AUTUMN 2016 SUMMONS AN PUBLICATION FOR MEMBERS

• Changing Faces • Refusing treatment • Managing the fearful child • Global knowledge from healthcare experts

SAVE 15% and get FREE worldwide delivery when ordering at www.crcpress.com Enter code CBQ07 at checkout

www.CRCPRESS.com

MDDUS Summons.indd 1 29/04/2016 11:32:19 Global knowledge from healthcare CONTENTS experts

SAVE 15% and get FREE worldwide delivery when ordering at www.crcpress.com THERE is widespread article on page 16 introduces the use of algorithms in order to concern that general improve diagnostic accuracy in this field. Also in this edition, Enter code CBQ07 at checkout practice in the UK has medical adviser Dr Greg Dollman reviews the difficult ethical FROM THE EDITOR reached crisis point, and legal position when a patient refuses treatment (p. 12). judging by the number of recent articles in the medical and lay The rising cost of claims is a concern to all those involved in press which have voiced alarm. And yet 85 per cent of patients medical defence work, and in this issue, risk adviser Cherryl in a 2016 Ipsos MORI survey described their experience in Adams reports on the types of claims that tend to be most general practice as ‘good’ or ‘very good’ – it is clearly a service costly (p. 8). that the public values and trusts, and it lies at the heart Adam Campbell describes the inspiring and invaluable work of the NHS. of the charity Changing Faces, which supports patients with In this issue, Professor Maureen Baker, outgoing Chair of the disfigurement (p. 14), and Deborah Bowman presents some RCGP, provides her views on the challenges faced in funding, thought-provoking insights into the ethics of judgement (p. 9). workforce planning and workload. She discusses the highs and lows A fearful child in the dentist chair is a situation most dentists of her tenure as Chair and her hopes that the new GP Forward dread. On page 18, paediatric dentist Fiona Hogg provides some View sets out a successful strategy to tackle the difficulties (p. 10). useful practical advice on dealing with dental phobia in children. Acute eye presentations can be problematic for non- specialists, and consultant ophthalmologist Dr Mark Wright’s Dr Barry Parker

TAKING A FORWARD VIEW algorithms for non-specialists faced 10 Professor Maureen Baker with common ophthalmological discusses the challenges facing complaints general practice and the highlights of her time as Chair of the RCGP TREATING THE FEARFUL CHILD 18Paediatric dentist Fiona Hogg THE RIGHT TO CHOOSE offers advice on dealing with dental 12A patient refusing treatment anxiety in young patients can present a difficult ethical dilemma. Medical adviser Dr Greg 10 Dollman offers his insight REGULARS 4 Notice Board CHANGING FACES 6 News Digest 14Adam Campbell discovers how 8 Risk: Paying a high price this innovative charity is working 9 Ethics: A matter of judgement to make life more manageable 20 Case studies: A bleak outcome, for people with facial or other Two teeth too many, No blood wanted disfigurements 22 Addenda: Object obscura: Powered toothbrush, Book review – The gene: CLINICAL RISK REDUCTION: an intimate history, Crossword and 16PATHWAYS IN SIGHT Vignette – Helena Rosa Wright, Dr Mark Wright champions the pioneering family planning practitioner 14 use of a unique set of diagnostic

AUTUMN 2016 SUMMONS Cover image: Sheepcraig, Editor: Please address Design and production: AN PUBLICATION FOR MEMBERS Fair Isle, Hazel Walker. Dr Barry Parker correspondence to: Connect Communications Oil on paper, 1991 Managing editor: 0131 561 0020 Hazel Walker, born Jim Killgore Summons Editor www.connectmedia.cc near Aberdeen in 1963, studied at Edinburgh Associate editor: MDDUS College of Art between Joanne Curran Mackintosh House 1981 and 1985. This Editorial departments: 120 Blythswood Street colourful, almost abstract MEDICAL Dr Richard Brittain Glasgow G2 4EA study of Sheep Rock or DENTAL Mr Aubrey Craig Printing and distribution: Sheep Craig has a dream- LEGAL Simon Dinnick [email protected] L&S Litho • Changing Faces • Refusing treatment • Managing the fearful child • like nature, unlike her other landscapes which are often bleak and eerie. Summons is published quarterly by The Medical and Dental Defence Union of Scotland, registered in Scotland No 5093 at Mackintosh House, Art in Healthcare (formerly Paintings in Hospitals 120 Blythswood Street, Glasgow G2 4EA. • Tel: 0845 270 2034 • Fax: 0141 228 1208 Scotland) works with hospitals and healthcare Email: General: [email protected] • Membership services: [email protected] • communities across Scotland to encourage patients, Marketing: [email protected] • Website: www.mddus.com visitors and staff to enjoy and engage with the visual The MDDUS is not an insurance company. All the benefits of membership of MDDUS are discretionary arts. For more information visit as set out in the Articles of Association. www.artinhealthcare.org.uk Scottish Charity No SC 036222. The opinions, beliefs and viewpoints expressed by the various authors in Summons are those of the authors alone and do not necessarily reflect the opinions or policies of The Medical and Dental Defence Union of Scotland. www.CRCPRESS.com AUTUMN 2016 3

MDDUS Summons.indd 1 29/04/2016 11:32:19 NOTICE BOARD

Discounted legal advice Sturgeon said: “Our members already have primary care contracts. MDDUS members access to expert medico-legal advice from can also get advice in relation to CQC on business matters our team of highly-skilled advisers and inspections and health and safety issues. MDDUS has announced a new partnership lawyers. We are delighted to work Sam Hopkins, Capsticks partner and with law firm Capsticks Solicitors LLP to alongside Capsticks to ensure that our head of the firm’s GP legal support team, support GP and practice manager members members’ needs will be enhanced further commented: “We are very excited to be in England and Wales. Capsticks will with access to advice on non-indemnity working in partnership with MDDUS and provide a host of benefits including up to issues.” look forward to supporting their GP and 20 minutes of free business and corporate GPs and practice managers will be able practice manager members with their non- legal advice, as well as access to a full to call on Capsticks to provide discounted indemnity legal issues during what is a range of practice and business legal legal assistance on issues such as property particularly challenging time.” services at specially discounted rates. advice, practice mergers and acquisitions, Find out more in the Advice & Support MDDUS Director of Development David partnership agreements and disputes, and section of mddus.com

Treating transgender patients along with the added effect of delays in accessing TRANSGENDER people and those with gender appropriate care. incongruence could make up to 1 per cent of patients. It is well In relation to the first point, patients may seek bridging understood that these patients have complex healthcare needs, prescriptions until they are seen by a specialist. In these including a greater incidence of depression and risk of suicide. circumstances, GPs may feel out of their depth and worry that Access to appropriate healthcare is compounded by long waiting they risk acting outside their level of competence and times to see specialists for gender reassignment treatment. expertise. Regarding the second point, any patient with In March of this year, the GMC published new advice to help significant mental health issues may need referral to doctors support transgender patients. It is based on core appropriate mental health services. guidance from Good Medical Practice and is also informed by It is helpful that the GMC has entered the discussion, when relevant legislation including the Equality Act 2010. The advice many doctors who are not specialists in this field have followed publication of a report on transgender equality by the questions about their roles and responsibilities. The GMC House of Commons Women and Equalities Committee. The reminds all doctors that in relation to transgender patients: report said doctors and other health professionals often lacked “Do your best to understand your patient’s views and an understanding of how to provide effective care for preferences and the adverse outcomes they are most transgender patients, including referring pathways and their concerned about. It may well be that the risk to your patient own roles in prescribing treatment. of continuing to self-medicate with hormones is greater than MDDUS has certainly seen an increase in calls from the risk to them if you initiate hormone therapy before they’re members seeking advice and guidance when treating people assessed by a specialist.” with gender dysphoria, and they are often concerned about In regard to bridging prescriptions, a matter which delays in accessing appropriate specialist help. Many doctors generates a significant proportion of calls to MDDUS, the GMC have and will have transgender has issued specific guidance (go to persons as patients but few doctors http://tinyurl.com/grugw8z). are well equipped to deal with the It is important that all doctors issues that arise. Currently medical dealing with the health issues of training does not produce doctors patients with gender dysphoria skilled in transgender health. understand and follow the regulator’s There are specific risks associated advice. The GMC guidance also provides with meeting the healthcare needs of useful links, including an e-learning transgender persons and two areas in module produced by the Royal College particular are: of General Practitioners and the Gender • Patients who self-medicate from Identity Research and Education unregulated sources. Society (GIRES). • The risk of self-harm due to the Dr Gail Gilmartin is risk and medical inherent increased risk in this group, adviser at MDDUS

● DENTAL TRAINING DAY issues. Attendees can earn 5.5 MDDUS. Workshops for groups of Popular topics include managing MDDUS will be running another hours of CPD accredited by NHS up to 50 GPST members are being complaints, avoiding missed dental training day on 20 Education Scotland. Find out more offered in which participants can diagnoses and prescribing risks. September 2016 in Glasgow. at [email protected] ask questions, share experiences Email [email protected] Dental adviser Aubrey Craig will ● CALLING ALL GPST GROUPS and take part in polls offering ● MDDUS PODCASTS Our risk headline a varied group of expert Apply for a personalised webinar valuable instant feedback. Sessions team has produced a series of five speakers discussing key dento-legal by the risk education team at can be arranged to suit your group. podcasts based on the fictitious

4 SUMMONS NOTICE BOARD

MDDUS response to Brexit MDDUS Chief Executive Chris Kenny has commented on the referendum vote to leave the European Union. “MDDUS is monitoring the potential impact of the referendum outcome closely. Our members’ needs do not change at all as a result of the vote. We’re still here to give you a professional, responsive and great value service. And that applies just as much to those members from other EU jurisdictions as it does to those coming from the four countries of the UK. “However, we face a tougher economic climate going forward, which we will need to manage alongside the continued pressure on subscriptions from growing claims numbers and regulatory activity. We will continue to manage our resources carefully to protect the mutual fund and our services. We have the advantage of well-diversified resources, and the fact that we do operate only in the UK is also helpful. “We are continuing to work with both UK and Scottish Government to press them to make sure that current initiatives do not undermine the business model of MDOs which have delivered the optimum protection for both patients and professionals alike in the long-term.”

NHS England pledges action and April 2018, and the scheme will then “We welcome the fact that the on indemnity costs be reviewed. government and NHS England have found NHS England has pledged funding to NHS England says that by basing the indemnity market to be efficient and offset the rising cost of GP indemnity as payments for practices on the list size, the competitive. They have not reached for part of new implementation plans set out scheme will include provision for the naive solutions with unpredictable effects in its General Practice Forward View. additional indemnity premiums faced by in the long-term and should not be A new Indemnity Support Scheme will all GPs at the practice as well as partners. tempted to do so in the future. be introduced in April 2017 providing a GP practices will be expected to provide “We welcome the measures to relieve financial contribution to practices in an appropriate share of their payment to immediate pressures. It is now vital to England to alleviate “exposure to their salaried GPs and locum GPs. address causes, not just symptoms. So we indemnity inflation in scheduled work”. The review concludes that longer-term urge the government to make rapid NHS England will provide an additional action is necessary to address the root headway on the tort reform and payment to each practice based on causes of rising indemnity costs. It states recoverable costs agenda to build calculated estimates of the average annual that the Department of Health will begin sustainability. inflationary increase in indemnity costs an urgent piece of work to identity “We will continue to work with the faced by GPs. effective ways of addressing these causes profession and the NHS to ensure that In its review on GP indemnity, NHS and will continue with efforts to cap the indemnity keeps up-to-date with the needs England states: “This amount will then be amount legal firms can recover in clinical of a changing service. We look forward to distributed amongst practices based on negligence cases. working actively with government and their list size, not on weighted capitation.” Following the announcement, MDDUS NHS England on the further actions Payments will be made in April 2017 Chief Executive Chris Kenny commented: detailed in the review.”

case of Mrs Roberts, a 51-year-old and discussion. The podcasts can minimum of 28 days’ notice for therefore advise new GPs in your patient diagnosed with breast be accessed in the e-learning prospective members to apply practice to submit membership cancer. Each focuses on a specific centre of the Risk Management for membership. To assess an applications at least four weeks in development in the case: the section at mddus.com application, we must request advance. It is important that GPs initial complaint handling, SEA, a ● NEW GP IN YOUR PRACTICE? information from the GP’s existing maintain alternative indemnity clinical negligence claim and GMC Please note that MDDUS indemnifier and responses can take arrangements until MDDUS investigation – with commentary Membership Services require a as long as four weeks. We would membership is confirmed.

AUTUMN 2016 5 NEWS DIGEST

Sharp rise in negligence Treat sepsis as “urgently payouts by NHS as heart attack” COMPENSATION payouts and legal costs PATIENTS showing signs of sepsis should be for clinical negligence covered by the NHS treated with the same urgency as those with in England increased by more than a suspected heart attacks, according to new quarter last year, reaching almost NICE guidance. £1.5 billion. The guidance advises NHS health New figures from the NHS Litigation professionals that they should think about the Authority (NHSLA) show that in 2015/16 possibility of sepsis in all patients who may total payments relating to their clinical have an infection because “sepsis can affect schemes increased by £319 million (27 per anyone at any time”. It acknowledges the cent) – from £1,169.5 million to difficulty in diagnosing sepsis as symptoms can £1,488.5 million. vary from person to person. These can range from a high temperature, to fast While new clinical negligence claims in heartbeat to a fever or chills. 2015/16 fell in number by almost five per Sepsis can often be mistaken for common infections like flu. Quick identification cent to just under 11,000, damages paid and early treatment are key. Doctors are urged to start asking “could this be sepsis?” to patients jumped 23 per cent from £774 earlier on “so they rule it out or get people on treatment as soon as possible”. million to more than £950 million. The UK Sepsis Trust estimates there are around 150,000 cases in the UK every Claimants’ legal costs saw another big year, causing 44,000 deaths annually. A report published last year found that in increase – rising by 43 per cent, from more than a third of cases (36 per cent) there were delays in identifying sepsis and £292 million in 2014/15 to £418 million many hospitals had no formal protocols in place to recognise it. last year. Professor Mark Baker, director of the NICE Centre for Guidelines, said: “When The report said that clinical negligence hospitals are well prepared, clinicians do better at responding to patients with costs remained a key issue last year, with sepsis. If there is any delay in spotting the signs we will fail patients by leaving them contributors to the scheme (mainly NHS with debilitating problems, or in the worst cases people will die.” providers) seeing contributions to settle Access the new guidance at www.nice.org.uk/guidance/NG51 claims rise by 35 per cent in 2015/16, with a further increase of 17 per cent in 2016/17. from the General Dental Council. been criticised by the British Society of Commenting on the report, NHSLA Clinicians are also required, where Dental Hygiene and Therapy (BSDHT) Chief Executive Helen Vernon said: “The possible, to “put matters right” and explain which commented: “being forced to key to reducing the growing costs of the short and long-term effects of what apologise, potentially a legal admission of claims is learning from what goes wrong has happened. fault, positions the clinician in and supporting changes to prevent harm These requirements are set out in the professional jeopardy”. in the first place. regulator’s new guidance on the But the GDC guidance reassures “We want to reduce the need for professional duty of candour, Being open clinicians, saying: “Apologising to the expensive litigation. This means increasing and honest with patients when something patient is not the same as admitting legal the use of mediation in the NHS, early goes wrong, which came into effect liability for what happened. This is set out transparency, saying ‘sorry’ and on July 1. in legislation in parts of the UK and the demonstrating that lessons have been The new guidance makes it clear that NHS Litigation Authority also advises that learned to prevent the incident “candour means being open and honest saying sorry is the right thing to do. You happening again.” with all patients, whether they have made should not withhold an apology because a complaint or not”. It sets out the ways in you think that it might cause which dentists must demonstrate this, problems later.” Dentists “must apologise” beginning before treatment is even carried when care goes wrong out. It describes what to do when things DENTISTS must tell patients when go wrong, when and how to tell the GMC to revamp something has gone wrong with their care patient and apologise. medical register and apologise, according to new guidance The requirement to offer an apology has DOCTORS’ photos and more detailed

● INCREASED MOUTH of the National Cancer Institute. ● ETHNICITY STILL A FACTOR that the average exam pass rate CANCER RISK WITH HCV Researchers in Texas found that New research from the GMC has for all UK medical graduates is INFECTION Patients infected patients with HCV seropositivity found that white UK medical 71 per cent but rises to 75.8 per with the Hepatitis C virus (HCV) were more than twice as likely graduates remain more likely to cent among white graduates and are at a greater risk of developing to develop either cancers in the pass specialty exams than their falls to 63.2 per cent for UK BME mouth cancer, according to new mouth cavity or of the oropharynx. black and minority ethnic (BME) medical graduates. Pass rates for research published in the Journal Extra vigilance is urged. counterparts. The report found international medical graduates

6 SUMMONS NEWS DIGEST

information about current job status could Dental neglect a problem in care homes be included in the online medical register MORE than half of older adults living in care homes have tooth decay under new proposals from the General compared to 40 per cent of over-75s and 33 per cent of over-85s not in care Medical Council. homes, according to NICE. A consultation has been launched into New NICE guidance is calling for dental health in residential care to be given the plans to modernise the publicly-available same priority as general medical care. register which has remained largely It is estimated there are more than 400,000 adults living in UK care homes, 80 unchanged since it was created more than per cent of whom have some form of dementia. Older adults in care homes are 150 years ago. more likely to have fewer natural teeth with resulting difficulty in eating and The register currently lists every doctor socialising without embarrassment. who is licensed to practise in the UK and The new guidance recommends greater focus on improving and maintaining was searched nearly seven million times day-to-day oral healthcare among residents and ensuring there is adequate access last year. It includes each doctor’s name, to dental services. All residents should have an oral health assessment as part of GMC reference number, gender, year of their personal care plan. qualification, whether they are on the Staff should be competent to perform routine daily mouth care for those who specialist register and their may not be able to do this for themselves, including brushing natural teeth with registration status. fluoride toothpaste twice a day, daily oral care for full or partial dentures and daily But the GMC believes the register says use of mouth care products prescribed by dental clinicians. little about a doctor’s actual practice and Professor Elizabeth Kay, Foundation Dean of Peninsula Dental School, Plymouth often contains out-of-date information. University, said: “Everyone should be able to speak, smile and eat comfortably, but They are consulting on ways to improve it all too often this is jeopardised by poor oral health which can have a significant while also safeguarding doctors’ privacy. negative effect on a person’s wellbeing and quality of life. They recommend moving to a “two tier” “Awareness of oral health needs to be raised within care homes and we want to approach, with tier 1 covering information see more staff given training about what they can do to help.” that must be provided by law, including all Access the guidance at www.nice.org.uk/guidance/ng48 the information currently on the register. Tier 2 would be additional information to be supplied and maintained voluntarily by the registrant. The GMC suggests this could include a registrant photo, languages spoken, higher qualifications, scope of practice and a link to the website of their place of work. The GMC said tier 2 data would provide “a much richer description of a doctor’s professional life than is currently possible”, but acknowledged that this approach could lead to inconsistency in the information available as doctors could choose not to provide it. This additional data would not be routinely verified by the GMC before being published on the register, but sample audits would be carried out to check for accuracy. The consultation is open until early October and can be found on the GMC website.

(IMGs) – those doctors who launched by the GMC. It can be ● NO ADDRESSES ON GDC The registration number will qualified outside the UK and EEA – used across the UK and includes REGISTER Location details become the primary identifier are 41.4 per cent. a case study at each stage of the of dental professionals will be sometime after October of this ● NEW CAPACITY AND decision-making process to show removed from the GDC register. year on formal approval of the CONSENT TOOL A new how GMC guidance applies to the The decision follows a public change. The full consultation interactive mental capacity clinical situations doctors may consultation which received response will be published shortly decision-support tool has been face. Access at www.gmc-org.uk. responses from over 2,500 people. on the GMC website.

AUTUMN 2016 7 RISK

PAYING A HIGH PRICE Cherryl Adams

A QUICK look at MDDUS files reveals that there are hundreds of active cases being managed by our advisory and legal teams at any one time. The causes vary widely and the estimated costs of resolving each one can range from as little as £100 to more than £5,000,000. While so-called “high value claims” are consideration of symptoms, poor increasing and changing symptoms, mercifully rare, they can have an enormous communication, failure to recognise or act despite analgesic therapy and/or impact on the lives of all involved. upon red flags, and lack of adherence to physiotherapy. Again, lack of recognition available guidelines. Systemic factors also or appreciation of red flag symptoms Causes and outcomes feature and include issues such as poor contribute to the adverse incident. In a Failure to diagnose a condition or refer for record keeping and failures in the results number of these cases, even where the investigation of symptoms are the most handling process. patient indicates symptoms of saddle common causes of negligence claims, with anaesthesia – a clear red flag – the over two-thirds of MDDUS cases falling Meningitis and meningococcal disease clinician does not act upon this into these categories. Further analysis Meningitis is often a difficult condition to information. Other common features demonstrates that high-value claims often diagnose in the early stages, with include inadequate safety netting and a share causal similarities to lower value symptoms often resembling common viral failure to communicate the need to seek ones. The systemic or human factor issues illnesses like flu. Of our cases involving urgent emergency treatment should which contribute to the alleged failures in patients with meningitis and symptoms worsen. these cases can be the same – it is in the meningococcal disease, almost 60 per cent outcome and impact on the patient that involve contacts made with clinicians in Key learning points they differ. For example, failure to refer the out-of-hours setting and more than 70 The main factor that distinguishes a someone for investigation of symptoms per cent feature children under three high-value claim from one of lower value is which ultimately are diagnosed as chronic years old. the severity of injury sustained and the migraine has a very different outcome to a A typical scenario involves a parent or life-changing consequences for the patient. missed brain tumour. carer seeking advice via telephone But closer analysis reveals a number of consultation and the clinician then failing factors common to both types of claim Missed and delayed diagnosis to pick up on reported red flag symptoms. that provide valuable learning points. In Missed or delayed diagnosis, resulting in A repeated factor in cases involving young terms of systems, MDDUS has found that late treatment and subsequent life- children is the clinician attributing comprehensive record keeping together changing sequelae, are a particular feature symptoms to seasonal viral illnesses with effective results handling and of this group of claims. More than a third (something that’s “going round”), even prescribing systems are key to minimising (38 per cent) of our current high-value when the presenting symptoms do not clinical risk. On an individual level, it is claims feature conditions which have quite fit the picture of that seasonal invaluable to ensure skills and knowledge resulted in brain injury (e.g. meningitis, illness. This advice can provide false are up-to-date, to use effective two-way hydrocephalus, stroke and tumour), while reassurance to patients and carers, who communication (in particular listening 29 per cent feature conditions resulting in may potentially delay seeking further skills), and to widen the scope of diagnosis spinal injury (e.g. cauda equina syndrome, advice even when the illness appears to in the presence of indicators that tumour and undiagnosed fracture). Cauda progress or change. support doing so. equina syndrome appears relatively frequently within spinal injury claims, Cauda equina syndrome • Access a wide range of practical making up 12 per cent of our current total Missed or delayed diagnosis of cauda learning resources, including videos, of high-value claims. Similarly, delayed equina syndrome is the most common interactive modules, checklists, diagnosis of cancers of any type sits at single condition featuring in large claims. webinars and articles, in the Risk around 11 per cent of the total. Again, this condition often presents with Management section of Particular themes have emerged from commonly encountered symptoms www.mddus.com our analysis of high-value claims and it is suggestive of less serious disease. useful to note common failings include Particular features in these cases  Cherryl Adams is a risk inadequate examination and/or include multiple consultations with adviser at MDDUS

8 SUMMONS ETHICS

unequally distributed. Openness about persuade others. Statements about what A MATTER OF discretion, and therefore judgement, in constitutes ‘futility’ may be a composite of clinical practice provides support to clinical information and experience JUDGEMENT colleagues: it creates space for reflection coupled with beliefs about quality of life. Deborah Bowman and permission for discussion about What we choose to include, emphasise or difference. It allows for exploration of omit when explaining treatment options difficult features of clinical practice such may reflect, often unconscious, our own as uncertainty and risk. preferences and beliefs, perhaps Judgement, or more accurately its particularly if we or someone we love have IN these most tumultuous of times, the absence or misdirection, is a concern in had similar experiences. concept of judgement has been much on professionals. To show poor judgement is Even that which is represented as my mind. I make no comment on recent an indictment on someone’s competence knowledge is underpinned by values to political events but, as I listened with or suitability for a role. In recent weeks, some extent: the research that is funded increasingly wide eyes to the latest twist politicians’ careers have been derailed by and the evidence of which care is in an epic saga of tribalism and ambition, that most damning of assessments: he or predicated reflect the priorities and the theme of judgement has recurred. she lacks judgement or showed poor choices of organisations and individuals. Judgement is integral to healthcare judgement in something said or done. That is inevitable, but judgement depends practice. No matter how much medical What does this mean? If judgement is on recognising the limits of knowledge, the students might wish it were otherwise, about discretion and is naturally required place of interpretation and being honest clinical practice cannot be definitively when a situation is captured by a list of learning objectives, contested or however enormous and far-reaching. On uncertain, does poor qualification, the messy and ambiguous judgement or a lack realities of clinical practice can be startling of judgement mean and discomforting. The place of judgement anything other than quickly becomes apparent, even to those someone has acted in who have denied and resisted it as a way that differs undergraduates. Yet judgement is itself a from that which we layered and complex concept which would have done? warrants further exploration. There seem to me Judgement is the essence of ethics. It to be two examples resides in situations that are often that suggest that contested and where there are multiple criticisms about possible ways to proceed. Judgement is absent or poor the tool of choice where discretion exists. judgement are more Sociologists characterise the professions than merely as occupational groups that self-regulate disagreements. The and enjoy discretion over specialist first example occurs knowledge and expertise. Discretion is when someone often concerned with the moral appears not to dimensions of care. Daily questions such as recognise that they what constitutes sufficient information for are operating in the arena of discretion at about the implications of the same. Where a particular patient to make a meaningful all: situations in which individuals speak or facts and values collide without insight or choice and give consent or how to work act without appearing to notice that they openness, judgement may be impaired or with families who disagree about the best are within the realm of judgement. It is an even said to be absent. course of action for an incapacitated absence of care and of thought that Judgement then is unavoidable. individual are ethical choices in which matters most, not the decision or choice Whether in referenda or the clinic, it is a discretion is embedded. that an individual has made. The inability necessary, challenging and significant part Recognising these as questions of ethics, to recognise that judgement is required is, of the choices and decisions we take. The and therefore judgement, is important in in itself, important; as is the capacity to real risk with judgement is that we fail to itself: accepting that equally well- demonstrate that one is making a choice recognise its importance: that we motivated and well-qualified individuals in the context of discretion and with thoughtlessly place our cross, literally or can reach different judgements. By regard to those who may do differently. metaphorically, in a box without realising acknowledging discretion, one also The second example is when facts elide that matters of judgement cast becomes aware of relative power in with values or preferences without long shadows. therapeutic relationships. The discretion acknowledgement, leading to claims that often rests, albeit unarticulated, with the are overblown, excluding or unsustainable.  Deborah Bowman is Professor of professional. Its implicit nature depends We are all susceptible to mixing questions Clinical and Mental Health Ethics at The on differential knowledge and occurs in an of knowledge with our values and Tavistock and Portman NHS environment where emotions are preferences, especially when seeking to Foundation Trust

AUTUMN 2016 9 Taking a forward view N NOVEMBER of this year Professor Summons speaks with that’s a hugely powerful statement coming Maureen Baker will step down after from the head of the NHS. So I don’t think Ithree testing years as Chair of the Royal Professor Maureen Baker it’s any one initiative: it’s putting them all College of General Practitioners, making together and applying them at the same way for her successor Dr Helen about the challenges facing time. The aggregation of marginal gains – Stokes-Lampard. general practice and the the Team GB Cycling approach – is what Professor Baker worked for over 15 years we need to bolster the workforce. as a GP in Lincoln and was Honorary highlights and frustrations of Secretary of the RCGP from 1999 to 2009. Could the rise of primary care specialties In 2007 she joined NHS Connecting for her time as Chair of the RCGP help encourage more doctors into Health (CfH) and was Clinical Director for general practice? Patient Safety at the Health and Social Care For me there is something very important Information Centre. She has also held statement of confidence in the service of about the expertise of the generalist. We appointments with the National Patient general practice and we were very pleased talk about GPs as the expert medical Safety Agency, NHS Direct and the to welcome it. Is it enough? Well I hope generalist – the last bastion of clinical University of Nottingham. so. I certainly hope it is enough to turn medicine. Where else in medicine are you She is originally from Scotland and around the fortunes of general practice making decisions based on your clinical studied medicine at the University of and the profession, and to be able to build skills, the patient history, doing something Dundee. on from there. I do think the direction is there and then without a panoply of other absolutely right in terms of addressing the colleagues or the ability to get instant How have we come to the current state of fundamental issues of funding, workforce investigations? But generalists, almost by “crisis” in general practice? and workload. definition, have a wide range of interests. I do think it’s largely because of the Therefore it is not at all surprising that consistent, repeated underfunding of the Do you think there should be an people might like doing some of the things service over the last 10 years. There have equivalent GP Forward View in Scotland? they learned in hospital and applying those been a variety of reasons for this. There was I think there should be a plan to in the community setting. For many people an abreaction following the 2004 contract address these three key issues in every it’s an added attraction. So, for example, where the press kept going on about GP nation of the UK. people who like doing minor surgery can pay and how GPs had done too well out do that in general practice. of that – which in no way justifies not What do you think is the highest priority investing in the service adequately. Also for the NHS in addressing recruitment in Considering the talk around mass I think there has always been this short- general practice? resignations how can the government term reaction to the part of the system that In England, I think the GP Workforce 10 best retain the GPs it does have makes the most noise. Generally over the Point Plan set us off in the right direction working in the NHS? last 10 years that’s been the acute sector. – looking to see what is working and how Again, by addressing the fundamental Pressure on the acute sector becomes we can build on that. For instance, the issues of funding, workload and workforce. very visible with pictures of ambulances financial incentives to recruit trainees into It has to be an enjoyable, worthwhile queuing outside A&E departments and under-doctored areas: initial impressions job and if it doesn’t feel like that, patients made to wait many hours. What suggest that this is having an effect. people won’t stay. was happening in general practice wasn’t So if that works it might be extended. hitting the headlines; so it wasn’t picked up Recruitment roadshows are also important: Do you think that GP induction and and addressed. spreading a positive message about general refresher schemes could be improved to practice and helping to dispel some of the boost GP numbers? Do you think NHS England is on the myths. In his foreword to the GP Forward They are much better than they were. right track with its General Practice View, Simon Stevens writes: “There is But the one in England, which I’m most Forward View? arguably no more important job in modern familiar with, still has a huge number of Yes. I do. I think it’s a hugely ambitious Britain than that of the family doctor”. Now hoops to be jumped through. It’s not very

10 SUMMONS Q&A

That is undoubtedly the case – the most highly valued public service by far. But we are also an easy target and certainly the media in recent years has really jumped on the GP-bashing bandwagon. No denying there are problems – one of the issues they get very agitated about is access and that is a legitimate problem. There is more demand than there is supply when it comes to GP appointments. I think recently the media have maybe started to realise that the issues around access are not because GPs aren’t working flat out; it’s just that there aren’t enough of us.

What is your take on Brexit and the implications for healthcare in the UK? Certainly the most immediate implications are on the wider NHS workforce – EU nationals who work with us in general practice or in the wider NHS or in nursing or care homes. The next thing I would say is economic stability. It’s hard enough in the NHS without more economic difficulties and this will undoubtedly add more pressure on the NHS and general practice.

What do you feel was the high point of your time as Chair? Publication of the GP Forward View. We’ve been campaigning for the best part of three years and this is the response to just about everything we have been asking for in our Put patients first: Back general practice campaign. It was a really “I think we always important moment. need to come back What has caused you most frustration? to GPs being hugely It’s very frustrating to get lots of grief for things you have no responsibility for or valued by the public” remit in. As an example, we get quite a lot of criticism when there are problems with pensions. We’ve got nothing to do with pensions; it’s not our remit. It’s well integrated and could be very much associates in general practice, we’re neutral. nothing to do with patient care. That’s just more streamlined, and I think we could They have never really taken off in general one example. support people through it much better. We practice and I’m not sure why that is. On are keeping the pressure on NHS England the other hand, if practices feel that having What would be your one piece of advice and HEE to try and do that. a PA works for them and that they are to your successor in the job? valuable members of the team – that’s great. It’s a marathon not a sprint. The term is Do you worry that recruiting physician Why would you stop that? But I think the three years and you have to pace yourself associates and similar initiatives to jury is out in that we haven’t yet had much and give time for things: work something address GP shortages could undermine experience of this role in general practice to up, sell the idea, get it rolled out, get it the profession? determine whether it’s useful or not. evaluated and start seeing it take root. I do think there is a case for extending You can’t expect to change the world the workforce in general practice and for Are GPs misunderstood in general and of general practice in three months, six introducing additional skills; for instance, more particularly by the media? months or a year. having practice-based pharmacists is a very I think we always need to come back to good example of this. In terms of physician GPs being hugely valued by the public. n Interview by Jim Killgore

AUTUMN 2016 11 The right to choose

MIDDLE-AGED patient is diagnosed with a recurrence of an “absolute right” to refuse medical treatment “for any reason, a cancer. The doctor explains the treatment options, rational or irrational, or for no reason at all,” even where this A including one rather taxing regimen with excellent clinical choice may result in their death. outcomes. The patient returns with a decision not to undergo Secondly, statute in England and Wales entrenches the right of any further treatment. He says: “Enough is enough. We all die an individual to refuse treatment through an advance decision. e v e ntu a l l y.” Although the AWIA does not include a similar right for persons A 28-year-old pregnant patient with placenta previa signs a in Scotland, a valid and applicable advance directive (its directive refusing any blood products in accordance with terminology north of the border) is likely to be respected if her beliefs. challenged in court. Doctors can find it difficult to accept when patients choose to The MCA allows a person, aged 18 and over whilst still refuse treatment; particularly when beneficial or potentially competent, to make an advance decision about the treatment and life-saving treatment is available. Such “inaction” can seem to care that they wish for a time in the future when they may lack run counter to the professional instinct to help someone in the capacity to consent to or refuse that treatment. Individuals difficulty or suffering: the desire to preserve life or to avoid the can only make advance decisions to refuse treatment (rather perceived failure that comes with a patient’s death. Whatever the than demand treatment) and cannot refuse in advance basic or reason, the GMC reminds us that we must set aside our own essential care needed to keep them comfortable. beliefs when making the care of patients our primary concern. The MCA specifies very little formality in regard to the format Sometimes the law provides a solution to such dilemmas, of an advance decision, apart from when the decisions relate to particularly when a patient refusing treatment is assessed to lack life-sustaining treatment (these must be in writing and the capacity to make such a decision. The Mental Capacity Act witnessed). All other decisions may be written or verbal, and a (MCA, England and Wales) and the Adults with Incapacity Act clinician may record a verbal advance decision in a patient’s (AWIA, Scotland) both require that decisions about medical medical notes. treatment are directed by a patient’s best interests – in other words what would be of overall benefit to that person, taking Good medical practice into account both clinical and non-clinical considerations. This When a patient refuses treatment, a practitioner may explore the may not be a straightforward decision in itself (or a foregone reasons for this – as the patient allows – also considering if (and conclusion that treatment is in that person’s best interests), and a how) the patient’s physical comorbidity, mental health and social doctor may feel more comfortable with a team approach to circumstances are affecting decision-making. decision-making rather than individually facing a patient Communication remains crucial in such refusing treatment. cases, and the GMC’s Good Medical Practice reminds doctors that they An absolute right to refuse treatment must give patients the information But what about the more challenging scenario of a competent they want or need to know in adult patient who refuses treatment? Firstly, case law clearly sets a way they can out the rights of patients and duties of doctors in this regard. understand, While doctors are not obliged to provide a requested treatment taking which they believe, after appropriate assessment, is not clinically care indicated or of overall benefit to the patient (notably in the case of Burke v GMC), they certainly are obliged to respect a competent person’s decision not to consent to treatment (considered in Re MB (An Adult: Medical Treatment)). In the latter case, the court held that such a person has

12 SUMMONS MEDICAL ETHICS

A patient refusing treatment can present a difficult ethical dilemma. Medical adviser Dr Greg Dollman The right to choose examines options and obligations in such cases

not to make assumptions about the same. Doctors should practice. Doctors should discuss complex clinical matters with involve others (healthcare professionals and those close to the colleagues, who may be able to assist them through what is patient) when breaking bad news (as far as is appropriate), potentially a distressing period for all parties involved. ensuring that information is relayed in a balanced way. GMC guidelines on Consent: patients and doctors making Conscientious objection decisions together and Treatment and care towards the end of life The GMC expects doctors to treat patients fairly and with provide helpful guidance to doctors facing difficult conversations respect, whatever their life choices and beliefs. The GMC does with patients. A patient should be involved in all decision- recognise, however, that doctors hold their own beliefs and making, as far as they choose, with the doctor-patient values. Its supplementary guidance, Personal beliefs and medical partnership based on openness, trust and good communication. practice, states that doctors may practise medicine in keeping Doctors must consider the patient’s views of their condition, as with their beliefs, provided that they act in accordance with the well as their needs and priorities, and should establish whether law and professional guidance. patients have understood the details they have been given and Should a doctor feel unable to be part of a clinical team where a whether or not they require or wish more information prior to or patient refuses potentially life-saving treatment, they must explain after making a decision. Patients have the right to change their to the patient this conscientious objection, informing the patient mind about a decision at any time, and doctors must keep them of their right to see another doctor or actively seek a suitable informed accordingly. practitioner to take over that patient’s care. Doctors must not Doctors making recommendations about treatment options imply or express disapproval of the patient’s choices or beliefs. must be cautious not to sway inappropriately a patient’s decision making. They must take care not to express personal beliefs in a “I don’t want to talk about it, doctor” manner that may be seen to put Patients who refuse treatment may choose not to communicate pressure on the patient, cause further about their decision, or may ask someone else to make distress or exploit their decisions on their behalf. Doctors should follow the guidance as vulnerability. set out in Good Medical Practice, and discussed above, if faced The GMC reminds doctors to with the former scenario. In the latter case, the GMC reminds act within the scope of their doctors that while patients may ask family or close friends to competence, seeking expert play a significant role in decision-making, no one else can make review from a colleague when a decision on behalf of a competent adult who has capacity. appropriate. Patients have a If, despite all attempts, a patient still does not want to know right to seek a second about their condition or management, a doctor should respect opinion should they have their wishes as far as possible. The GMC states that doctors are concerns about their care, still obliged to engage with these patients as best they can, and practitioners should offering even basic information as the patient allows and remind them of this. reminding them of their right to change their mind at any time. The GMC requires So in summary, the law entrenches a patient’s right to say doctors to be “enough is enough” in any treatment, and professional guidance insightful and to directs a doctor how to proceed in these invariably complex reflect on the cases. But please do not hesitate to contact an adviser at MDDUS various situations if you are uncertain how to proceed when a patient refuses they encounter medical treatment. in their everyday n Dr Greg Dollman is a medical adviser at MDDUS

AUTUMN 2016 13 PROFILE

Changing faces

Adam Campbell learns how childhood and into her 20s, helping to goals. One was to support individuals and change her appearance and stabilise her their families to regain or build confidence this innovative charity is medical situation, but for a long time she and to have the health system helping them remained extremely nervous about to do that. The second was to transform working to make life more interacting with people she didn’t know public attitudes from being rather manageable for people with well. “I used to be so shy. I couldn’t speak uninformed and, dare we say it, stigmatising to anybody without getting really to being positive and inclusive.” facial or other disfigurements embarrassed.” Twenty-four years later, Changing Faces is a £1.8 million charity employing around Society obsessed with appearance 30 people and supporting the estimated O WALK down the street, oblivious to James Partridge, the founder and CEO of 540,000 people in the UK with a disfiguring those around you, except perhaps for the charity Changing Faces, understands condition to their face, hands or body – be T the occasional glance from a passer-by, Linzie’s predicament better than most. In it from birth, accident, cancer surgery, skin is an everyday occurrence for most people. 1970, at the age of 18, he was involved in a and eye conditions, facial paralysis or For Linzie, who grew up in Fife in the 1970s car fire that left him with 40 per cent burns medical accidents. and now lives in Kirkcaldy, such anonymity on his body and face. His recovery was would be nothing short of a luxury. Born prolonged and he remained profoundly More than physical needs with a double hare lip, a cleft palate, disfigured. With much understatement, he One of the fundamental reasons for setting hydrocephalus and three missing fingers, describes first facing the difficult business up Changing Faces, says James, was to she has always attracted more than a little of going out into the world: “I suddenly address the gap he perceived in the available interest from passers-by – and frequently it thought, I actually have to walk down the therapy for people with disfigurement: the has been negative. street. I have to try and rejoin this society, need for a psychosocial aspect to what was From a young age, she says: “I would which is rather appearance-focused – and already very good physical care. dread going out. It was like, ‘Am I going to I’m not looking at my best, as it were.” “It’s clear that around 30 per cent of people actually get to where I’m going and back It was the realisation that the cope quite well and quickly, but actually without being bullied?’ It was constant. I’d rehabilitation he required went far beyond 60-70 per cent really don’t, and some never come in and, you know, I’d be really upset. the surgery and the dressings that ultimately do. Time isn’t necessarily a great healer. My mum would be the one who I would led him, in 1990, to write a book, Changing People have come to see us 20 years later scream at. At school I was bullied very Faces, about his experiences. It was well saying, ‘Actually my life has been pretty much because of looking different. received and before he knew it he was horrible. I’ve felt isolated, I’ve been distressed Thankfully I was born before all the mobile setting up a charity of the same name, to and I’ve been on antidepressants.’ That, in my phones and that kind of bullying started. pass on his unique insights and fight for the view, is a failure of the medical system.” But it got quite bad.” rights of people with disfigurement. As part of its support for individuals, the

PHOTOGRAPHS: YAKUB MERCHANT FOR CHANGING FACES CHANGING FOR MERCHANT YAKUB PHOTOGRAPHS: Linzie had operations all through “It was a very small, tiny thing, with two charity has developed a care package called

14 SUMMONS Linzie, far left, underwent extensive surgery to improve her condition. James Partridge, left, set up the charity Changing Faces in 1990

charity is trying to influence, with some success, NICE guidelines, clinical reference groups and medical curricula. “For example, we’re trying to get to plastic surgeons when they’re being trained, so they can’t become a consultant unless they’ve done a module on psychosocial issues. And the plastic surgeons are very open to this – they’re definitely in the lead.” In addition to their work in healthcare, Changing Faces advocates for people with disfigurements in schools, by raising awareness among and offering guidance to teachers, teaching assistants and anyone working in education. They are also FACES. It is a psychosocial toolbox for in children’s hospitals in Scotland, one in pushing for real equality in the workplace people with disfigurement, which helps Sheffield Children’s Hospital, one in Great and more positive and inclusive portrayals them to find out about their condition and Ormond St and one in Salisbury in the of disfigurement in the media. Their ‘face its treatment, to develop a positive outlook head and neck cancer team.” equality’ campaign aims to transform for the future, to deal with the complex It’s all part of the goal to have both the opinions in a similar way to the campaigns associated feelings and to learn strategies physical and psychosocial needs of people for racial and sexual equality. for coping with negative reactions when with disfigurement addressed as part of the Back in Kirkcaldy, Linzie is living proof out and about in the wider world. patient care pathway, particularly in of the charity’s beneficial effects. Though it “So if you’re walking down the street and specialities such as plastic surgery, burns, came along too late to help in her own somebody’s staring at you, that’s par for the dermatology, maxillofacial surgery medical care, her association with it has course I’m afraid. But there are ways of and neurology. nevertheless helped to boost her dealing with it. You might, on some days, self-confidence. want to step back or wave, or in certain Educating clinicians Attending their workshops, doing circumstances you might want to say The growing number of CFPs are one role-plays and learning strategies to deal something. Having strategies for dealing route to achieving that goal, but there with social situations have all played their with other people’s reactions is absolutely are others too – among them a call to part. Since becoming a media volunteer in fundamental and shouldn’t be left to the clinicians to think about the psychosocial 2010, she’s gone from strength to strength, person to dream up on their own.” element when first assessing patients. As sometimes talking to groups of up to 200 But you need more than a package, says James explains: “Consider the GP who sees people. She has even appeared live on a James, you also need someone to deliver it. somebody coming in with a Bell’s palsy – it TV chatshow. This is where the Changing Faces might take three months to go away but “I had about four days’ notice. We should Practitioners (CFPs) come into their own. it might not. Is it okay just to say: ‘Here have been on the day before and it was Trained by the charity, these specialists in are some steroids, it’ll be fine, come back going to be recorded. But then I was told, disfigurement almost always come from and see me in three months if it doesn’t go you’re going on live. It was absolutely the caring professions – they might be away’? We think not – we think that the petrifying! nurses, counsellors, assistant psychologists initial diagnosis needs to take account of “But,” she says, laughing at the memory or social workers. People with psychosocial concerns.” – and this is the important part – “it was a disfigurements can gain access to CFPs Changing Faces is also active in research, really great experience as well.” directly through Changing Faces, but the through its 18-year partnership with charity is increasingly succeeding in its bid University of the West of England in the n Adam Campbell is a freelance writer in to have them embedded in the health Centre for Appearance Research, which is Edinburgh and a regular contributor to system. developing a considerable evidence base MDDUS publications “So, for example, we have three CFPs for the psychosocial consequences of working with kids and families embedded disfigurement. At a policy level, too, the www.changingfaces.org.uk

AUTUMN 2016 15 CLINICAL RISK REDUCTION

Pathways in sight

Dr Mark Wright champions the use of a unique set of diagnostic algorithms for non-specialists faced with common ophthalmological complaints

OST UK physicians including GPs and most commonly encountered scenarios: red eye(s), accident and emergency doctors will have had visual loss and diplopia. Mbetween two and 12 days ophthalmology attachment during their entire undergraduate Diagnostic frameworks training1, leaving them inexperienced and wary of These diagnostic algorithms allow the inexperienced dealing with patients presenting with eye problems. clinician (in ophthalmological terms) to start to Red eye is a common presenting complaint in utilise and build upon their existing knowledge patients attending A&E, optometrists and GPs and by consulting a framework which represents the has been reported to account for 0.9–1.5 per cent of thought processes of their more experienced GP consultations.2 Making the correct diagnosis can colleagues. Algorithms are, therefore, simply a be difficult for non-experts, given the diversity of user-friendly version of these diagnostic and/or possible diagnoses ranging from self-resolving treatment thought processes. bacterial conjunctivitis to sight-threatening acute Algorithms are always a compromise between angle closure glaucoma (AACG). having enough detail to cover the most commonly There are many excellent ophthalmology encountered diagnoses while remaining simple textbooks which give the novice the appropriate enough to use. They rely upon the clinician being knowledge, however very few indicate how to apply able to clarify the history and elicit the clinical signs it. For this reason I have developed along with which act as signposts on the road to diagnostic colleagues a series of diagnostic algorithms nirvana. How successful are the Edinburgh (Edinburgh Diagnostic Algorithms) for the three Diagnostic Algorithms?

16 SUMMONS REFERENCES

1 Welch S, Eckstein M. Ophthalmology teaching in Improved accuracy medical schools: a survey in cent, indicating a need for a diagnostic aid. The the UK. Br J Ophthalmol 2011; Baseline diagnostic accuracy for non- overall diagnostic accuracy of the Edinburgh 95: 748–749. ophthalmologists with patients presenting with Diplopia Algorithm is 82 per cent, even when used AACG has been demonstrated as 21 per cent (GPs) by very inexperienced clinicians. 2 Dart JKG. Eye disease at a community health centre. Br to 64 per cent (A&E),3 and 44 per cent for iritis The diagnostic improvement resulting from the Med J 1986; 293: 1477–1480. (GPs).4 When equally inexperienced observers (GPs use of these algorithms should result in more 35 per cent, A&E nurse practitioners 23 per cent, accurate triage of patients referred to the hospital 3 Siriwardena D, Arora AK, opticians 18 per cent) assessed patients presenting eye service. This should help prevent delayed Fraser SG, McClelland HK, Claoue C. Misdiagnosis of with red eye(s) using the Edinburgh Red Eye presentations of serious eye conditions and reduce acute angle closure glaucoma. Diagnostic Algorithm, the diagnostic accuracy for morbidity from delayed treatment. Age Ageing. 1996;25(6):4213. AACG rose to 100 per cent (4/4 cases) and for iritis it rose to 82 per cent (9/11 cases).5 Access other algorithms 4 Sheldrick JH, Vernon SA, Wilson A. Study of These are the first diagnostic eye algorithms to be A number of open access learning tools including diagnostic accord between subjected to scientific analysis and demonstrate downloadable copies of the five diagnostic general practitioners and an significant improvements in accuracy by algorithms and narrated lectures accompanying the ophthalmologist. BMJ.1992; inexperienced clinicians in the three most algorithms are available on a dedicated Edinburgh 304:10961098. commonly encountered ophthalmic scenarios. Take University web page. Access at tinyurl.com/ht69sag 5 Accuracy of the Edinburgh diplopia as another example: the baseline diagnostic Red Eye(s) Algorithm. Eye n accuracy of non-ophthalmologists including Dr Mark Wright is a consultant ophthalmologist 2015; 29: 619624.

PHOTOGRAPH: SCIENCE PHOTO LIBRARY; EDINBURGH RED EYE DIAGNOSTIC ALGORITHM ADAPTED FROM AN ALGORITHM IN BOROOAH S, WRIGHT M, DHILLON B. POCKET TUTOR OPHTHALMOLOGY . LONDON: JP MEDICAL, 2012. JP MEDICAL, . LONDON: OPHTHALMOLOGY POCKET TUTOR B. M, DHILLON S, WRIGHT IN BOROOAH AN ALGORITHM FROM ADAPTED ALGORITHM DIAGNOSTIC RED EYE EDINBURGH LIBRARY; PHOTO SCIENCE PHOTOGRAPH: optometrists, hospital doctors and GPs was 24 per and honorary senior lecturer at Edinburgh University

AUTUMN 2016 17 DENTAL COMMUNICATION

Treating the fearful child

Paediatric dentist Fiona Hogg offers advice on dealing with dental anxiety in young patients

ANDS UP who has experienced a little stress rapport builders and can help ensure a child is more when managing an anxious child patient. likely to co-operate with treatment plans.1 It will HOkay, maybe more than a little stress. Treating come as no surprise that fear experienced in the fearful child can be one of the most difficult previous unhappy dental visits has been related to challenges we face in dentistry and is experienced poor behaviour at future visits, and there is certainly by both general dental practitioners and paediatric merit in parents bringing children for routine dental dentists alike. Is this stress avoidable? exams from infancy so that the surgery environment Despite improvements in children’s dental health, becomes more familiar.2 caries continues to affect around one third of young children in the UK and with this challenging Managing anxiety situation comes the need to consider how we can Dental anxiety is common and occurs as a result best manage treatment for the anxious child. of the reaction of the patient to perceived danger – known in physiological terms as the “fight-or-flight Establishing trust response”. Dental phobia is essentially a stronger From the first appointment, the dental practitioner reaction to the same fear, where the symptoms should aim to establish a positive relationship based of the fight-or-flight response occur even when on trust with the child and parent. The triad of just thinking about the threatening situation. communication between dentist, parent and child Children with a vivid imagination can create an can become complicated: young children tend to overwhelming physical response by thoughts alone.2 concentrate on only one individual at any given Dental anxiety can be initially addressed when time. A smiling, welcoming dental team who show taking a child’s dental history. Ask questions about empathy to parent and child is the best start to the previous dental pain and reactions to past dental initial appointment. treatments. In children over eight years, a validated Always make eye contact with the child, use their scale such as the Modified Child Dental Anxiety name and talk to them as opposed to talking over Scale (MCDAS) can be a useful assessment of the them – and aim to say something that will make child’s level of anxiety and helpful in planning them smile. These simple suggestions are excellent appropriate treatment strategies. The MCDAS

18 SUMMONS consists of a simple 40-point scale, with children appropriate to refer the patient to the local public rating their level of anxiety in regard to eight specific dental service or paediatric dental department for questions on a scale of 1-5. Scores of 27-40 indicate further assessment. severe dental anxiety or phobia.3 Guidelines produced by the British Society of Other points for consideration Paediatric Dentistry describe a full range of Avoidance. Consider when treating children that behaviour management techniques and suggested your aim is not only to prevent and treat dental situations for use in dental anxiety.2 The chosen disease but also to avoid treatment-induced anxiety. management technique should be based on Consider the holistic needs of the child when individual circumstances; no single method will be treatment planning. For example, a child with pulpitis applicable in all situations. in one primary molar may well have a number of other carious teeth that also need to be taken into Mild to moderate anxiety consideration. Take appropriate radiographs and Fear of the unknown can often be easily diminished consider how other carious teeth will be managed. with good rapport building and empathy. The Prioritise prevention of caries in permanent molars following techniques can be useful: and where possible avoid carrying out an extraction Positive reinforcement. Use stickers, colouring at the first dental appointment. sheets or simply verbal praise to reward the child Parent in or out? Some dentists prefer one-to-one when they co-operate well. Keep praise and rewards interaction with a child without the parent/carer specific: “Well done for keeping your mouth open so present. Research suggests, however, that co- well” is more effective than “good boy”. Asking the operation is widely unaffected by having a parent child how they are doing during treatment, present in the surgery or not. In the case of communicating with thumbs up, has been shown to pre-school children, however, behaviour tends to be be more effective than reassurance. better when a parent is with them. Tell-show-do. Although requiring time at the Watch your language. Take care with your choice initial treatment appointment, this technique is an of words. “Don’t be scared, I’m not going to hurt excellent way to introduce patients to new you” will unfortunately do little to alleviate anxiety. experiences, increasing the chance of future Negatives like “Don’t” and “not” tend to be bypassed co-operation. This might include using the by the mind – a little like telling a child not to look REFERENCES three-in-one on the child’s hand prior to drying out the window, it becomes the first thing that they teeth or demonstrating the slow-speed on a 1 Prevention and Management do! Focus instead on positives: “You will manage finger-nail prior to caries removal. Should the child of Dental Caries in Children. this just fine” and “lift up your hand if you need a ask to see the local anaesthetic prior to injection, Scottish Dental Clinical break and I’ll stop”. Effectiveness Programme. show them the individual components and Dundee 2010 Failed appointments. Dental anxiety is often emphasise how fine and thin the needle is and how http://www.sdcep.org.uk/ cited as a reason for not attending dental little of it needs to touch the gum. published-guidance/caries-in- appointments. However, children deserve access to Voice control. This is especially helpful with children/ (accessed 3.7.16) dental care and require a responsible adult to get young children who respond better to tone of voice them there. It can help by explaining via letter or 2 Campbell C, Soldani F, rather than actual words, switching to a different, Busuttil-Naudi A, Chadwick telephone that the first visit is for assessment and slightly sterner tone when necessary to improve B. Update of Non- planning only. If a parent or guardian is repeatedly attention, compliance and establish authority. pharmacological behaviour failing to bring their child to their scheduled Distraction. Short-term distracters are useful, for management guideline. Clinical appointment or only bringing the child when they example chatting and pulling the lip taut to distract Guidelines in Paediatric are in pain, discuss your concerns with an from the sensation of local anaesthetic (and always Dentistry appropriate colleague. All concerns should be fully http://bspd.co.uk/Portals/0/ dry mucosa before using topical, allowing four documented and local health board Public/Files/Guidelines/ 4 minutes for it to work!). If facilities allow, playing a Non-pharmacological%20 protocol followed. cartoon on a ceiling television screen during behaviour%20 Check out www.dental.llttf.com for valuable treatment has been demonstrated as being effective. management%20.pdf downloadable resources aimed at dental Giving control. Be honest with the child. If you (accessed 3.7.16) practitioners, young people and their parents on set up a stop-signal, promising that you will stop if 3 Freeman R. An evaluation coping with dental anxiety, including leaflets on how the patient indicates for this to happen, you must of the PALS after treatment to prepare children for their dental visit. The website adhere to it. Not doing so can have disastrous modelling intervention was produced by a team of researchers in the UK, consequences with the breakdown of trust between to reduce dental anxiety experienced in research and treatment regarding patient and dentist. in child dental patients. anxious young people. 2009 International Journal Treating children can certainly bring its More severe cases of anxiety of Paediatric Dentistry challenges, but careful planning and management 19(4):233-42 If it becomes clear during the initial appointment can go a long way towards easing the stress for that the patient has more severe anxiety, additional 4 Children and Young People patient and dentist alike. strategies will be necessary. These might include (Scotland) Act 2014 conscious sedation, general anaesthetic or non- http://www.legislation.gov. n Fiona Hogg is a specialty registrar in paediatric uk/asp/2014/8/contents/ pharmacological techniques such as cognitive dentistry at Glasgow Dental Hospital and the Royal enacted (accessed 3.7.16) behavioural therapy or hypnosis. It may be Hospital for Children, Glasgow

AUTUMN 2016 19 These studies are summarised versions of actual cases from CASE MDDUS files and are published in Summons to highlight common pitfalls and encourage proactive risk management and best studies practice. Details have been changed to maintain confidentiality

TREATMENT: A BLEAK OUTLOOK

BACKGROUND: Mr M visits his GP, Dr C, complaining of Following a practice significant event review, Dr C writes to difficulty sleeping and anxiety which is exacerbated by painful Mrs M apologising for the manner in which he gave Mr M’s swelling on his face. The 61-year-old, who has a recent history prognosis and offering his sympathies over the patient’s death. of insomnia, heart problems and various minor medical An investigation carried out by a local health authority complaints, is diagnosed with suspected facial cellulitis. Dr C suggests the clinical treatment provided was appropriate but prescribes medication for the cellulitis and further medication Mrs M is not satisfied and complains to the General for his insomnia and anxiety. Medical Council. Mr M consults with another doctor at the practice on several occasions over the following two months, continuing to ANALYSIS/OUTCOME: Dr C informs MDDUS he is one of two complain of insomnia, anxiety and occasional tightness in his doctors at the practice being investigated by the GMC chest. In addition to the strain of recovering from cellulitis, he following the patient’s death and a medico-legal adviser helps highlights a number of stressful personal issues he is struggling him prepare a response. with and fears he is at risk of a heart attack. The GP prescribes An independent expert report commissioned by the beta blockers and antidepressants and reassures the patient regulator into Dr C’s handling of the patient’s care is supportive there are no other issues of concern. The doctor also discusses of his clinical decision making, describing it as “adequate and using a self-help guide to reduce anxiety. On two occasions the appropriate”. It states there was no indication for Dr C to GP adjusts Mr M’s medication dosage in response to reports of obtain a more detailed medical history or for him to arrange or minor side effects and later diagnoses him with depression. He conduct any further tests or investigations in the consultations switches the patient to a different antidepressant and a leading up to the patient’s death. The report supports the GP’s different drug for insomnia. actions in prescribing and reviewing Mr M’s medication. The Four months after their initial expert adds that there was no consultation, Mr M returns to indication that Dr C did not Dr C. He is still feeling anxious adequately inform Mr M about and finds it difficult to potential medication side concentrate, but there is a effects and that it was “quite slight improvement in his appropriate” for the GP to sleeping patterns. Dr C makes advise that his anxiety and no changes to the patient’s insomnia could persist for up medication and advises him to two years. that the insomnia and anxiety Based on the evidence could potentially continue for provided, the GMC concludes up to two years, but there the case with no further action. should be improvement if his personal issues can be resolved. KEY POINTS One week later the practice is • Be conscious of a informed that Mr M has patient’s state of mind/ committed suicide. His widow mental health, complains to the practice about particularly when the treatment he received in the delivering bad news or months before his death. In a bleak prognosis. particular, she questions • Fully discuss treatment whether his prescription options, potential risks medication and the bleak and side effects prognosis delivered by Dr C – tailored to individual increased his risk of suicide. patient circumstances.

20 SUMMONS DIAGNOSIS: TWO TEETH TOO MANY

BACKGROUND: Adam is nine years old and attends the dental eruption of the adult incisors. The delay has meant that /1 has surgery with his mother for a regular check-up, having been a been pushed so far out of line by /sn that is now impossible to patient at the practice for the last four years. His dentist – Dr align this tooth. It is alleged that Adam now faces the prospect G – notes (for the first time in the records) that Adam still of having unnecessary surgery including future removal of /1 retains his upper baby central incisors (A/A), although the with replacement by a single tooth implant at around age 18. contralateral lower adult incisors have erupted. Examining further she finds the unerupted adult upper incisors (1/1) are ANALYSIS/OUTCOME: MDDUS commissions an expert palpable buccally. In the notes she records: “Watch 1/1”. report from an orthodontist who examines the patient records Six months later Adam is back at the surgery for another from the practice and the dental hospital. He is of the opinion check-up and his mother expresses concern that he still hasn’t that there were several missed opportunities by Dr G to take lost his front baby teeth. Dr G exams the teeth again and finds radiographs when it was clear there was delayed eruption of they are “slightly mobile” and she advises there is no call to the adult upper incisors (normally between ages six to nine intervene just now but to keep monitoring the situation. years). Guidelines from The Royal College of Surgeons of Nearly a year later Adam returns to the surgery still with England call for intervention in cases when eruption of the “wobbly front teeth” and in an appointment two weeks later Dr contralateral teeth occurred six months previously or there is G extracts A/A under local anaesthetic. Dr G tells Adam’s deviation from the normal sequence of eruption (e.g. lateral mother that the boy’s adult incisors should erupt soon. incisors erupt prior to central). The expert believes these Ten months later Adam is back in the surgery for an conditions applied at the time of Adam’s first consultation with emergency appointment with a toothache in a back molar. Dr G Dr G regarding his upper front teeth. restores the carious tooth. She notes that 1/1 are still unerupted Radiographs taken at this time would have revealed the and arranges for a referral to the local dental hospital. supernumerary teeth and allowed for extraction (along with Adam is now age 12 and attends the dental hospital. the deciduous teeth) with a reasonable chance that the adult Radiographs reveal impacted central incisors caused by two incisors would have come down normally into position. upper supernumerary teeth (sn/sn) – one is palatal to Given the unsupportive expert opinion it was decided in unerupted 1/ and the other is in the /1 position with that adult consultation with the member to settle the case for a sum incisor significantly ectopic, lying horizontally close to the floor commensurate to the cost of future remedial treatment. of the nose. A treatment plan is formulated to remove sn/ to allow for eruption of 1/, and to surgically expose /sn and in KEY POINTS time apply a veneer. • Ensure treatment decisions are backed up by appropriate A letter of claim is received two months later from solicitors diagnostic investigations. acting on behalf of the patient claiming clinical negligence on • Re-consult guidelines when uncertain over treatment the part of Dr G for failing to diagnose the presence of the course. supernumeraries so they could be removed allowing normal • Be prepared for the unexpected.

CONSENT: NO BLOOD WANTED

BACKGROUND: Mr J is a fit and healthy 46-year- document (or documentation of the decision) in the medical old company director who lives and works in records as it relates to the ongoing care of the patient. Birmingham. He makes an appointment with his local It is unlikely that the practice will be required to GP surgery to discuss a “confidential matter”. In intervene acutely where urgent care with blood consultation with the attending GP – Dr K – he products might be required but it may be states that he is a Jehovah’s Witness and contacted by a secondary care provider seeking requests to have a refusal of blood products clarification of the patient’s advance decision. The card added to his patient records. Dr L contacts practice is also advised to document any MDDUS for advice on the matter. discussion about this decision, noting the patient’s capacity to make such a decision. ANALYSIS/OUTCOME: An MDDUS adviser discusses the matter with the GP by phone and KEY POINTS follows up with an advice letter. The England • Respect any competent patient’s right to and Wales the Mental Capacity Act 2005 refuse particular forms of treatment. entrenches the right of an individual to refuse • Ensure advance decisions regarding treatment through an advance decision and as treatment and any discussion are such the practice is advised that it should include the highlighted in the patient notes.

AUTUMN 2016 21 ADDENDA

Object obscura: powered toothbrush Book review: This ‘Kavor’ hydraulically powered toothbrush was manufactured The Gene: An Intimate History around 1932 by Jenkins Productions Ltd of Dereham, Norfolk. The first practical electric toothbrush – the Broxodent – was By Siddhartha Mukherjee invented in 1954 by Dr Phillippe Woog in Switzerland. Bodley Head, £25 hardcover Review by Jim Killgore, managing editor

“IT has not escaped our notice that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material.” This example of “supreme understatement” can be found in the 1953 Nature article by James Watson and Francis Crick detailing the molecular structure of DNA and it is just one towering milestone celebrated in Siddhartha Mukherjee’s artful new “intimate history” of the science of genetics. Mukherjee is an assistant professor of medicine at Columbia University and a stem cell biologist and cancer geneticist. He is also a talented science writer and his The Emperor of All PHOTOGRAPH: SCIENCE MUSEUM/SCIENCE & SOCIETY PICTURE LIBRARY PICTURE & SOCIETY MUSEUM/SCIENCE SCIENCE PHOTOGRAPH: Maladies: A Biography of Cancer won a Pulitzer Prize in 2011. Crossword This new book is “intimate” first in its focus on key 1 2 3 4 5 6 7 personalities involved in the epic discovery and elucidation of the gene, from the early observations of inborn “likeness” by Greek scholars to the meticulous work of the Augustinian monk Gregor

8 Mendel demonstrating inheritance in pea plants (carried out at the same time as Darwin postulated his theories of evolution 9 through natural selection) to further work on genetic traits in

10 11 12 the fruit fly by cell biologist Thomas Morgan and the subsequent search for the “missing” biochemical mechanism that makes it all 13 possible, in which Watson and Crick were so instrumental.

14 15 “Message; movement; information; form; Darwin; Mendel; Morgan: all was writ into that precarious assemblage of molecules.” 16 Mukherjee’s history is also intimate in his account of the

17 18 19 interplay of genetics in his own family where there is a history of schizophrenia, such that he felt compelled to inform his fiancée. 20 21 “It was only fair... that I should come with a letter of warning.”

22 23 The structure of the book is chronological, covering the major developments in genetics by scientists working in partnership or competition or sometimes – as with Mendel – in painful isolation.

24 25 Mendel’s seminal paper was not “rediscovered” until 1900, after his death, by the English biologist William Bateson who later ACROSS DOWN wrote: “When power is discovered, man 1 Betrothed (7) 1 Perform beyond expectations (5) 5 Incontrovertible principles of 2 Pressure build-up in eye (8) will always turn to it…The science of faith (5) 3 Intermediary (2-7) heredity will soon provide power on a 8 Politician, piece of paper in 4 Proponent of evolution by stupendous scale.” hand (11) natural selection (6) 9 Record label, owner of Abbey 5 Long polymer containing It is a prescient observation that Road Studios (3) genetic code of lifeforms (3) Mukherjee explores in the latter part 10 Scarlet resinous secretion 6 Basic functional unit of from insects (3) heredity, made from 5 (4) of the book, looking at the growth 11 Grouped according to 7 Nervousness (7) of biotechnology, the vast and ethnicity or allegiance (6) 12 Set of rules for calculation (9) “dangerous” potential of 14 Curve upwards in the middle (6) 13 Double vision (8) 15 Without elegance or grace 14 Permission (7) recombinant DNA, gene therapy (adverb) (6) 16 Secretion of mucus, bacteria and the sequencing of the entire 17 Prevents vessel from drifting (6) and debris (6) 18 Medical workplace or dog 19 Plays music outdoors for small human genome, recording our (abbr.) (3) change (5) evolutionary history in the 20 Rest upon one’s posterior (3) 21 Person appointed by government 22 Assumed traits based on to advise on policy (4) carcasses of inactivated genes ethnicity or religion (11) 23 To supplement with great “littered throughout its length, 24 Violent spasm or pang (5) effort (3) like fossils decaying on a 25 Dogs, humans and whales (7) beach”. This is a profound and See answers online at www.mddus.com/news/notice-board engrossing book.

22 SUMMONS ADDENDA

Vignette: pioneering family planning practitioner and sex therapist Helena Rosa Wright (1887-1982)

ORN in late-Victorian London, the She found a willing and virile young man daughter of a Polish-Jewish called Derek who would serve as a Bimmigrant, Helena Rosa Lowenfeld surrogate. Between them they provided a said she wanted to be a doctor from the secret fertility service, and Derek is said to age of six. Against her middle-class have discretely visited around 500 of family’s wishes, she went on to study at Wright’s patients between 1916 and 1950, the London School of Medicine for leaving 496 pregnant. Women (now part of the UCL As well as arranging for women to Medical School). Her father, still become pregnant, Wright made no opposed to her career choice but secret of the fact that she had also hopeful that she might see sense, arranged for illegal abortions since said that if she left university and the 1940s. As a result, she was the gave the London Season a try for a subject of a police enquiry in 1947. In year, he would withdraw his the 1950s, she was also instrumental objection. She agreed to the deal, in arranging the adoptions of but after the year went back to unwanted illegitimate children. This medical school and graduated brought her again into conflict with the MB, BS in 1915. authorities and in 1968 she was During her career, she was in turn a prosecuted. Although she pleaded guilty, junior civilian surgeon in a military she was given an absolute discharge. hospital, a gynaecologist and missionary in Throughout her life she was out of step China, a family planning practitioner and with societal norms and establishment sex therapist in London and founder mores, but far from this causing her member of the International Planned stimulation. concern she was proud of saying: “Today’s Parenthood Federation. She was also an In the 1930s, the term sex therapist was cranks are tomorrow’s prophets”. esteemed educator and outspoken unknown, but Wright is now Her attitudes to sex were liberal and champion of contraception throughout her retrospectively regarded as one of the outspoken. Her own marriage to a fellow long life. Indeed, she worked closely with earliest practitioners in this field. Her first surgeon was open, and she strongly Marie Stopes, whom she had first met in work on this topic, published in 1930, was advocated pre-marital sex and extra- 1918 and whose handbook Wise called The Sex Factor in Marriage and its marital affairs at a time when such things Parenthood, she read in manuscript and success meant three printings within the were considered by much of society as claimed to have taken out “all the first six months. In 1935, she also wrote a immoral. She expressed these views plainly nonsense”. It is perhaps testament to both handbook for patients, entitled Birth in her final book in 1968, Sex and Society: a her conviction and her powers of argument control: advice on family spacing and New Code of Sexual Behaviour. and persuasion that in 1930 she addressed healthy sex life. She was driven by a desire In her obituary, the BMJ described her as the Lambeth conference of the Church of to help women plan their pregnancies and “the ‘mother’ of family planning in the England, persuading the assembled bishops enjoy their sex lives and to achieve what UK”. Although Wright was first and to give modified approval to the use of she called “positive health” as a result. This foremost a doctor, she would probably not contraceptives within marriage. approach has been regarded by some as an have objected to the maternal description. In 1929, in addition to her work in two early form of well-women clinic. She fought hard through a lifetime of work London family planning clinics, Wright She was also keen to address what she to improve women’s health and is said to setup in private practice to advise those saw as a significant unmet need in the have referred affectionately to her many who were “too shy or embarrassed to visit a inter-war years. The atrocities of the Great patients as her “chicks”. clinic”. She continued this practice until her War had not only claimed the lives of 89th year in 1975, by which time she had thousands, but had left many of the men n Dr Allan Gaw is a writer and cared for some 20,000 patients. During this who returned home traumatised and educator in Glasgow period she developed her own approach to impotent. Wright claimed that she had women’s sexual problems and, hundreds of married women patients who SOURCES unconventionally for the time, counselled were desperately seeking to become Oxford Dictionary of National Biography that her patients should take responsibility pregnant, but whose husbands were unable BMJ, 3 April 1982. for their own arousal and satisfaction, to father children. Wright allegedly

PHOTOGRAPH: WELLCOME LIBRARY WELLCOME PHOTOGRAPH: emphasising the importance of clitoral addressed this need with a simple solution. Spectator 3 August 2013.

AUTUMN 2016 23 LISTEN & LEARN

Want to learn more about how to handle a:

• complaint • significant event review • negligence claim • GMC investigation?

Tune in to the MDDUS Risk Bites podcast series. Each 20-minute episode offers a fascinating insight into the different ways two practices handle the case of Mrs Roberts, a 51-year-old patient diagnosed with breast cancer.

Learn how to minimise risk across key areas in your everyday practice and explore the latest advice and guidance with our expert risk team.

Find the podcasts at www.mddus.com in Risk Management’s eLearning centre.