QUARTER ONE / 2017 INSIGHT A QUARTERLY PUBLICATION FOR MEMBERS
DR FIONA GODLEE DEMENTIA DENTISTRY ON MAKING AN APP FRIENDING DILEMMA Profile of the BMJ editor A new toolkit offers guidance What goes into the Is it ever okay to accept a and campaigning medical on providing dental care to development and testing of a Facebook Friend request from journalist dementia patients medical app? a patient?
QUARTER ONE / 2017
Editor Dr Barry Parker 10 12 Managing editor Jim Killgore Associate editor Joanne Curran Editorial departments Medical Dr Richard Brittain Dental Mr Aubrey Craig Legal Simon Dinnick Design and production Connect Communications 19 0131 561 0020 www.connectmedia.cc Printing and distribution L&S Litho Correspondence Insight Editor MDDUS Mackintosh House 120 Blythswood Street Glasgow G2 4EA Photograph: Magda Rakita Photograph: [email protected] 4 MDDUS news 16 Case files QUARTER ONE / 2017 INSIGHT 6 News digest Decade of neglect, Google gaffe, A QUARTERLY PUBLICATION FOR MEMBERS Transgender records, Recurrent cancer, 8 Briefing Out of scope, He said, she said Can we reduce overtreatment? 20 Dilemma 9 Risk Do I accept a “Friend” request from Free will in consent a patient? DR FIONA GODLEE DEMENTIA DENTISTRY ON MAKING AN APP FRIENDING DILEMMA Profile of the BMJ editor A new toolkit offers guidance What goes into the Is it ever okay to accept a and campaigning medical on providing dental care to development and testing of a Facebook Friend request from journalist dementia patients medical app? a patient? 10 The accidental editor 21 Ethics COVER IMAGE Adam Campbell meets Dr Fiona A vice-like grip on virtue Nor any drop to drink, Gail Lemasurier Godlee, the forthright BMJ editor not Screenprint, 1993 afraid to take a stand 22 Addenda Gail studied fine art printmaking at Manchester Book choice: A is for arsenic, 12 Making a medical app Metropolitan University and graduated in 1990. Object obscura: Laennec stethoscope, Matt Wickenden describes how an She moved to Edinburgh and joined Edinburgh Crossword and Vignette – innovative medical app was custom Printmakers, working on community arts projects. Dame Cicely Saunders, innovator created for use by respiratory specialists She is now an art psychotherapist and works full in palliative care time in the NHS. 14 Dementia friendly dentistry Dental care for patients with Art in Healthcare works with hospitals and dementia presents some obvious healthcare communities across Scotland to challenges – but also opportunities encourage patients, visitors and staff to enjoy and engage with the visual arts. For more information visit www.artinhealthcare.org.uk Scottish Charity No SC 036222.
Insight is published quarterly by The Medical and Dental Defence Union of Scotland, registered in Scotland No 5093 at Mackintosh House, 120 Blythswood Street, Glasgow G2 4EA. Tel: 0333 043 4444 • Fax: 0141 228 1208 • Email: General: [email protected] • Membership services: [email protected] • Marketing: [email protected] • Website: www.mddus.com The MDDUS is not an insurance company. All the benefits of membership of MDDUS are discretionary as set out in the Articles of Association. The opinions, beliefs and viewpoints expressed by the various authors in Insight are those of the authors alone and do not necessarily reflect the opinions or policies of The Medical and Dental Defence Union of Scotland.
MDDUS INSIGHT / 3 MDDUS News
FROM THE EDITOR YOU may be wondering what happened to Summons. Well after some long thought and discussion – informed by a recent readership survey – we have decided that now is the time to relaunch the magazine under a new name – Insight. Summons has been the title of the MDDUS membership journal since 1989 when it was little more than a newsletter. It has undergone various revamps over the years under the same name – and for longstanding members has been a familiar and regular item in the letterbox. But the name has always been a source of debate, with some members finding it “quirky” and memorable, and others less than amused receiving a regular “Summons in the post”. So we have opted for a title “We have opted that is decidedly more positive for a title that is and aspirational – our aim to offer more positive members helpful and interesting “insights” and aspirational into good practice MDDUS advice line there to be used and proactive risk – our aim to management. MDDUS is keen to dispel the myth that contacting the advice line impacts on We have also taken individual subscription rates. Members are encouraged to seek advice from this opportunity to our team of experienced medico-legal and dento-legal advisers at the earliest offer members make a few changes opportunity – and are not penalised for doing so. on the inside in MDDUS chief executive Chris Kenny said: “As we have repeatedly made helpful and response to reader clear to the BMA and a number of LMCs who raise this issue, we can give a feedback. Our case categorical assurance that the underwriting and pricing decisions of MDDUS interesting studies section has are not affected by the number of times members contact the organisation for been expanded from advice. ‘insights’” two to four pages “Indeed, MDDUS positively encourages members to make use of the advice along with the range line available to them as a benefit of membership. We believe seeking our of case types – as advice will assist the member in adopting safer clinical practice and we would stories are always never penalise them for contacting us for advice.” more compelling when considering risk. We have added a couple more semi-regular features – a Briefing page that picks apart a current regulatory or medico- legal issue in more detail and also a Dilemma page to alternate with occasional first person is required then please inform us accounts of particular difficulties faced by Subscription immediately so that a revised renewal members. notice can be issued. Design-wise, we have tried to make the pages renewal advice We realise that it may be difficult a little less text heavy as the one thing all our to predict accurately the extent of members have in common is hefty workloads MEMBERS receiving their annual your future work – we will allow you and often little time to wade through long renewal notice in 2017 should note to make reasonable adjustments at articles. We hope you will appreciate this new- that the subscription has been any time during the year and up to look magazine and we welcome any feedback calculated on the basis of the NHS one year following the end of each or suggestions – as it is your Insight. post, private earnings or sessions membership year. Please note that declared to us at the time of joining or we may require proof of earnings Dr Barry Parker last renewal (whichever came later). or clinical activity, as set out in the You should check this carefully and MDDUS Membership Agreement. ensure that it remains appropriate MDDUS provides direct debit for the year to come.If any change facilities for your convenience,
4 / MDDUS INSIGHT / Q1 2017 News
including the option to spread the increasing claims frequency and the ratio of q subscription fee over 10 monthly payments at costs to damages. NEW MDDUS no extra cost (which the majority of members “It is by no means unusual for costs to TELEPHONE take advantage of ). This also ensures exceed damages by a very substantial degree, NUMBERS continuity of renewal. even if the claims are promptly settled with Our new contact numbers Membership is provided on an annual basis the minimum necessary investigation,” make it easier for and should you decide not to renew, please Kenny added. “This is due to the very members to get in touch. contact our Membership Services Department considerable front-loading of legal cost Contact our main on 0333 043 0000 at least seven days prior by claimant lawyers before a claim is even switchboard on 0333 043 to your renewal date. Once payment is taken, intimated to the practitioner. 4444 and our membership annual membership is deemed to have "Money expended in compensating for team on 0333 043 0000. commenced and cannot ordinarily be cancelled. clinical accidents should, as far as possible, These are charged at the Failure to maintain direct debit payments may find its way to the injured patient and not same rate as normal local result in this facility being withdrawn. disproportionately to the lawyers supporting or national landline (‘01’ or those patients’ claims. ’02’) numbers. "The proposals will ensure far tighter GPs working management of costs at the level of q the individual case, but it will PRACTICE AND in minor surgery have the right incentive effects CORPORATE SCHEMES in ensuring that strong cases Members with Practice or MDDUS recognises that are selected and prepared Corporate Scheme GPs may undertake a in the most cost-effective membership should note range of relatively minor manner. That enhances, that it is their invasive procedures, such rather than subtracts from, responsibility to ensure as contraceptive implant access to justice. that membership is being or coil fitting, joint "MDDUS will continue adequately maintained by injections, acupuncture to work together with the a scheme administrator, or minor surgery for skin Department of Health and such as the practice lesions and "lumps and NHS England to ensure early manager. Failure to bumps". We will extend the and successful change." maintain adequate cover, benefits of GP membership to for example failing to include work as described above where inform us of a return to it accounts for less than 50 per cent of GDC reform work following maternity a member’s clinical time and where it is or paternity leave, cannot provided to NHS patients. MDDUS believes patients and dentists will normally be rectified Members must ensure that they work benefit if reform proposals from the General retrospectively. within the limits of their competence Dental Council are implemented swiftly, fairly and training, and that the time spent and consistently. q undertaking such work is included within Following the launch of the GDC’s Shifting the BLEAK PRACTICE 4 the sessions declared to MDDUS for the balance: a better, fairer system of dental regulation, The fourth episode in our purposes of calculating their subscription. MDDUS chief executive Chris Kenny said: "The popular video learning Members undertaking more complex or current dental complaints system is outdated module Bleak Practice is specialist work, who are treating private and cumbersome. The often unjustified threat now available. It follows patients or who are exceeding the 50 per of regulatory action can destroy careers and on from the characters cent limit set out above, should contact our reputations and lessen public confidence. That and events introduced in Membership Services Department for a serves neither patient nor dentist. the first three modules tailored quote. "So we welcome the ambitious and radical – this time focusing plan from the GDC to shift the priority to on a new set of risks. upstream prevention from downstream A discussion guide is Capping legal costs punishment, to refocus fitness to practise work available and members and to make the complaints process more can access the module MDDUS welcomes the announcement transparent, consistent, fair and responsive. in the Risk Management of a government consultation on capping "We look forward to continuing to work section at mddus.com. excessive legal costs in clinical negligence with the GDC to develop momentum in Verification for CPD claims. implementation and to make sure that available. Responding to the launch of a Department detailed processes and procedures match the of Health consultation, Introducing Fixed scale of ambition." q Recoverable Costs in Lower Value Clinical MDDUS Head of Dental Division Aubrey MDDUS WEBINARS Negligence Claims, MDDUS CEO Chris Craig added: “We support all steps that will Check out our risk Kenny said: "We welcome this long-promised make the complaints and regulatory processes webinars which are consultation on capping recoverable costs less stressful for dentists and reduce the delivered by in-house in clinical negligence cases. The proposals number of unjustified final hearings. advisers and focus on are thorough-going and capable of early “Early local action is key to defuse areas of risk in everyday implementation. complaints. In our experience, patient practice. Go to the Risk MDDUS' experience in this field mirrors complaints that are dealt with quickly and Management section at the published data from the National Health efficiently between the patient and the www.mddus.com for Service Litigation Authority, both as to practice are far more likely to be resolved.” more details.
MDDUS INSIGHT / 5 News Digest
Mental health support for GPs GPs in England suffering from stress, depression or addiction can now seek help from a new NHS GP Health Service offering specialist mental health support. The new confidential service, backed with funding of up to £19.5 million over the next five years, operates on a self-referral basis but is not intended for emergency or crisis issues. It is staffed by professionals specialising in mental health support to doctors, who will be based in each of the 13 NHS England local team areas, available from 8am to 8pm Monday to Friday and 8am to 2pm Saturday. It is being provided by The Hurley Clinic Partnership, who operate a similar service based in London, and can be accessed via phone 0300 0303 300, email gp.health@nhs. net or app.
More urgent dental Revalidation needs care needed greater clarity DENTISTS could help ease pressures on A REVIEW of medical revalidation urges accident and emergency departments if more greater clarity in required supporting in-hours urgent care slots were commissioned, information, as well as re-doubled efforts according to the British Dental Association. to reduce workload and duplication for The BDA estimates that around doctors also engaged with the CQC and other 135,000 dental patients attend A&E per year regulatory bodies. at an annual cost of nearly £18 million. The The review into the operation and impact majority of visits (95,000) are for toothache, of revalidation throughout 2016 was carried costing the health service £12.5 million, while a out by Sir Keith Pearson, independent chair further 600,000 patients a year seek treatment surgeries may be paying “unwarranted” fees to of the Revalidation Advisory Board. This from GPs. Neither are best equipped to treat collection agencies PRS for Music and PPL to involved gathering practical feedback from a dental pain. listen to music in waiting areas or consulting wide range of individuals and organisations By commissioning more in-hours urgent rooms. The article cited a decision made by involved in the process, as well as analysing care slots, the BDA argues this would help the European Court of Justice in 2012 (Società the findings of research into revalidation since NHS 111 by giving a clear indication as to Consortile Fonografici v Marco Del Corso) its implementation. which dental practices have the availability which found that broadcasting music within Overall the report is positive. In his and capacity to treat patients in need. private dental practices in Italy did not require executive summary, Sir Keith states: Chair of the BDA's General Dental Practice the purchase of a licence. "Revalidation is still a new process; it is Committee, Henrik Overgaard-Nielsen, said: But a PRS for Music spokeswoman has important that we learn from the first cycle “We believe dentists could ease the burden [on confirmed that the ruling “concerns specific to make it more effective in the next. I do not NHS hospital and GP services] if more slots types of rights and remuneration which are not believe major overhaul is needed." were commissioned for in-hours urgent care. relevant in UK law or to PRS for Music”. Among key recommendations in the This would ease the frustration for patients She said: “The law in the UK clearly report he calls for updated guidance on the who cannot get the care they need from seeing provides that the performance and playing supporting information required in appraisal their GP or going to the A&E.” in public of works, sound recordings, films or for revalidation to make clear what is broadcasts, is an act restricted by copyright mandatory (and why), what is sufficient, and and exercisable only with the consent of the where flexibility exists. He believes the system Practices playing music copyright owner. Therefore, PRS for Music has needs to be more robust for doctors who work the right to license businesses who use PRS outside mainstream clinical practice “must buy a licence” members’ musical works in this way.” and those who move around the A PRS licence for a practice waiting room, system, such as locums. Sir Keith also DOCTORS and dentists who play the radio or she added, costs from £84.13 a year. Practices calls for the GMC to continue working other forms of music in their practice must buy may also require a PPL licence. Find out more with the CQC and NHS England to a licence or risk legal action. at www.prsformusic.com and reduce workload and duplication for A recent media report suggested dental www.ppluk.com doctors, and to address similar issues
6 / MDDUS INSIGHT / Q1 2017 in Northern effect from Ireland, 25 April 2017 q Scotland and and applies to all REGISTRATION Wales. doctors practising in DEADLINE FOR Access the report the UK. It will replace INDEPENDENT Taking revalidation the current guidance CLINICS forward at https://tinyurl. which was published in All independent dental com/jcnq4dm 2009. clinics (totally private The new guidance also practices) in Scotland promises clarification on the must be registered with New guidance on importance of sharing information Health Improvement for direct care, recognising the multi- Scotland (HIS) by 1 April conflicts of interest disciplinary and multi-agency context 2017.Practitioners can doctors work in and the circumstances in register using an online NEW guidelines to strengthen the which doctors can rely on implied consent to service and more management of potential conflicts of interest share patient information for direct care. A information is available among NHS staff have been published by NHS new statement has also been included on the from the Independent England. "significant role" that those close to a patient Healthcare Enquiry line at Guidance will permit staff to receive small can play in their care, and "the importance of 0131 623 4342 or via email tokens of gratitude from patients, for example acknowledging that". at www.hcis. a box of chocolates, but will require them to Access the revised guidance at [email protected]. decline anything that could be seen to affect www.gmc-uk.org Failure to register will professional judgement. Gifts with a value result in the operating over £50 will need to be declared. dentist being reported to It will also be standard practice for NHS GMC proposes single the procurator fiscal commitments to take precedence over service for prosecution. private practice, and for any member of staff licensing assessment – clinical or non-clinical – to declare outside q employment and the details of where and ALL doctors wanting to join the medical IMPROVED LUNG when this takes place (although not earnings). register and practise in the UK may be CANCER SURVIVAL The guidance has emerged from a six-week required to pass a standardised Medical A new report shows a consultation conducted by NHS England in Licensing Assessment (MLA), under new seven per cent increase in September of last year inviting views on gifts, proposals by the GMC. lung cancer patients hospitality, outside employment and private The regulator has begun to consult on what surviving for longer than practice, sponsorship and other interests. it calls a "single route to the medical register one year compared with The resulting proposals were bench marked for all doctors who wish to practise in the results from 2010. against best practice in other industries. UK". The National Lung Cancer The guidelines are expected to come into Currently there is significant variation in Audit Report 2016 reveals force on 1 June. arrangements for medical students across that one-year survival rose the UK and those wishing to join the register from 31 to 38 per cent in the from outside the UK. International medical five-year period from 2010 Clearer guidance on graduates (IMGs) have a number of means to 2015, and also that 60 of entry, including the Professional and per cent of lung cancer confidentiality Linguistic Assessments Board (PLAB) test, patients received anti- but doctors from the EU can secure a UK cancer treatment such as DOCTORS may be allowed to breach licence to practise without any test of their chemotherapy, radiotherapy confidentiality without consent to protect a competence. or surgery, meeting a target patient from a serious crime such as murder Professor Terence Stephenson, Chair of the set out in 2015. – even if no one else GMC, said: "Medical is at risk, according to training in the UK q updated guidance from is among the best NEW APP FOR the General Medical in the world – our GMC GUIDANCE Council. graduates do well here An app that allows In "very exceptional and when they work healthcare professionals circumstances", overseas. However, to conveniently access disclosure without current arrangements Good medical practice consent may be do not allow us to (GMP) guidance has been justified in the public assess whether UK launched by the GMC. interest even if a graduates and overseas My GMP can be patient with capacity has refused and no one graduates have attained the same threshold of uploaded for use in else is at risk. But the regulator says there competence when they are seeking the same smartphones and tablets must be clear evidence of an "imminent risk licence to practise in the UK.” and is designed to allow a of serious harm" and advises clinicians to seek The GMC hopes to incorporate the new quick on-the-spot search independent legal advice before acting. assessment into existing testing by medical for relevant guidance. This advice forms part of the GMC’s schools – subject to approval – by 2022. A Find out more and new "revised, expanded and reorganised" consultation at www.gmc-uk.org is open for download the app at Confidentiality guidance which comes into feedback until 30 April 2017. www.gmc-uk.org
MDDUS INSIGHT / 7 BRIEFING CAN WE REDUCE OVERTREATMENT? Joanne Curran Associate editor of Insight
HE more advances are benefits of treatments and procedures”. adoption of shared decision-making (SDM) made in medical tests, They highlighted a 2015 study in which 82 in order to help manage patient treatments and other per cent of doctors said they had expectations, coupled with a shift away interventions, the greater prescribed or carried out a treatment from a so-called “more is better” culture. the pressure can be for which they knew to be unnecessary. The NHS England describes SDM as “a clinicians to use them. Faced vast majority cited patient pressure or process in which patients… can review all the with a patient seeking relief patient expectation as the main reason. treatment options available to them and from pain, suffering or anxiety, the question As a first step, Choosing Wisely listed 40 participate actively with their healthcare Toften follows: “Surely something can be treatments and procedures said to be of professional in making that decision.” done?” But the fact that something can be little or no benefit to patients. In terminal Writing for the Guardian’s Healthcare done is no guarantee of a positive outcome cancer cases, for example, they say: Network, GP Dr Steven Laitner says SDM and in some cases the intervention may do “chemotherapy may be used to relieve can lead to a better patient experience: “[It] more harm than good. symptoms but can also be painful, cannot can reduce treatment disagreements, lead to The Academy of Medical Royal Colleges cure the disease and may well bring further more realistic expectations, reduce clinically (AoMRC) recently launched their Choosing distress in the final months of life.” unwarranted treatments, and potentially Wisely campaign, part of a global Patients are also urged to ask five key reduce litigation. Importantly, patients are movement to reduce “over-medicalisation”. questions when seeking treatment: more likely to stick with a course of action or At its heart is a call to both doctors treatment when they have chosen it, rather and patients “to have a 1. Do I really need this test, than had it foisted upon them.” fully informed treatment or procedure? What’s more, the Royal College of conversation 2. What are the risks or downsides? Surgeons (RCS) argue that, following the about the 3. What are the possible side effects? landmark 2015 Supreme Court judgement risks and 4. Are there simpler, safer options? in Montgomery v Lanarkshire Health Board, 5. What will happen if I do nothing? there is now a legal imperative for doctors to adopt SDM in order to secure informed A 2015 BMJ article, 'Choosing Wisely in the consent. An article in the January 2017 UK: the AoMRC’s initiative to reduce the edition of their Bulletin magazine states the harms of too much medicine', describes how ruling “has confirmed that a patient’s right under the campaign: “[D]octors and patients to self-determination in treatment decisions will be supported to acknowledge that a triumphs over medical paternalism”, and minor potential benefit may not outweigh that “the principles of shared decision- potential harm, the minimal evidence base, making must become the norm.” and substantial financial expense and There are concerns this approach may be therefore that, sometimes, doing nothing unrealistic due to time pressures, but the might be the favourable option.” RCS say “it need not be so”. They point to the range of available tools to support decision- “A 2015 study found 82 per cent making that “enable the doctor and patient to of doctors had offered treatment share information in an efficient and they knew to be unnecessary” comprehensive way.” In the feedback report for Realistic Medicine, the Academy Chair Professor Dame Sue 2016 annual report from Scotland’s chief Bailey says that improved patient outcomes medical officer Dr Catherine Calderwood, rather than financial savings are the main there are also calls for a change in culture motivation behind the campaign. “What’s “that permits doctors not to over treat – important is that both doctors and patients for example, treating an elderly patient in really question whether the particular community and not hospital”. treatment is necessary,” she says. “Medicine Looking to the future of healthcare, the or surgical interventions don’t need to be the key message seems to be less is more: less only solution offered by a doctor and more medicine and more patient involvement. certainly doesn’t always mean better.” So how will this translate into day-to-day LINK: clinical practice? The secret to success for • Choosing Wisely UK - Choosing Wisely appears to lie in wider www.choosingwisely.co.uk
8 / MDDUS INSIGHT / Q1 2017 RISK FREE WILL IN CONSENT Gail Gilmartin Medical and risk adviser at MDDUS
UCH has been written best interests, but care must be taken not took the matter to court and it eventually about the need to to inappropriately pressurise a patient to went to the Court of Appeal where it was determine make a particular treatment choice. It is found that T had been pressurised by her competence and what one thing to check the patient’s beliefs mother. This, along with the effect of information a patient and reasons for their choice but it is wrong drugs she had at the time, rendered her should have when to try to impose a choice upon them. refusal invalid. The decision was that the providing valid consent Equally those close to a patient should not transfusions could proceed. to treat – but there is also a vital third seek a decision of their preference as In the Court of Appeal decision Lord Melement: ensuring free choice. opposed to the patient’s own. Staughton wrote: “... every decision is Respect for autonomy is a fundamental In the landmark case of Re T (Adult) made as a result of some influence: a ethical principle underpinning medical 19921, the judgement looked closely at patient's decision to consent to an ethics. We must respect the right of any these issues. operation will normally be influenced by person to make decisions affecting their T was a 20-year-old pregnant patient the surgeon's advice as to what will own bodies and lives. This also means who was injured in a car accident and happen if the operation does not take protecting them from adverse influences ultimately needed to have blood place. In order for an apparent consent or which interfere with their ability to make a transfusions after complications arising refusal of consent to be less than a true free choice. from a caesarean section. On admission consent or refusal, there must be such a In Consent: patients and doctors making to hospital she had indicated that she was degree of external influence as to decisions together, the GMC states: an ex-Jehovah’s Witness and information persuade the patient to depart from her “Patients may be put under pressure by from the patient and those close to her own wishes, to an extent that the law employers, insurers, relatives or others, to demonstrated that her lifestyle departed regards it as undue. I can suggest no more accept a particular investigation or from the teachings of that religion. precise test than that.” treatment. You should be aware of this Although there had been no discussions The ethical and legal position is clear and of other situations in which patients with the patient about transfusion, after that patients must be allowed to make may be vulnerable. Such situations may spending time with her mother, a their own decision on consent without be, for example, if they are resident in a practising Jehovah’s Witness, T announced undue influence. This can on occasion lead care home, subject to mental health that she did not want to have blood to concerns about valid consent. If such a legislation, detained by the police or transfusions. At that time it was not case arises it is important to seek immigration services, or in prison. anticipated that she would require blood appropriate legal advice and if in any “You should do your best to make sure or blood products. doubt contact MDDUS for guidance. that such patients have considered the Later when she needed to have blood available options and reached their own she continued in her refusal. Her father 1 Re T (Adult) [1992] 4 All ER 649 decision. If they have a right to refuse treatment, you should make sure that they know this and are able to refuse if they want to.” “It is one thing Here the GMC highlights several situations where patients may be to check the adversely influenced in their decision making. Many relatives and friends do patient’s beliefs influence patient choices – but this must not amount to substituting their decision and reasons for for that of the patient. For any treatment decision, the their choice but patient’s choice depends on various factors, such as the impact on their day-to-day life, family responsibilities, it is wrong to employment, time of year and even personal foibles. As healthcare try to impose a practitioners we need to be sensitive to these matters and be alert to any choice upon influence which crosses a line, even from a practitioner themselves. them” Tensions often arise when a patient refuses treatment. A clinician can explore the reasons for making a decision which may not appear to be in a patient’s own
MDDUS INSIGHT / 9 FEATURE PROFILE THE ACCIDENTAL EDITOR SK FIONA GODLEE how she went from being Adam Campbell meets Dr Fiona a registrar in general medicine to editor of one Godlee – the forthright BMJ editor of the longest-running and most influential medical journals in the world and she’ll tell you not afraid to take a stand it was all a bit of an accident. To be fair, speaking to me down the line from Cambridge, where she did her graduate medicine and now lives, she’s actually Aexplaining how she came to work for the BMJ in the first place in 1990, after a year’s placement turned into two years and then a full-time job. The placement – as editorial registrar – was set up as a “bridge” between the journal and young clinicians, who would bring a fresh injection of expertise and energy into the BMJ before heading back to the medical coal face. But for Godlee there was to be no return journey. “It was very clear when I took the editorial registrar job that I wanted medicine as a career. It’s not intended as a way out for doctors who are disillusioned. But it became very compelling, engaging, huge fun, very broad, wonderful people, all of that. I was drawn into it. So it happened by mistake really.” Fifteen years later – having in the meantime led the development of BMJ Clinical Evidence and, in a three- year hiatus from the BMJ, established the open access publisher BioMed Central – her “accidental career move” paid its biggest dividend of all when she was named as successor to the legendary BMJ editor, Richard Smith. At 43, she was to be the first female editor in the journal’s then 165-year history. She had not been gunning for the role, she says, but she was ready for it. “Richard had been my mentor. He’s very generous and creative and I’d learnt a vast amount working with him. We were all very sad that he went. But then someone needed to do the job and I thought I could do it.” MORE THAN ACADEMIC Godlee was a new broom but she was not in the business like, to put a knife into the oyster and try to winkle it open,” of sweeping away the past. Her tenure, she says, has been she says. “Over the 11 years I’ve been editor, it’s become a “natural evolution” of the direction of travel already in clear to me what the BMJ can do and what it can’t do.” place. A key aspect of this has been to ensure the BMJ’s output is actually read – so that it can contribute to the AN INDEPENDENT VIEW debate. Readers’ feedback is that they want things that are Falling firmly into the ‘can do’ column is the belief short and punchy. More “magazine-y”, as she puts it, “a that the journal should take strong positions in the key pleasure read rather than a necessary work read”. But, she health debates, and the BMJ under Godlee wears its says, “they also want credibility and care and accuracy. So campaigning heart on its sleeve, with a page on the website to try to do both of those things is really the challenge.” dedicated to its current campaigns. Whether it’s NHS This has meant professionalising the journalism, funding, overdiagnosis and waste of resources, corruption bringing in dedicated health writers and also using in healthcare, the decriminalisation of illicit drugs, investigative techniques to shine a light into some of the transparency in clinical trial data or the health impacts of darker crevices of the medical landscape. At the same time climate change, the BMJ has tackled them all – and firmly. it has been crucial to maintain the academic standards A major priority for the coming year is the idea of of research which underpin the credibility of the BMJ’s patient partnership, putting the patient’s voice into output. It is this combination of academic strength and research and education of doctors. The BMJ has already journalistic enterprise that gives the BMJ its unique done a lot of work on this, including its regular ‘What position, she says. your patient is thinking’ series. Godlee explains: “It’s the This twin-pronged approach has seen the BMJ idea that you need to take the patient’s perspective into getting together with the likes of the BBC, the Centre account, not just because it’s the right thing to do but for Evidence-Based Medicine and Channel 4 News to because it actually leads to better decisions.” investigate issues, such as the lack of evidence behind Of course, campaigns such as these are never one-sided many costly add-on treatments for IVF and the costs and affairs and there have been a few high-profile spats, including (lack of ) benefits involved in the switch from human one with the editor of the Lancet over statins (the BMJ has insulin to analogues in the treatment of type 2 diabetes. been critical – unjustifiably so, says the Lancet). There was “Repeatedly it does seem to be that because the BMJ can also a fundamental disagreement with her employer, the be both of those things, it can be used as a sort of tool, if you BMA, which owns the BMJ, over assisted dying.
10 / MDDUS INSIGHT / Q1 2017 THE ACCIDENTAL EDITOR
“I initially argued the BMA should go to a neutral stance “Readers of the BMJ want a pleasure read rather but I now think it ought to be a decision for society. If that was the case, I think society would probably vote for it.” The BMA, on the other hand, is firmly against, though it than a necessary work read…they also want has respected the journal’s independence on this issue. The decision to start talking about climate change as credibility and care and accuracy” being a result of human activity and a risk to human health also provoked a considerable backlash. “A lot of it was, you’re naive and stupid to think it’s real – and even if it wished she had gone back across that bridge into medical is real, what’s this got to do with medicine? That seems practice? She was, after all, breaking with a firm family extraordinary now but that was the initial response. I think tradition: her father was an oncologist and all three of it is a bit of a no-brainer now but it gets back to the question, her siblings are GPs. Further back, her medical pedigree what is the BMJ? What is a medical journal there for?” includes a great-great uncle who was none other than These “skirmishes”, as she calls them, are all part of the Joseph Lister, pioneer of antiseptic surgery. job, in other words. It is a question, she says, of “behaving “I did feel quite nostalgic at one point, when my well and reasonably” when putting your case. In this way children were young. I was living up in Lincolnshire and the skirmishes are resolved and you move on. commuting into London and I used to think, ‘Gosh what would a local life be like? Could I retrain as a GP?’ There’s FEW REGRETS something magical about the interaction with patients Another key challenge of the job, of course, is keeping your and I also love the community of working in a hospital, readership happy. On this score, with a global circulation the social scene – and moving into an editorial office is a of 122,000 for the print edition and 2.5 million hits every rather smaller environment.” month on the website, her approach is clearly paying off. But no, she confesses, the regrets have been few. After There have been accolades from her peers, too, and all, she is positioned at the very centre of the worldwide Adam Campbell is in 2014 Godlee was named Editor of the Year at the medical debate. She puts it succinctly, as she remembers a freelance writer Professional Publishers Association awards and the that first move: “Medicine had been a vocation for me in Edinburgh and a following year the BMJ was named Magazine of the Year. – and the BMJ, well, I wasn’t going into just any old regular contributor to So, despite all her success as a publisher, has she ever publishing.” MDDUS publications
MDDUS INSIGHT / 11 FEATURE TECHNOLOGY MAKING A MEDICAL APP What goes into the development and testing of a medical app? Here Matt Wickenden describes how one innovative app was custom created for use by respiratory specialists
HE list of things that smartphones can do is need to move with them. constantly growing – and their role in assisting Our app is designed to make that possible. healthcare professionals on the ward and in practices is also expanding almost daily. WHAT ARE THE GUIDELINES FOR? Apps in particular have the potential to offer When a nodule is found on a scan, doctors must quickly quick and simple answers to some of the key decide if it needs further investigation. They have to questions doctors face every day. But they need balance this with avoiding unnecessary tests and worry to be reliable and effective. for patients who may have harmless (benign) nodules. TRecently Cancer Research UK has been involved in The guidelines help doctors decide these next steps developing an app for iPhone and iPads in partnership – whether to discharge the patient, bring them back for with the British Thoracic Society (BTS). monitoring, or offer further tests that may lead to a lung Our goal is to make it easy for health professionals to cancer diagnosis followed by treatment. access comprehensive guidelines published in 2015 by The guidelines recommend using three different the Society on how to manage patients with small tissue mathematical calculations to assess the risk that the growths – called pulmonary nodules – that can appear on nodule is cancerous and how quickly it’s growing. lung scans. These nodules can be harmless, but they can These have been turned into online calculators which also be cancerous and need treatment. are available on the BTS website (tinyurl.com/ The guidelines have been very popular with doctors and h6cpemn). the teams they work with, offering information to help The guidelines and online calculators have been really diagnose patients with lung cancer as quickly as possible – popular. Since the start of 2016, the online calculators and without carrying out unnecessary tests on people who have been used over 18,700 times, helping doctors make don’t need them. But the different hospital staff who use vital decisions around the care of thousands of patients. the guidelines are almost always on the move. When we But there’s a problem. spoke to them it was clear they want the information they HOW CAN AN APP HELP? As is often the case in medicine, the lung nodule guidelines contain a huge amount of information. The detail is vital but not something a doctor can quickly refer back to while they’re in the clinic or in a multidisciplinary team meeting (MDT) planning how best to care for their patients. Also, while the calculators are available online, it’s awkward for doctors and their teams to access them when they’re on the wards or in MDTs. Simply using their phone isn’t easy either because they often can’t reliably get Wi-Fi or a mobile signal in hospitals. Our app gets around both these problems. Summaries of the key information are already downloaded onto their phone, purpose built for handling the maths and available whenever clinicians need it. DOCTORS HELPED DESIGN THE APP TOO From the start we wanted to ensure that the design and functionality of the app did exactly what the doctors needed it to. First we collected feedback from 18 health professionals. We found that 11 were already using smartphone apps for their work at least several times a “From the start we wanted to ensure that month, with three using them several times a day. The feedback also showed that 11 were very likely to use an app the design and functionality of the app version of the guidelines and calculators. We then worked with our in-house digital experts to did exactly what the doctors needed it to” develop a prototype app that we took to hospitals in Leeds
12 / MDDUS INSIGHT / Q1 2017 MAKING A MEDICAL APP
and London to get more feedback and understand how doctors might use it. We found that the doctors and their teams were always on the move around the hospital. This means they often won’t have easy access to a computer when they need to make decisions about their patients. We also found that there are a lot of different people who need to use the guidelines. And they all have slightly different needs. For example, the nurses supporting patients as they are having the scans and tests might use the app in a different way from the doctors interpreting what the scan results mean. So the easier we could make it for different people to access what was relevant to them, without having to spend lots of time referring back to the full guidelines, the better. WHAT DIFFERENCE WILL IT MAKE? We hope the app gives health professionals all the information they need, where and when they need it. After extensive tests, a group of health professionals from across the country have been using the app in their hospitals over the last month. They’ve kindly given us their feedback, and early signs are positive. “The app makes it much easier to plan nodule follow- up in clinics and MDTs as you don’t have to wait for the website to load and it’s much more phone-screen- friendly,” said one user. “Having the calculator immediately to hand saves me time spent finding a PC and getting through to the risk calculator online or trying to use mobile data to get there,” said another. We hope that many more doctors will now get similar benefits from the app and that it can help make sure the thousands of patients found to have pulmonary nodules each year get the best possible care. WHAT HAPPENS NEXT? Since launching in December 2016 the app has already been downloaded over 1,000 times. We’re going to collect more feedback on the app to understand what features are most valuable to people and any areas we could improve it. Assuming the app continues to be successful, we’ll be working with the British Thoracic Society to develop Matt Wickenden is a versions that will work across other mobile operating cancer intelligence systems, such as Android and Windows. manager at Cancer We hope this app can help us to start to realise Research UK the potential for smartphones in supporting doctors and improving patient care. We’ll be keen to learn A version of this article any lessons that can help us develop more apps to originally appeared on support other areas of cancer patient care. the Cancer Research We also hope this app will prove a useful UK Science blog example of how apps can help improve patient (access at www. care in general with quick and simple solutions. cancerresearchuk.org)
MDDUS INSIGHT / 13 FEATURE DENTAL PRACTICE
DEMENTIA FRIENDLY DENTISTRY Dental care for patients with dementia presents some obvious challenges – but also opportunities
ARELY a week goes by without another media diagnosed with dementia to local dental practices for story about the growing number of people living early assessment and care planning, and to streamline the with dementia and the challenges we face as a dental care pathways between general dental practice, society. Current predictions are that by 2025 community and hospital services. there will be over one million people with the condition in the UK. DEMENTIA AND ORAL HEALTH So what are the implications for the dental Following a dementia diagnosis, there are many issues to team? Whilst the increasing number of people consider around the health and well-being of a patient Bwith dementia can bring challenges, there is also an and their future care – and oral health is an important opportunity for the primary care dental team to make a component. In the early stages of dementia, oral care real difference. follows the same principles as for any patient. Preventive Good oral health enables people to enjoy a healthy strategies should be tailored to the individual risk of and varied diet, to smile and interact socially – these oral disease, including caries, periodontal disease, oral are especially relevant for people living with dementia cancer and toothwear. Current guidelines may be used to to support adequate nutrition and a good quality of life. identify appropriate intervals for recall, radiographical Dental pain can be detrimental to all of these aspects, thus examination and fluoride regimen. mouth care and effective oral disease prevention should be Early treatment decisions should take into account the a high priority. expected disease course and result in a dentition which Even experienced special care dentists will agree that can be maintained long term. As dementia progresses, risk the provision of operative dental treatment in the later of plaque-related disease increases and it may become stages of dementia can be challenging. A thorough oral more difficult to achieve a high standard of plaque control, assessment as soon as possible after diagnosis and careful particularly where a third party is relied upon for personal treatment planning and prevention can significantly care. Advanced restorative dentistry, for example fixed reduce the chances of future dental problems and allow bridgework and implant retained prosthesis, can present patients to make decisions for themselves. a particular challenge when dementia has progressed and Visiting the dental practice can be bewildering for oral hygiene may deteriorate. people with dementia, even in the earlier stages. The A number of other factors may affect diet and nutrition appointment and reminder systems, busy waiting rooms, and as a consequence increase the risk of dental caries. complicated forms and even shiny floors can all present These include an increased reliance on convenience foods, difficulties. changes to taste and appetite, increased snacking and subsequent increase in sugar consumption. TOOLKIT Dietary choices may be made by a patient’s carers, Cheshire and Merseyside are exploring a partnership or directed by medical needs. Nutritional supplements approach to dental care for this patient group. Each dental may be required in order to increase calorie intake, but practice in the region could have as many as 120 patients these can also be high in sugar. Chewing may become with dementia seeking dental care by 2025. Community more difficult, fluids may need to be thickened to prevent dental services and hospital-based special care dentistry aspiration, and clearance of food from the mouth may be services have clinicians with additional skills and expertise – but care pathways and shared care arrangements with general dental practitioners are also needed. To this end a toolkit for the primary dental care team “Special care dentists will agree that the was recently developed and tested in Cheshire and Merseyside as part of a ‘dementia friendly dentistry’ provision of operative dental treatment in the programme. Subsequent phases of this programme will establish systems to direct those who are newly later stages of dementia can be challenging”
14 / MDDUS INSIGHT / Q1 2017 delayed. These changes, together with a dry mouth due to to make their own treatment decisions for as long as xerogenic medicine, significantly increase caries risk. possible, with information pitched at the right level and pace. Where capacity is shown to be lacking, any action PREVENTIVE DENTAL CARE taken must be in the patient’s best interests, taking into Access to dental care can become more problematic as account any advanced decisions, previous wishes and memory deteriorates. Communication of pain can be less beliefs. Those close to the patient should be consulted and specific, and it may become necessary to consider other the least restrictive options chosen. Onward referral to a behavioural changes such as altered demeanour, sleep and more experienced or specialist colleague may be necessary eating patterns, alongside objective signs such as swelling where assessment of capacity is unclear. or reaction to palpation of soft and hard tissues. Anxiety and cognitive decline can mean reduced CARE PATHWAYS AND CLINICAL NETWORKS cooperation in dental treatment and it may become Local structures will vary across the UK but the principle necessary to consider intravenous sedation or general remains of using the right skill mix for patients matched anaesthesia in some cases. It is vital to carefully balance to the complexity of their care. Supporting GDPs to the risks of these procedures against the benefits of provide care for people with dementia offers the benefit of Suzanne Burke is a treatment. Medical comorbidities, such as chronic establishing a familiar contact within the local community. specialty trainee in cardiorespiratory disease, may present increased risks Many dentists will have always provided long-term special care dentistry such as aspiration pneumonia or post-operative delirium holistic care for patients with dementia and will continue at Liverpool University in the cognitively impaired patient. to do so. These skills and experiences can be shared with Dental Hospital Prevention of oral disease remains the foundation of healthcare colleagues. care for people with dementia. The best time to discuss A whole-team approach is recommended, as Lesley Gough is a possible future problems associated with dementia is receptionists and dental nurses have a vital role to play consultant in dental following diagnosis, whilst cognition and the ability to in identifying ways to support patient care and could be public health at Public accept care are largely unchanged. Removal of non- the first to spot behaviour changes or difficulties which Health England (North functional, non-aesthetic, carious and heavily restored may indicate progression of dementia. Sometimes simple West Centre) teeth may be advised, rather than providing treatment adjustments and greater general awareness of dementia which is unlikely to be maintained in the longer term. The can greatly benefit the patient/carer experience, and Andy Kwasnicki shortened dental arch approach may be considered, with increase their ability to access dental care in the longer is a consultant in the overall aim of providing a functional, easily maintained term. special care dentistry, dentition with good long-term stability. Specialist services will always be required for those with Liverpool University Regular preventive planning, including fluoride complicated cognitive and medical issues, but these should Dental Hospital application, can be provided through a team approach be reserved for the most complex cases. Thorough early using hygienists and therapists to deliver appropriate assessment, regular review and tailored evidence-based Access the full care – and this may be vital in establishing a continuing prevention can have a significant impact on maintenance Dementia Friendly relationship with patients. of good oral health in the long term, and can be effectively Dentistry toolkit at A patient living with dementia should be supported provided by the primary care dental team. tinyurl.com/h74krcx
MDDUS INSIGHT / 15 These studies are summarised versions of actual cases from MDDUS files and are published in Insight to highlight common pitfalls and encourage proactive risk management and best practice. Details have CASE FILES been changed to maintain confidentiality.
CLAIM DECADE OF NEGLECT
BACKGROUND attempts to encourage better oral hygiene, records, though there is reference to pocket A 42-year-old woman – Mrs T – attends a though with little success. charting by the hygienist. The record does dental surgery as a new patient and is Bitewing radiographs were taken on two reflect discussion of Mrs T’s poor examined by Mr P. The dentist notes that occasions over the period showing periodontal condition and the need for Mrs T is suffering from gross periodontal increased generalised bone loss. Mrs T improved oral hygiene so it is unlikely that disease with numerous mobile teeth. The suffered with bleeding gums and lost the patient was unaware of her condition. patient is referred to the periodontal interdental papilla. Scaling and root planing The expert is of the opinion that referral to department at the local dental hospital were undertaken along with occasional a specialist was indicated, especially when where she is examined and a report sent to antibiotic therapy and the patient was the second radiograph confirmed the Mr P. advised repeatedly of her poor periodontal progressive nature of the patient’s The report indicates aggressive condition and the importance of proper condition. periodontitis in 15 teeth, with pockets tooth brushing technique. Her husband In regard to causation the expert states greater than 6mm and generalised bone eventually insisted that Mrs T consult Mr P that it is not certain if earlier intervention loss of 60 to 80 per cent. Almost all the for a second opinion. would have prevented or at least delayed teeth show varying degrees of mobility and A letter of claim is later received by Mr F Mrs T’s tooth loss but earlier referral to the consultant recommends a treatment alleging clinical negligence in his failure to hospital for aggressive therapy might have plan involving the extraction of seven teeth diagnose periodontal disease over the made a difference. and the fitting of a partial upper denture. 10-year period Mrs T was in his care. In MDDUS lawyers and advisers decide in Mr P carries out the treatment over a series particular he did not carry out BPE agreement with Mr F to settle the case . of appointments. examinations and it is alleged he failed to Questions then arise over Mrs T’s act on radiographic evidence of the previous dental treatment and it transpires patient’s deteriorating periodontal she had been under the care of another condition. It is also alleged that the dentist KEY POINTS dentist – Mr F – for the last 10 years. Mrs T did not undertake systematic deep scaling ●●Ensure that patients understand the first attended the dentist for treatment of and root planing, nor did he refer the serious nature of periodontal disease caries in an upper molar and was referred patient for specialist treatment. Mrs T also and the likely outcomes should to a hygienist for “perio pocketing” and claims that the dentist failed to inform her treatment advice be ignored. poor oral hygiene. A pocket chart was taken of the condition and the serious ●●Record BPE at each routine and oral hygiene instruction provided to implications of her poor oral hygiene. examination. A visual examination, Mrs T but compliance was poor. Over the even if recorded, is insufficient. next few years Mrs T attended Mr F for ANALYSIS/OUTCOME ●●Maintain full records including routine scale and polish and examinations, MDDUS instructs an expert to report on treatment provided and any lack of in which over time her deteriorating the case and she is first critical of the lack compliance. periodontal condition was noted along with of any recorded BPE screening in the
16 / MDDUS INSIGHT / Q1 2017 GDC GOOGLE GAFFE
BACKGROUND Whitening Specialist”. Use of Ms B is a principal in a practice offering DKI had not been explained or general dental treatment along with minor okayed by the practice and a cosmetic procedures. She receives a letter letter setting out the error is from the GDC requesting information in provided by the company for regard to an anonymous complaint evidence to the GDC. concerning a Google Ad for the practice with the headline “Tooth Whitening ANALYSIS/OUTCOME Specialists”. MDDUS replies on behalf of Ms In the letter it is first pointed out that a B along with copy dentist is not allowed to use the term correspondence demonstrating “specialist” unless qualified to appear on her efforts to comply with one of 13 GDC specialist lists – and second relevant guidance in regard to there is no specialist list for tooth digital marketing – including the whitening. letter from the web company. Ms B contacts an MDDUS adviser who The letter also enquires why the helps her draft a reply. It emerges that Ms GDC decided to take the matter B had employed a web company to forward for investigation when manage her online advertising campaign. usual practice in such cases is in The company removed the phrase “Tooth the first instance to simply request changes Whitening Specialists” when informed of to ensure compliance. the complaint and re-checked the “key KEY POINTS The GDC acknowledges receipt and words” agreed for the Google campaign. ●●Be careful not to use the title explains that because Ms B had been “Specialist” was not on the list of “specialist” unless you are registered on subject in the past to a fitness to practise approved terms the practice asked to be one of 13 GDC specialist lists. concern it was decided to look further into used in the promotion of the business. The ●●Use of terms such as “special interest the present matter. A few weeks later Ms B term had been inserted inadvertently via in” or “experienced in” are permitted receives another letter confirming the “dynamic keyword insertion” (DKI) when a for non-specialist registrants. matter will not be taken forward and that user on Google typed in the phrase: “Tooth the case file has been closed.
ADVICE TRANSGENDER RECORDS
BACKGROUND and gender (with the patient’s consent). If guidance on trans healthcare on their A GP practice has been supporting a male the patient wishes to be issued with a new website, including the process for patient transitioning to female over the past NHS number then this can be taken care of changing name, title or NHS number year. The patient is now demanding that by the CCG who will ensure the records are across the UK. Note that it is a criminal personal details be changed in the medical transferred to the new identity. offence to share, without the patient’s record to reflect a new name and change of The practice is advised to explain that consent, information which reveals gender gender. The practice contacts MDDUS to the patient may not be contacted for reassignment has occurred, where the ask if the patient should current or future patient has received a GRC. As such, provide some kind of screening programmes provision of information on referrals etc. formal certificate or associated with the should be carefully reviewed. authorisation first? sex at birth and explain the ANALYSIS/ implications of this. OUTCOME Decisions about KEY POINTS MDDUS advises that the screening should be made in ●●Transgender patients are not patient should submit a signed the same way as any other required to provide a certificate or request in writing. A Gender health decisions (ensuring authorisation before requesting Recognition Certificate (GRC) informed consent is in place). changes related to gender status. or updated birth certificate is Gender marker, pronouns and ●●A signed request from the patient is not required in order to have the names on all the patient sufficient to make such changes. record amended. The practice should information held should also be ●●Consult GMC and other guidance on then inform its CCG (Practitioner changed. trans healthcare. Services in Scotland) of the new name The GMC has published
MDDUS INSIGHT / 17 CASE FILES
CLAIM RECURRENT CANCER
BACKGROUND rectal bleeding, though still evident, has ANALYSIS/OUTCOME Mr D is 72 years old and attends his GP eased. He is worried that it might all be Expert reports commissioned by MDDUS surgery complaining of rectal bleeding. He related to his cancer. Dr F exams him and are critical of the GP in minor respects but had felt constipated about a week before finds good forward flexion and no para- with the overall opinion that no action on and had taken a laxative which relieved the spinal tenderness. He diagnoses his part would have changed the outcome symptoms but in the past two days he has mechanical pain and prescribes codeine of the case. A primary care expert notes noticed more bleeding. There is no history with a laxative as necessary to avoid that Mr D first presented with symptoms of melaena or weight loss. constipation. Mr D mentions he has not that were suggestive of haemorrhoids. It The GP – Dr F – notes in the patient had a recent CT scan and the GP agrees to was four weeks later when blood results records that two years ago Mr D had been chase the hospital for an expedited scan indicated low haemoglobin (with weakness, treated for bladder cancer and later and review. weight loss and continued rectal bleeding) underwent a nephrectomy and partial A week later the patient is back in the and the patient was given a fast-track cystectomy after the cancer had spread to surgery again with back pain. This time he referral. Bloods might have been taken his ureter and right kidney. In the months that is seen by another GP – Dr K – who makes earlier but again this would not have followed the patient had regular routine a referral for an X-ray and orders bloods. changed the outcome in this very cystoscopies and a CT urogram and these Mr D is then called back two days later and aggressive cancer. were normal. Eight months ago a cystoscopy informed that his haemoglobin is low (7.7). It is also alleged Dr F should have been revealed follicular cystitis but no tumour and The patient confirms that he has noticed a aware of the missed CT scan, but there is the practice prescribed low-dose antibiotics. dip in energy and also that he has dropped no evidence in the records that the practice A further CT scan was to be carried out in a few pounds in weight. He is also still had been informed of ongoing hospital three months but this was not recorded in finding blood in his stools. On examination investigations. the patient’s primary care records. Dr K notes that Mr D is pale but not acutely A letter of response is sent to the Dr F undertakes an examination of Mr D unwell and the possibility of an abdominal claimant solicitors and the case is dropped. and records that the abdomen is soft and mass is noted. non-tender with no masses. Digital rectal A fast-track cancer referral is made and examination reveals an external pile and Mr D is seen by a general surgeon. A CT some light bleeding but no rectal masses. The scan reveals an abdominal tumour which is GP advises the patient the bleeding is likely diagnosed as a recurrence of the ureteric KEY POINTS due to haemorrhoids and that he should cancer. The patient deteriorates rapidly and ●●Even if evidence of a breach of duty continue to take laxatives as necessary and dies two months later. of care is proven it is still necessary to avoid straining. He asks the patient to make A letter of claim for damages is received establish causation. an appointment for review in 2-3 weeks but at the practice from solicitors acting on ●●Sound medical records with clinical to return if the bleeding worsens. behalf of Mr D’s wife. It alleges clinical justification are essential to a strong Three weeks later Mr D is back at the negligence on the part of Dr F in the defence. surgery complaining of lower back pain delayed diagnosis of the cancer such that it radiating down his leg but he says that the became inoperable.
18 / MDDUS INSIGHT / Q1 2017 ADVICE OUT OF SCOPE
BACKGROUND A dental hygienist – Ms B – is an associate member at MDDUS and contacts the dental advice line in regard to a prescription from a dentist to provide additional treatment out with her scope of practice. She has been asked to drill out composite covering implant screws in order to remove a superstructure of dentures and then carry out scaling of the restoration and the implants. She would then have to re-fit the appliance. ANALYSIS/OUTCOME A dental adviser responds to Ms B advising her that this procedure (beyond the scaling) would not be considered within the scope of practice of a dental hygienist. He warns her that the potential pitfalls in such a treatment plan are not insignificant and could lead to a claim of negligence and likely GDC proceedings.
KEY POINTS ●●Do not give into pressure to act beyond your competence. ●●To do so could lead to a negligence claim and GDC involvement.
COMPLAINT HE SAID, SHE SAID
BACKGROUND ANALYSIS/OUTCOME with the response but still feels there was a A letter of complaint is sent to a hospital Dr D contacts MDDUS for advice in regard lack of communication – and the ST is ward by a patient – Mr K – in regard to a to her draft response. In the letter she encouraged to reflect on this. recent in-patient stay for assessment of a states that, although considered, she did suspected neurological condition. In the not offer an MRI and her notes from the letter he claims that an ST in the various consultations confirm this. This was department – Dr D – had in an out-patient also supported by admission documents KEY POINTS appointment stated on several occasions and a letter to the patient's GP. ●●Ensure patients are provided with that he would receive an MRI scan, EMG In regard to a follow-up appointment to clear, accurate information about (electromyography) and blood tests, with discuss results, Dr D was advised by the proposed investigations/treatments, an appointment two weeks later to discuss consultant neurologist that this was not presented in a way they can the results and a referral for genetic necessary, and she regretted if this had not understand. counselling. been clearly communicated to Mr K. Her ●●Ask patients to confirm their In the event the patient did not have the notes also indicate that she informed the understanding of what is being MRI and was still waiting months later for a patient that genetic counselling would only proposed to ensure they know what to follow-up discussion of his results (which be necessary if the test results were positive. expect. were negative) and for the genetic MDDUS reviews the complaint response ●●Record what has been discussed with counselling. The hospital contacts Dr D to which is forwarded to Mr K via the hospital. patients regarding treatment plans. ask for a response to the complaint. The patient replies to say he is satisfied
MDDUS INSIGHT / 19 DILEMMA DO I ACCEPT A “FRIEND” REQUEST FROM A PATIENT? Dr Barry Parker Medical adviser and editor of Insight
NE of my regular and viewpoints both written and received such as those commonly posted on sites patients has a keen from others. The BMA states in its social like Facebook you may increase the interest in cycling – media guidance that although doctors often likelihood of ethical difficulties. which I share. “choose to divulge personal information There are steps you can take to minimise Sometimes we enjoy a about themselves during face-to-face the chances of patients contacting you via quick chat about bikes consultations with patients, they are able to social media. Take a good look at your after a consultation. control the extent and type of this self- privacy settings to make your profile as I am on Facebook and recently received a disclosure. The accessibility of content on secure as possible, and try to keep a clear OFriend request from the patient. Is it okay to social media however raises the possibility line between any professional and personal accept? that patients may have unrestricted access pages. Facebook allows users to block their Some healthcare professionals in this to their doctor’s personal information and profile from public searches which may help situation might feel that to refuse such a this can cause problems within the doctor- reduce contacts from patients. However, request would be rude. Certainly Facebook patient relationship”. care should be taken in terms of anything has now become an almost universal Ask yourself would you feel as able to you upload on your Facebook page, bearing means of communication – with over 31 discuss treatment plans or difficult in mind that social media sites cannot million users in the UK or nearly half of the decisions with a patient who has seen guarantee confidentiality whatever privacy population. How is sharing personal details photographs from your beach holiday or settings are in place. via social media any different from doing so Christmas night out? Do you think it would Should you be approached on Facebook face-to-face in a practice setting? impact the level of professional trust in regard to a medical matter the advice Well, regulators have some very definite between you? from the GMC (Doctors’ use of social views on this matter. In 2013 the GMC The two-way nature of the exchange can media) is clear cut: “If a patient contacts published updated guidance on Maintaining also create complications. The BMA states: you about their care or other professional a boundary between you and your patient “Difficult ethical issues can arise if, for matters through your private profile, you which states: “You must consider the example, doctors become party to should indicate that you cannot mix social potential risks involved in using social media information about their patients that is not and professional relationships and, where and the impact that inappropriate use disclosed as part of a clinical consultation.” appropriate, direct them to your could have on your patients’ trust in you The GMC is clear that doctors should be professional profile.” and society’s trust in the medical careful not to invite unwanted attention But what about the scenario posed profession. Social media can blur the from patients in the first place. There is above? MDDUS would recommend that you boundaries between a doctor’s personal always the risk that personal relationships decline the Friend request in this case and all and professional lives and may change the may veer into entirely unintended such contacts from patients or former nature of the relationship between a directions. Your fitness to practise may still patients on Facebook. Should the matter be doctor and a patient.” be questioned even if a relationship seems raised in a later consultation then politely Just what is meant by professional open and consensual with no obvious explain the importance of maintaining a boundaries can be widely interpreted but adverse consequences for the patient. Such strictly professional relationship. Be sure to Facebook profiles can feature some highly a relationship need not be long-term or keep a clear record of your discussion with personal information including photographs even sexual in nature to attract censure. In the patient so there will be no doubt how and details of friends and family, comments exchanging personal details with a patient you resolved the situation.
“Would you feel as able to discuss treatment plans or difficult decisions with a patient who has seen photographs from your beach holiday?”
20 / MDDUS INSIGHT / Q1 2017 ETHICS A VICE-LIKE GRIP ON VIRTUE Deborah Bowman Professor of Bioethics, Clinical Ethics and Medical Law at St George’s, University of London
HIS week I was in Warwick however, wonder about two common Secondly, I have been thinking about speaking at a conference on features of healthcare practitioners and ‘vocation’ in clinicians. I have written before the theme of Professional their work, which are offered here in the about the ambivalent and complex Vices in Modern Medicine. It spirit of inquiry and curiosity. relationship between idealism and realism was an invitation that First, I am fascinated by “ways of in healthcare, and the concept of vocation hooked me from the outset. knowing” in medicine and healthcare, and raises similar problems and questions. The speakers were the relative weight and attention afforded Might it be that the all-consuming impressive and the subject was irresistible. to different types of knowledge in making dedication in which professional and TParticipating in the conference has led me decisions. Whatever the speciality or clinical personal identities are inextricably to think explicitly about the relationship context, most consultations will involve entwined is less positive than is often between virtues and vices, specifically when multiple types of knowledge: the assumed? In professions where burnout, might virtues themselves become vices and quantitative and the qualitative, the compassion fatigue, excessive stress, are there ‘vices’ to which those working in generalisable and the particular, and the relationship breakdown and health healthcare are particularly susceptible? expert and the experiential all coalesce in a problems are regrettably more prevalent than in most other occupational groups, might the demands and expectations created by a sense of vocation contribute, “Might the demands and expectations created by paradoxically, to vice-like emotions and behaviours in some? a sense of vocation contribute, paradoxically, Of course, not everyone has a sense of vocation and some progress to vice-like emotions and behaviours in some?” through their
Aristotle (forgive me, I know this is not necessarily the stuff of columns to thrill the busy clinical professional) argued that virtues and vices are inextricably linked. By identifying spheres of specific feelings or actions, he argued that those feelings or actions in excess or deficiency would be undesirable. It was in moderation – the golden mean - that virtue was single interaction. found. For example, in the sphere of Illness itself involves chosen clinical confidence, an excess would lead to questions of existential specialty with a clear rashness or impulsive risk-taking whilst a knowledge in its impact on identity. understanding that their work is simply deficit would result in cowardice. Only in Attending to all these ways of a job. It may be a job that is valued and balance, could the virtue of courage thrive. knowledge is difficult and demanding. Yet enjoyable, but it is not integral to an Aristotle’s approach has found not to do so is to risk what Havi Carel has individual’s sense of self or identity. Perhaps contemporary empirical expression in work described as “epistemic injustice”, whereby those are the people who have an inbuilt carried out for the National Clinical an individual’s testimony or experience is resilience born of their perspective, their Assessment Service, which found that overlooked or disregarded. Moreover, even boundaries and a balance between realism practitioners in difficulty are often the evidence on which ‘gold standard’ and idealism that enables them to adapt struggling with character traits that, were clinical practice is predicated is to the unpredictable course of a career in they in balance, would be considered problematic. The matter of who decides healthcare. desirable and virtues. So it is that the what to research (and to fund), how to Vices are a difficult concept, implying as conscientious professional may, often as a design research, who participates in they do something character-based, result of external pressures, become research and the ways in which findings individual and in some way blameworthy. obsessively perfectionist or unforgivingly are, or are not, disseminated determine the Perhaps Aristotle was right to suggest that critical of others. ‘evidence’ and, of course, the ways in which most vices derive from an excess or Are there particular vices to which it is interpreted. Epistemological insight deficiency of virtue. What he was less able healthcare professionals are inclined or and interrogation of ways of knowing are to help with was articulating how we susceptible? It seems like a risky exercise to integral to virtuous practice. The absence recognise where we might be on the generalise about a group or groups of of the same may result in profession- spectrum of virtues and vices. Perhaps people by professional affiliation alone. I do, specific vices. even asking the question is a virtuous start.
MDDUS INSIGHT / 21 Addenda
BOOK CHOICE characters more OBJECT OBSCURA often than any other method and in each A is for Arsenic: of the 14 chapters of A is for Arsenic, Harkup Laennec The Poisons of takes a different novel and investigates the Agatha Christie poison(s) the murderer stethoscope By Kathryn Harkup employed – considering THIS is one of the original the origin of the substance, stethoscopes belonging to the French Bloomsbury; £9.99 paperback, 2016 its development and use physician René Théophile Laennec, Review by Jim Killgore, managing editor throughout history, how it who devised the first stethoscope in interacts with the body to 1816. It is made of brass and wood IN 1921 a review of a book published kill (or cure) and how it is and consists of a single hollow tube. by a first-time novelist appeared in obtained, administered and Laennec is regarded as the father of The Pharmaceutical Journal, which declared: detected. Harkup writes: chest medicine and – sadly ironic – “This novel has the rare merit of being “Christie never used untraceable poisons; she died of tuberculosis in 1826. correctly written”. Not exactly fulsome praise carefully checked the symptoms of overdoses, but it was a cherished compliment for the and was as accurate as to the availability and writer – a young Agatha Christie. detection of these compounds as she could be.” The book was The Mysterious Affair at The book is a delight of fascinating facts Styles and first introduced the famous fictional and stories including real-life murder cases detective Hercule Poirot. It was Christie’s that inspired some of Christie’s plots, such curiously accurate account of how strychnine as that of Glasgow socialite Madeleine was used in a murder that earned the praise of Smith, accused of putting arsenic in her the scientific journal, assuming that the author lover’s cocoa when he refused to break off must have some pharmaceutical training or their relationship and threatened to expose the help of an expert. private letters. Smith was found ‘not proven’ Indeed, Christie was something of an in the murder trial but she lived out her life expert when it came to drugs and poisons, under suspicion. The book details succinctly having trained as an apothecary’s assistant how various poisons act to disrupt the when she volunteered as a hospital nurse body’s basic biochemistry resulting in during World War I. Her extensive chemical characteristic symptomology and fatal knowledge is the subject of a fascinating decline. Arsenic for example is particularly book by research chemist and science writer efficacious, producing symptoms similar Kathryn Harkup, which was shortlisted in the to those of food poisoning, cholera and 2016 BMA Medical Book Awards. dysentery. These and other such unsettling
Photograph: Science & Society Photograph: Agatha Christie used poison to kill her facts make for an intriguing read.
1 2 3 3 4 5 6 7 Crossword 8
9 10 ACROSS DOWN 1 Location (4) 1 Palliative care pioneer, 3 Poirot creator, Agatha Cicely Mary ______(8)
11 ______(8) 2 Merger (3-2) 9 Urinal tube (7) 4 ______(or ample) portion (6) 12 10 Rounded swelling (5) 5 To become mutually
13 14 15 11 People to whom things are connected (12) lodged in trust (12) 6 Victorian ‘mannequin 16 13 Pertaining to the “back challenge’ (7)
17 18 passage” (6) 7 Currency throughout most of 15 Elevated area of tissue or Europe (4) 19 fluid inside or under the skin (6) 8 From Thessaloniki (12)
20 21 17 Impossible to control (12) 12 Senility (8) 20 Oil from the frankincense 14 Permission to receive family (5) medical treatment (6)
22 23 21 Most unwell (or best, 16 Bodily over-response to in hip hop slang) (7) infection 22 Tardiness (8) 18 Fracture (5) See answers at www.mddus.com/news/notice-board 23 Ladies’ fingers (4) 19 Skin of fruit (4)
22 / MDDUS INSIGHT / Q1 2017 Photograph: Anne-Katrin Purkiss © National Portrait Gallery D to acalmandpain-free experience. They care ofthedyingmightbetransformed love andspentlonghoursdiscussinghow Cicely visitedhimtheyimmediately fellin argument, Tasma was anagnostic. When he hadadeepknowledge ofrabbinic his grandfather was aPolish rabbi and had norelatives inEngland,andalthough dying ofcancerinArchway Hospital. He émigré namedDavid Tasma whowas St Thomas’. qualified asaladyalmonerand returned to in publicandsocialadministration. She in 1944 was awarded adegree anddiploma valuable skills. Shereturned toOxford and fortunately ledtoherlearningother injury forced hertogive upnursingbut hard-working, efficientnurse. Aback made friendsandbecameanadmired, at St Thomas’Hospital. There she Nightingale Training SchoolforNurses life foreveryone. Cicelyenrolled atthe Christianity becameasource ofstrength. fervent evangelist andfrom thistimeon a retreat inScotlandandreturned a and economics).At age20sheattended Anne’s toread PPE(philosophy, politics college thatwas theprecursor toSt crammer gave heraplaceatthe University ofOxford, aspellat After afailedattempttoenterthe Roedean, shefoundmusicacomfort. mother’s lackofaffection. was intelligent,shy andpainedby her family anupperclasslifestyle. Cicely as anestate agent and provided his of London. Her father made his fortune brothers inacountryhousetothenorth Dame Cicely Saunders Saunders Cicely Dame At theend of1947 shemetaPolish The SecondWorld War changed At thegirl’s boarding school Cicely grew upwithtwo younger medicine. essential disciplineinmodern establishing palliative care asan hospice –andwas instrumental in – foundingthefirst modern transformed care ofthedying AME CicelySaunders Innovator in palliative care inpalliative Innovator most cases. Tranquil, pain-free dyingwas achieved in well andwere more available than doctors. the doseby nurseswhoknewtheirpatients prevent pain.Sheadvocated adjustment of have morphineorally astheyneededitto changes thatshemadewas toletthepatient they were dying. Oneofthemost important not customary atthattimetotellpatients information astheyreally wanted. It was their worries andofferingonlyasmuch calmly listening to thepatients, hearing She discovered thatshehadagiftfor sister atSt Luke’s –a‘homeforthedying’. volunteered towork intheevenings asa your home”. encouragement: “Letmebeawindow in Cicely £500, probably allhehad,andthe this. OnhisdeathTasma bequeathed nurse andtreat patientscouldbest provide realised thatamore home-like placeto Cicely now hadapurpose. First she VIGNETTE Julia Merrickisafreelance writer andeditor building. Never afraid ofhard work she to raise thehugefundsforlandsand to realise herambitionforahospiceand medically qualifiedtohave theauthority was soinstrumental in founding. 2005 atSt Christopher’s – thehospiceshe teach untilherdeathfrom breast cancerin in Religion. Cicelycontinuedtowriteand DBE andtheTempleton Prize forProgress honorary doctorates, MRCP, FRCP, and director. the airywards. Cicelywas themedical but Christian prayers were saiddailyin were acceptedregardless oftheir religion enough toaccommodatebeds. Patients design was agarden andachurch spacious received itsfirst patients. Importanttothe opened inSydenham, south Londonand lives anddeaths. care ofthedying–speakingherpatients’ raised fundsandspread herphilosophy on the public.Lecture toursinAmericaalso from citycompanies, charitabletrusts and and gradually secured substantial funds relatively young NHS. Sheinspired others a hospiceoutsideofthecontrol ofthe eventually married. Marian Bohusz.Theylived togetherand pressed for a place in medical school and pressed foraplaceinmedicalschool and by thelasting love ofaPolish artist qualified asadoctorin1952. Her first of many paperswas onthecare ofthe her father. Finally, shewas rewarded Cicely was advised that she needed to be Cicely was advisedthatsheneededtobe Recognition camefrom allquarterswith In 1967St Christopher’s Hospice was Cicely continuedtoraise fundsfor friend to her and then by the death of friend toherandthenby thedeathof dying, publishedinSt Thomas’Gazette. death of a lady patient who was a good death ofaladypatientwhowas agood She gainedfurtherexperience atthe Roman CatholicSt Joseph’s Hospice, a griefthatwas augmentedby the again aPole. Hisdeathfilledherwith fell inlove withanotherdyingpatient, Hackney. Now inherthirtiesandsingle, she (1918-2005) MDDUS INSIGHT /23 advert_2017 version 08/03/2017 20:50 Page 1
MDDUS Practice Managers’ Conference 2017
Book your place now for early bird rates Fairmont, St Andrews Rates frozen at 2015 prices 30 November and 1 December 2017
MDDUS Risk Management invites you to join us at the 2017 Practice Managers’ Conference at the Fairmont, St Andrews on 30 November to 1 December 2017. Book now and benefit from our early bird rates.
DAY 1: RETURN TO BLEAK PRACTICE DAY 2: INTERACTIVE WORKSHOPS Back by popular demand – join the healthcare team Delegates can select from a range of interactive of our Bleak Practice series as another dramatic day workshops, and engage in discussion around a range unfolds with a forgotten locum, out-of-date of risk topics, relevant to your own practice. Each procedures, poor communication and the suggestion session explores a current risk area within general of an assault. The 2017 conference will focus on practice and will allow delegates to share best another filmed dramatisation of events based on practice in order to mitigate these risks. actual MDDUS cases. A programme of masterclasses will then explore a range of related medico-legal risk areas. So just sit back, watch, analyse, share and be thankful it’s not you!
l For further information and to request a conference flyer contact Ann Fitzpatrick on [email protected] or at 0333 043 4444 l Early bird rates – available until 30 June 2017