- Include full name, qualifications, job title and how long you have been doing it.
- Don’t assume reader knows anything about the case
- Use first person
- Who did what, why, when
- Concentrate on your observations and your understanding (no need for long quotes of what was said to you, which is what a clinical report would require)
- Say what you found, but also what you looked for and didn’t find
- If you’re not exactly sure what you did, and nothing documented, acceptable to say “My normal practice would be…”
- When you have referred to or discussed with someone else, give their name and who they are, describe what they did on the basis of the notes and your understanding, but don’t comment on the adequacy or otherwise of their performance.
Category Archives: Generic
Safety Nets
Top tips for safety-netting
- Be specific in the advice given – ‘If xxxx happens, please ring the surgery or out of hours provider immediately.’
- Provide a likely timescale for when you believe symptoms should have resolved – ‘Your cough should clear up soon if it’s due to the chest infection. If it’s still there in two weeks, please book an emergency appointment to see me.’
- It can be helpful to book an appointment for follow up yourself. Telling a patient you’d like to book them in to review their progress in a couple of weeks is safer than just saying, ‘book an appointment if it’s not better.’
- Consider giving written information and patient leaflets to reinforce verbal advice.
- Document the specific advice, given rather than simply saying ‘advice given’.
- Check that patients are aware of how to access advice if you’re not available, such as by giving the number of the Out Of Hours provider.
- Bear in mind the need to re-assess if symptoms are not settling, or if there is no response to the treatment you have given. Be prepared to reconsider an earlier diagnosis.
[Sarah Jarvis, MDU]
Spiritual care
See also Difficult conversations.
Taking a spiritual history
- do you consider yourself religious or spiritually minded?
- where do you get inner strength from?
[Larry Culliford podcast]
[RCPsych leaflet]
All staff play a role in spiritual care. Definition – “Allow people to explore their innermost feelings and ask the most difficult questions about suffering, illness and death”. Aim to help those in need find peace of mind.
Many levels – speaking with dignity and respect, training in bereavement, specialist spiritual care provided by department of spiritual care and wellbeing. Spiritual care volunteers also available.
[NHSL spiritual care guidelines]
[Scottish government guidance CEL 2008.]
Staff care also important eg reflective practice, mindfulness, Schwartz rounds etc.
LGBT issues
Sexual orientation vs sexual practices vs gender identity.
“Coming out” means primarily acknowledging your own lesbian, gay, bisexual or transgender identity to yourself. Coming out to others is not a one-off experience, LGBT people have to make decisions on whether to (or not) disclose, often on a daily basis. This can be an ongoing source of stress and distress. Heterosexism – assumption of heterosexuality, +/- judgment of its superiority in terms of moral value.
Harassment in the workplace can lead to the organisation and/or the individual being found liable and having to pay compensation.
The umbrella term transgender includes transsexual people and transvestites.
A trans-man is someone who transitions from a female label at birth to a male gender identity. When the transition is complete, their trans identity could be considered a part of their past medical history, rather than an on-going identity.
Trans vestites (medicalized? “Cross-dressers” better?) have no desire for any permanent transition but enjoy aspects of the opposite gender and may have a temporary identity including a different name.
Trans sexual protected under Equality act by EU gender directive 2007.
It is the impact on the individual that determines whether bullying, harassment or discrimination has occurred, not the intentions of the perpetrator.
Gender recognition act 2004 allows trans sexual people to apply for full legal recognition of their acquired gender (evidence must be provided). It is also a crime to disclose previous gender without express permission.
Under legislation it is also illegal to discriminate against someone on the basis that they are heterosexual!
[Good LGBT practice in NHS document, Stonewall Scotland]
Parenting and permanence orders
Permanence order is mechanism for local authority to apply for parental rights and responsibilites to be removed from parents.
Not specifically detailed in law (2007) but “threshold test” must be satisfied:
- living with parent poses threat of serious detriment to welfare of child
- the need to safeguard and promote welfare of child is paramount consideration
- that it is better for the child that the order be made, than that the order not be made
Supreme Court decision In the matter of EV (A Child) (No 2) (Scotland) 2017 –
Not duty of parents to prove parenting ability, but for social work to prove lack of ability with full assessment (or adequate records and sworn evidence of non-engagement).
Also, although allegations of harm may be sufficient reason to place child in care, not sufficient for seeking “permanence order”. Given that this may mean waiting on criminal proceedings to be completed, children may be stuck in hearing system for longer than before.
Family centred ward rounds
A study highlighted that the attending physicians talk outside the room as much as or more than they do inside the room.
“It is frustrating to hear the team speaking about you in the hallway before they come in and wondering what they are saying. Then, after they leave the room, they continue to have discussions in the hallway, where we can hear pieces and parts but not all of the discussion.
“We would prefer that all discussion happen in the room with the nurses and the family present.”
The nurses are the ones who have spent the most time with the family, and they have a lot of information to offer. However, the study highlighted that the nurse does not have much of an opportunity to speak during the rounds.
Sometimes, the entire rounds process is effectively over by the time the medical team comes into the room, and rounds are more of a procedural event than a discussion.
Other comments from one family:
- It would be nice if all physicians involved in the care could participate in the family-centered rounds experience, even if some need to be on the phone. Many times, the rounding process happens but then we are left with a statement that they will wait until the other doctors come by to make a decision. This not only prolongs the decisions but also splinters the care that the concept of family-centered rounds is trying to improve.
- We appreciate when the medical teams sit down in the room with us. It makes us feel as if we are having a discussion where everyone is invited to participate instead of a group of people standing over us. This style of communication seems to engage the patient and family in honest, open conversation, and it seems to cause the team to slow down enough to listen to our story.
- It would be nice to have some idea of when they are coming to the room because it seems that no matter what we do, the team comes in when one of us has run to the cafeteria to get breakfast or to take a phone call in the lobby.
[Sarah Pickel, Mark W. Shen, Collin Hovinga. Hospital Pediatrics Jul 2016, 6 (7) 387-393; DOI: 10.1542/hpeds.2015-0136]
Patient centred care
As seen in previous studies of medical students, junior doctor patient-centred attitudes declined during their first year of residency.
There is a clear gender gap. Female residents were generally more inclined to a patient-centred attitude. The difference by gender was more evident for the caring component than the sharing component.
Male residents became less patient-centred in terms of caring attitude after 1 year, while female residents showed little decline.
A previous meta-analysis indicated that female physicians are more likely to address psychosocial issues, use emotional talk and positive talk, and more actively incorporate patient input. All of this could be considered patient centred.
Role models tend to be same gender, which perhaps explains why male doctors tend to learn patriarchal styles.
Interestingly, physicians’ confidence in communicating with patients increases more in those who showed a smaller decline in patient-centred attitude.
[BMC Med Educ. 2018; 18: 20. doi: 10.1186/s12909-018-1129-y]
See also Family centred ward rounds.
Bawa Garba case
High Court ruling regarding Dr Hadiza Bawa-Garba following the tragic death of a 6-year-old boy in 2011. Subsequently convicted of manslaughter. Removed from the GMC register, although Medical Practitioners Tribunal Service (MPTS) decision was to suspend for a year. GMC appealed, saying it had not taken into account the manslaughter conviction.
High Court then overturned erasure, saying that tribunal did not commit any errors in its procedures, and therefore its conclusions were valid.
The trust acknowledged systemic failures, so why the vindictiveness? Its report into the death (“no single error responsible for death”) was not brought before jury, as being beyond scope of the trial! Not lazy or under influence, rather, took on extra duties in overstretched hospital with very little supervision.
And since when was gross negligence manslaughter law the right way to deal with errors made by doctors in training?
Why not corporate manslaughter case against trust?
Concern about reflective notes being used in court – despite being confidential? Used in support of Dr Bawa-Garba to show remediation efforts.
Twitter response from consultants was to emphasise “WE are responsible – so long as you tell us what’s going on”.
Subsequently 2 reviews –
- Marx review by GMC
- Williams review by government into medical gross negligence.
- Suggested that GMC lose right to appeal Tribunal decisions. Most of these appeals have been regarding sexual misconduct cases. Professional standards Authority would still be able to appeal.
- Suggested that GMC not be allowed to access reflective notes eg portfolio. Could still be used as evidence in prosecution, however, not clear whether would help defence or prosecution more
- Touched on high rate of cases involving black or minority ethnic doctors, but did nothing other than suggest BAME representation in investigations
- Recommends explanatory note for gross negligence law, to improve consistency. Law remains the same, however
Insurance and genetic testing
You have to answer truthfully any question you are asked when applying for insurance. You do not need to volunteer information not asked for!
The Government and the ABI have a policy framework (‘Concordat’) for cooperation that includes a voluntary Moratorium on insurers’ use of predictive genetic test results (NOT diagnostic tests) until 1 November 2019, (to be reviewed in 2016). So for most tests, companies cannot force test before providing cover, customers do not need to disclose result while insurance in place, and do not need to disclose results of blood relatives.
Only one exception currently, for cover above £500 000 and Huntingdons. Certainly no need for time limited policies eg travel, private medical care; really just for life insurance, critical illness and income protection. Recognition that increased risks of a small minority can be mitigated by larger population of policies [2014] Evidence from US is that significant proportion conceal their diagnosis.
Asymmetry of information—when the customer knows more than the insurer—is the industry’s nightmare. Testing positive for ApoE4, a mutation of a gene related to increased risk of Alzheimer’s, would be a good reason to get life insurance before symptoms develop.
See also ethics.
Death certificates (Scotland)
New system from 2015. Medical Certificate of Cause of Death (MCCD) provides a permanent legal record of the fact of death and enables the family to register the death, make arrangements for the disposal of the body, and settle the deceased’s estate. In addition, a MCCD provides a record of causes of death for public health reasons.
Electronic system available but paper copy remains legal, and family needs it to register death.
Ideally consultant responsible for patient completes or is at least involved in completion. This should be recorded in notes.
New system of reviews:
- In the shorter level 1 review cause of death checked, reviewer will speak to the certifying doctor about anything unusual. If the certifying doctor is unavailable or incapacitated, the Medical Reviewer will discuss the MCCD with the consultant in charge of the case or another member of the team who knew the deceased and / or has access to the clinical records.
- A level 2 review is similar to a level 1 in that the Medical Reviewer will check the MCCD and speak to the certifying doctor. However, in addition, the Medical Reviewer will also consider relevant documents associated with the death, including health records and results of investigations. They may also wish to view the body.
These review types will be conducted through a random selection process, will be available on request in certain circumstances from interested persons, or may be targeted by Medical Reviewers in response to any emerging pattern that requires further checks.
The last type of review is the “Interested Person” review – provides further reassurance. Includes relatives, any person present at death, healthcare professional involved with deceased etc. Must be within 3yrs of death, and can only take place if not already reviewed randomly. Request to medical review service.
Tips for Certifying Doctors
Contact the Death Certification Review Service (DCRS) by phone or email for help, open Monday to Friday 08:30-17:30. There is an on-call medical reviewer available out of hours.
Consider whether there is any reason to report to or discuss the case with the Procurator Fiscal (guidance here) e.g. trauma has been identified as a cause or contributor to death, there is a complaint about the care provided prior to death etc.
If you have discussed a case and agreed with the Procurator Fiscal that the case does not need to be formally reported, then do not tick the “PF” box.
Your writing should be in CAPITALS using BLACK ink throughout when completed by hand.
The time of death is the time that to the best of your knowledge and belief you think the patient died and NOT the time that death was verified.
Use business telephone numbers; do not include personal mobile numbers.
You must not include any abbreviations except HIV or Aids which are both permissible.
The causes must make sense both medically and chronologically. If you use more than one line in section 1 then what is entered in 1a MUST be caused by what is in 1b which MUST be caused by what is in 1c etc. Durations likewise should be sequential.
Sites and organisms in infections, including resistance and routes of infection are important and should be entered if known.
If you wish to enter a cause of death that you believe is the case but you have no confirmatory evidence, you can qualify it with “Probable” or “Presumed”.
If obesity has significantly contributed to the death it should be included.
None of the form is optional and all parts and questions on both sides should be considered and answered as appropriate.
It is the statutory duty of the doctor, who has “attended” the deceased during the last illness, to issue the MCCD. There is no clear legal definition of “attended”, but it is generally accepted to mean a doctor who has cared for the patient during the illness or condition that led to death and so is familiar with the patient’s medical history, investigations and treatment. It is not unlawful to complete a certificate if you have not personally attended the patient but you have to be in a position to certify to the best of your knowledge and belief and willing to be personally accountable having had access to the appropriate records.
If you cannot issue an MCCD you should contact a colleague who can, or discuss/report to the Procurator Fiscal.
[HIS tips – Support around Death (SAD) website]