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Duties of a Doctor
Knowledge – keep up to date
Skills – keep up to date
Performance – provide a good standard of care
Safety – take prompt action if patient safety, dignity or comfort is compromised
Quality – protect and promote health of patients and the public
Communication – treat patients politely and with respect, provide the correct and
essential information in a way they can understand
Partnership – work in partnership with patients
Teamwork – work with colleagues in the ways that best serve patients’ interests
Maintaining trust – be honest, open and act with dignity, never discriminate or
abuse patient’s trust
General Practice
They work with patients in the community
There are two providers of primary care :
-GPs
-community health services
Together they provide over 90% of all health care in the UK
The WHO have characterised general practice as :
-general (not exclusive, limited or restricted)
-continuos (based on knowledge of the individual)
-comprehensive (integrated care across several interfaces)
-coordinated (involving care managers and appropriate referrals)
-collaborative (multidisciplinary team approach)
-family orientated (health needs of individuals)
-community orientated (health needs of population)
GPs provide personal, primary and continuing medical care to individuals and
families
Patients may be seen in their homes, consulting room or sometimes in hospital
They accept responsibility for making an initial decision on every problem a patient
may present and then consult with specialists if appropriate
They may intervene educationally, preventively and therapeutically to promote
patients’ health
The diagnosis will be a mixture of physical, psychological and social problems
GPs are independent contractors (not on a salary from the health board but are self
employed)
They employ many of the staff that work in the practice (receptionists, nurses etc)
There are “attached” staff such as health visitors and district nurses who are
employed by the local health care trust but look after patients in a particular practice
All of these people make up the primary health care team
Each member has an important role in the efficient running of the practice
Receptionists spend upwards of 40% of their time in direct patient contact
They are also responsible for keeping medical records up to date
Practice nurses share the care of patients with chronic diseases and provide
monitoring and education of these patients
They also carry out triage, minor illness/accident clinics, special clinics and cervical
smears
Some practices also employ Nurse Prescribers or Advanced Nurse Practitioners who
can see patients, examine and prescribe on their own
Hospice Care
Physicians can not always cure illness, but it is almost always possible to help
patients significantly
Examples vary from use of insulin in diabetes to analgesia to control pain, even if the
cause of pain cannot be removed
Even if the underlying pathology cannot be cured, many of the associated problems
can be addressed
This requires a multidisciplinary approach with each member of the team taking a
lead role depending on the patient’s problems
Hospices are charities and are funded by raising money themselves
They only receive about 30% of their budget from the government
Verbal Communication
There are many different types of questions :
-open ended
-focussed
-closed
-leading
-compound
-indirect
Open ended quesstions are ones which allow patients the maximum scope in
answering
They cannot be answered with a simple yes or no
They invite more information
Eg. “tell me about your problem”
Focussed questions define the area of enquiry more precisely but allow some scope
in answering
Eg. “what sort of chest pain is it?”
Closed questions can only be answered yes or no
Eg. “how many children do you have”
Leading questions implies a specific answer and should not be used as responests
tend to agree passively with the interviewer
Eg. “you don’t sleep well do you?”
Compound questions ask more than question at a time
This sends a mixed message
The answer is ogten confused or not complete
Eg. “do you need to take sleeping pills to help you sleep but feel tired in the
morning”
Indirect questions are rhetorical statements which imply that a response is expected,
without grammatically being an actual question
Eg. “in these situations some people find it difficult to get off to sleep”
As well as questions, laguage is used for other purposes :
-social exchanges
-facilitation
-repitition or restatement
-confrontation
-clarification or interpretation
-reflected statements or questions
-judgemental statements
-reassurance, explanation, instructuion or advice
-indirect statements or requests
Social exhanges establish and maintain rapport
Facilitation is any resposne which encourages the patient to continue eg. “go on”
Repitition is repeating all or part of what a patient has said eg. “so you have difficulty
getting off to sleep?”
Confrontation mena sconfronting the patient with an observation about themselves
eg. “you look worried”
Clarification is used to clarify what a patient has said
Reflected statements are responses which allow the patient to know that their
feelings have been recognised and accepted to establish rapport eg. “I can
undertsnad this must be worrying for you”
Judgemental statements are ones which clearly state the value judgements of the
doctor eg. “anyone who smokes is foolish”
Reassurance is often used towards the end of a consultation
Indirect statements are widely used in everyday conversation eg. Saying “it’s cold in
here” may often lead another person to shut the window
Rapport
In listening to patients it is very important to both really listen and to let the patient
know you are listening
This establishes trustu and makes it more likely that the patient will confide
From a patients’ point of you view, their feelings are often as important as the
diagnosis or any other medical aspects
Professionalism
Trust is central to the relationship between patient and doctor
Medical professionalism is described as the commitment to using knowledge, clinical
skills and judgement into the service of protecting and restoring human well-being
In day to day practice doctors are commited to :
-integrity
-compassion
-ltruism
-comtinuous improvement
-excellence
-team work
The GMC has 5 core functions :
-licenses doctors
-operates discplinary procedures
-keeps a register
-sets standards for the profession
-sets standards for medical education
All doctors have a revalidation folder and are appraised annually in all competencies
of their pratice
The results of these appraisals is reviewed by the GMC every 5 years
Problem doctors will be managed locally in the first instance
Serious cases will be referred to the GMC
Many organistations and professional groups have codes of pratice
They can be aspirational and visionary or concrete and behavioural
Ethical codes require a regulatory framework for professions and may be regarded
as serving to protect a profession
The codes tend to be :
-specific rules
-short list of guiding principles
-basic principles with extra information and explanatory guidance
The duties of doctor by the GMC states that as a doctor you must :
-make the care of your patient your first concern
-treat every patient politely and considerately
-respect patients’ dignity and privacy
- give patients’ information in a way they can understand
-respect the right of patients to be fully involved in decisions about their care
-keep your pfoessional knowledge and skills up to date
-be honest and trustworthy
-respect and protect confidential information
-do not allow personal beliefs to prejudice patient care
-avoid abusing position as a doctor
-act quickly to protect patients from risk if you have good reasono to believe
you or a colleague may not be fit to practice
-work with colleagues in a way that best serves patients’ interests
Reflection is the process of looking back on an event and learning from it
The process of reflection involves :
-learning from experience
-conscious activity
-undertsnading something that has happened in a different way
It is a cognitive process and can be enhanced and controlled
It can occur at any time – even before an event to challenge a particular perception
and enhance learning
Undertsnading personal values and beliefs and their influence on a particular
situation is a crucial part of reflection and life long learning
Reflection must change future responses and improve practice
Documenting reflection is essential
Different people reflect differently on similar situations
Reflection not only increases one’s self-awareness, it also can influence competence
There are many models of reflection
Gibbs reflective cycle is often used :
Doctors have a duty not to disclose information to a third party without the patient’s
consent
But there are expceptions including :
-colleagues assissting with patient care
-information required by a court
-information required by police that is necessary to assist in prevention,
investigation, detection or proescution
-disclosure that is justified in public interest (where others are at risk from
serious harm)
Police officers have a right to speak to the patient unless it interfers with the
patient’s care
If a blood test wants to be done, consent is required
If a patient is lacking capacity and there is no welfare guardian, the doctor primarily
responsible for the medical treatement shall have authority to do what is
reasonable to safeguard or promote the physical or mental health of the adult
Futility vs Utility
Care in medicine can conform to any of these models :
-curative
-research towards cure
-symptom management
These are not mutually exclusive
They can be viewed as a spectrum where failure to cure does not make a failure of
medicine
A treatemtn is likely to be considered futile if it is unlikely to be successful
Doctors have no obligation to provide treatment if they believe it to be futile
Futility of treatment is often value based and patients may have different attitudes
to doctors – consideration should be made of the possible psychological benefits of
treatment
A patient’s decision to withhold consent does not need to be rational from the
doctor’s point of view
consent may soemtimes be implied if a patient co-operates with the proposed
examination or treatment (however, the presumption is unsafe beyond minor or
routine treatments)
Patients may not wish to receive full details of the clinical picture despite being
entited to it
Abortion
The Abortion Act 1967 creates statutory immunity to criminal prosecution for
medical practitioners who carry out termination of pregnancy under the conditions
specified
There must be an agreement between 2 doctors that one of four specified grounds
for abortion is satisfied :
-the pregnancy has not exceeded its 24th week and that the continuance of
the pregnancy would involve risk or njury (greater than if the prengancy was
terminated) to the physical or mental health of the pregnant woman or any
exisintg children of her family
-the termination is necessary to prevent grave permanent injury to the
physical and menta l health of the woman
-continuance of the pregnancy would involve risk to the life of the pregant
woman greater than if the pregnancy was terminated
-there is a substantial risk that if the child were born it would suffer from
such physical or mental abnormalities as to be seriously handicapped
The Act says that, excpet in an emergency, the termination must take place in an
NHS hospital or approved clinic
In the 2nd, 3rd and 4th of the grounds listed, there is no gestational time limit
In emergency situations of grave or permanat injury or loss of pregnant woman’s
life, or serious handcap of child, terminations are lawful at any point beyond the 24
weeks
In the first two grounds specified, the assessment of health risk may take into
account the woman’s environment
Statistacally, there is less risk to health from undertgoing a termination prior to week
13 of pregnancy than from giving bith
Therefoore, terminations up to the end of week 12 are capable of being viewed as
satisfying the first of the specified grouns for abortion (sometimes called ‘social’
ground for abortion)
The act does not place a duty on helth care professionals to partcipate in
terminations if they hold an objection, excpet in emergency situations
The father of an unborn child has no legal right to prevent the pregnant woman from
having an abortion
Science in Medicine