are more likely to have patients disclose TCAM use.

Some cultures/religions are more likely to use TCAM, and are also more likely to suffer from heath inequalities and stigma. If seen as ‘alternative’ and contrary to mainstream medicine, discussion might be perceived by both patient and doctor as irrelevant. If perceived within a more ‘integrative’ framework, it is more likely that TCAM use will be a topic for discussion. The transition from a “traditional-alternative” to a “traditional-integrative” approach to care is being promoted by the World Health Organization’s Traditional Medicine Strategy (2014–2023).

Tangkiatkumjai et al. suggested that TCAM use can be accompanied by an expectation of benefit; perception of safety; and dissatisfaction with conventional medicine. Perception of safety can of course be very misguided, eg interactions between herbal products and cancer drugs.

In oncology, integrative programs focus on quality of life-related concerns, eg chemotherapy-induced peripheral neuropathy, preoperative anxiety and postoperative pain. These programs have been shown to increase patient adherence to oncology treatment regimens, within a safe and effective environment.

Patient trust in their HCP has been shown to increase when asked directly about TCAM use.

Try the LEARN (Listen, Explain, Acknowledge, Recommend, and Negotiate) model, proposed by Berlin and Fowkes.

Non-judgmental approach essential – stereotypes, prejudices, and misconceptions may compromise the therapeutic relationship.

Other family/community voices that can be included?

“What are your goals of treatment with TCAM? Is your primarily goal to relieve your symptoms and improve your quality of life? Or is it to “fight” or cure the disease, prolong life, “strengthen” your immune system, or another goal?”

[Humility about failures/faults of conventional medicine!] [Ben-Arye, 2024]

Letters to GPs

Communication, Generic, Patients

2020 interview study with GPs in the Midlands –

Giving letters to patients has benefits of a sense of patient inclusion, increased patient understanding, patient autonomy, enhanced communication transparency. The letter can act as a memory-aid (for example, medication). Paper-held summary may also act as a physical record of the admission for future encounters and communications, particularly if the patient sees a team who do not have access to the letter (for example, out-of-hours GP).

But if discharge letter is no longer simple summary, but exercise in patient education. GP then has to wade through a lot of excess information.

Letter to patient can alarm patients (especially if inaccuracies), language barriers and patient low literacy lead to health inequalities. GP may be asked to explain letters to patients. Ethics of cases where the diagnosis had not been disclosed, confidentiality breaching if the letter contains third-party information or if patient loses the letter. Patient can be upset by sensitive issues (eg, obesity).

Tips therefore include:

  • Give patient choice regarding getting letter
  • Give patient an abbreviated/edited version
  • Include simple interpretations of results (“normal”, “satisfactory”)
  • Insert a patient information section

Common gripes:

  • Hidden Actions: Critical requests (e.g., ordering blood tests or prescribing new drugs) are often buried in paragraphs rather than clearly itemized.
  • Missing Information: Letters frequently omit the specific rationale for medication changes or leave out essential physical measurements or mental health assessments.
  • Jargon and Acronyms: Traditional letters are often written with heavy medical terminology. This confuses patients who then book GP appointments just to have the letter explained.
  • Delays: Administrative backlogs and IT glitches often mean letters arrive too late to safely guide a patient’s ongoing primary care.

What GPs Actually Want:

  • A Dedicated Action Section: GPs overwhelmingly prefer structured letters that feature a bolded “GP Action” or “Please Consider” section at the very beginning or end.
  • Concise Formatting: Because GPs spend less than a minute reading most routine letters, they favor bullet points and standardized headings for diagnoses, management plans, and required investigations.
  • Direct Communication with Patients: Medical organizations like the Academy of Medical Royal Colleges heavily promote writing clinic letters directly to the patient (in plain English) while copying in the GP. This saves GPs time and boosts patient understanding

AI in portfolios

Generic, Teaching and training

RCPCH guidance –

Using AI safely, effectively and critically is a skill that all doctors need to develop!

Generative AI tools have a significant carbon footprint. 

Doctors are expected to demonstrate their ability to be a reflective practitioner by developing both written and verbal reflection skills. AI should only be considered as a supplement to writing skills and not as a substitute.  

While AI might help with creating an outline for reflection, using AI to create artificial patient encounters or to take a purely mechanistic ‘cut and paste’ approach to ePortfolio entries risks raising concerns surrounding probity.

Educational supervisors should explore reflective ePortfolio entries with their supervisee during supervision meetings and should routinely discuss reflection and encourage verbal reflection, an essential skill for trainees. [esp serious incidents].

Doctors in training should expect to have some of their ePortfolio entries explored by their educational supervisor and/or the ARCP panel. 

Feedback and self-reflection in MSF should not be generated by AI. 

Autonomy

Communication, Ethics, Generic, Patients

Autonomy is relational. A credible choice cannot be made without an appreciation of one’s situation and all the variables. That does not simply mean provision of information and options, because there is more going on in the consultation room, perhaps unexpressed: fear, shame, sadness, anger, doubt.

Time matters. Immediate impulse may not be how you ultimately decide if information shared in a paced, careful, caring, gentle way.

Don’t underestimate the power of written leaflets! Nothing compares to being able to explore in your own time, in your own home.

Being in touch with others who have navigated the same territory themselves is a uniquely therapeutic contribution when having to make choices in circumstances no one would choose.

Autonomy is not solely intellectual. To be vulnerable enough to express fears, to be confident enough to convey personal priorities, to be respected enough to have questions answered truthfully depends on trust in other human beings.

(Deborah Bowman)

Second Opinions

Ethics, Generic

Extensive guidance now at RCPCH.

Social media and access to Google mean families can find out about novel and unproven interventions/diagnoses. Some notorious cases where it has resulted in conflict between clinicians and families.

External second opinion (ESO) system requires “experts”, who have intimate knowledge of the case, without bias. All of which can be problematic.

Parents do NOT have a legal right to request a second opinion. Seeking an ESO could however been as within a doctor’s professional duty, if “in the best interests of the child”. A doctor does however need to to demonstrate they have provided appropriate care for their patients, which includes showing they have weighed risks against benefits, and made reasonable and logical decisions. These decisions must be in line with ‘a responsible body of medical opinion’.

GMC guidance specifically requires doctors to “respect the patient’s right to seek a second opinion”, as they have the right to make free, informed health care choices – to do that involves clarifying clinical facts and defining treatment options. So refusing a request for an ESO could breach a doctor’s obligation to respect patients’ rights and to provide the highest standard of care.

Courts will take account of professional and clinical guidance that it is good practice to request an ESO, as a way of determining what constitutes a responsible body of opinion. Of course it is not always feasible to obtain a second (or expert) opinion, particularly in situations where a decision must be made quickly.

Nuffield Council on bioethics review went to government – https://cdn.nuffieldbioethics.org/wp-content/uploads/NCOB-Disagreements-Critical-Care-Indepdent-Review-FINAL.pdf

Presenting a poster

Communication, Generic, Teaching and training

Eposters now of course as well as conference A1 old school ones.

Design

Same as with a presentation, really. Use headings and subheadings. Bullet points. Don’t mix up fonts and font sizes too much. Beware getting too close to the edges, and avoid the temptation to fill in white space! Beware jargon and acronyms.

The A4 test – if you can read your poster printed at A4, then it should work ok as an A1 poster too.

More tips here – https://xerte.shef.ac.uk/play.php?template_id=1259#page1

And use of images here – https://www.sheffield.ac.uk/library/copyright/using-images-and-other-media

Presenting

Have a pointer so you can talk through your poster easily. Turn back to your audience frequently and establish eye contact.

If a new person joins midway through, welcome them (if only with eye contact and a smile) and afterwards check if they need it explained again.

Prepare your “elevator pitch” – 3 sentence synopsis: What is it about? What did you find? Why is it important?

Keep bigger picture in mind, as some people might need more background info.

Present your poster as you would anything else – like a story. Context, characters, surprises, meaning, future.

Handouts – beware, you might stop someone talking to you by giving them a handout.

Business cards (if you don’t put your contact details on a handout).

Network – if someone particularly interested, offer to have a chat later rather than ignoring other people.

Get feedback – random comments sometimes indicate that you haven’t explained yourself fully, or you haven’t appreciated a different angle, so ask for clarification.

Thank people for interest – potential future colleagues/employers!

Primum non nocere

Ethics, Generic

“First do no harm” – fundamental of medical ethics.

Except dubious origins… The Latin makes people think it’s Hippocrates and in the Hippocratic oath – but Hippocrates was Greek and it’s not in the oath. He does say something pretty similar in the Epidemics.

Not in the Oxford English Dictionary. Well known in America in the 1930s.

1860 Medical Textbook by Inman says it comes from Thomas Sydenham, but not found in his work, and no one else confirms this. But Sydenham did like Latin.

Florence Nightingale says it in English in the preface to her book on hospitals but not in Latin.

Jack Eckert reckons it was the Latin versions of Hippocrates that started to circulate as printed versions that gave rise to the expression. But still odd that rarely used in either English or Latin until second half of 20th century.

Of course, it isn’t a great principle in any case. Most of medicine is a risk:benefit calculation, rather than avoidance of any possible harm.

Lots more discussion in Cedric Smith’s article.

McCulloch case

Communication, Ethics, Generic, Patients

Clarifies an aspect of the Montgomery decision in a way that supports healthcare professionals getting consent. The decision can be found here.

In Montgomery, the Supreme Court said that a doctor ‘is under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments’. In the McCulloch case, the Supreme Court was asked to decide what legal test was applicable when assessing whether an alternative treatment was ‘reasonable’. Was it the Montgomery test or was it the Hunter –v- Hanley test? Put another way, was the decision about whether to discuss an alternative treatment with a patient one of clinical judgement, or was it one for the Court to assess and determine?

The decision was that a doctor (or other healthcare professional) who has decided that a treatment is not a ‘reasonable alternative treatment’ for a particular patient will not be negligent in failing to inform the patient of that alternative treatment if the doctor’s view is supported by a responsible body of medical opinion. In other words, this decision involves an exercise of clinical judgement and any challenge to that decision by a patient is therefore to be determined by the Hunter –v- Hanley test. In the circumstances of the McCulloch case, the application of that legal test resulted in the claim being rejected by the Court.

The court said this:

“Taking a hypothetical example – say that there are ten possible treatment options; the doctor, exercising his or her clinical judgment, decides that only four of them are reasonable and that decision to rule out six is supported by a responsible body of medical opinion. The doctor is not negligent by failing to inform the patient about the other six even though they are possible alternative treatments.

“The narrowing down from possible alternative treatments to reasonable alternative treatments is an exercise of clinical judgment to which the professional practice test should be applied. The duty of reasonable care would then require the doctor to inform the patient not only of the treatment option that the doctor is recommending but also of the other three reasonable alternative treatment options (plus no treatment if that is a reasonable alternative option) indicating their respective advantages and disadvantages and the material risks involved in each treatment option.”

[Michael Stewart, Central Legal Office]

Bias

Ethics, Generic

In research, many studies are non-randomized, so risk of bias.

Newcastle-Ottawa scale is one attempt to assess bias formally – judged on:

  • the selection of the study groups;
  • the comparability of the groups;
  • the ascertainment of either the exposure or outcome of interest for case-control or cohort studies respectively. 

So things like cohort not being representative; control group coming from different population; measurement being rather subjective; duration of follow up – all increase risk of bias.

Publication bias

Suspicious if small study with big effect!