Medicine at a Glance

Chapter 1

How to be a medical student

In 1948 in Geneva the World Medical Association drew up a modern version of the oath.

At the time of being admitted a member of the medical profession:

I solemnly pledge myself to consecrate my life to the service of humanity;

I will give my teachers the respect and gratitude which is their due;

I will practise my profession with conscience and dignity;

The health of my patient will be my first consideration;

I will respect the secrets which are confided in me, even after the patient has died;

I will maintain by all the means in my power, the honour and the noble traditions of the medical profession;

My colleagues will be my brothers;

I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;

I will maintain the utmost respect for human life from the time of conception; even under threat I will not use my medical knowledge contrary to the laws of humanity.

I make these promises solemnly, freely and upon my honour.

Good doctors

Medicine can seem a large and daunting subject, not only for reasons of intellectual rigour, but also because so many facts need to be learnt. In learning (and practising) medicine, it is vital to realize that facts alone are not enough! Good physicians have the following characteristics:

A strong humanity, i.e. an interest in human beings.

An interest in disease, its causation and treatment.

An ability to communicate with patients, to obtain a correct and full understanding of their problems and, at the same time, to give accurate information sympathetically about the diagnosis, treatment and prognosis. Good physicians are non-judgemental, empathetic listeners.

An ability to examine patients and elicit abnormal physical signs.

An ability to marshal the facts into a coherent story and present them clearly to relevant parties, i.e. ‘case’ presentation of the history, examination and structured summary, a probable and differential diagnosis, with plans for further investigations, and treatment.

An up-to-date knowledge base so that appropriate management (diagnosis + treatment) plans can be made.

An ability to realize when knowledge/skills are deficient and an ability to learn in response to new knowledge, ideas, etc., from the best source available.

An ability to acknowledge errors and learn from them. It is important to be open with patients and colleagues as soon as errors/misjudgements are recognized.

Appropriate technical skills in diagnostic and therapeutic procedures.

An understanding of economic, social and cultural, political and health-care systems so that the best possible help can be delivered to patients in the most timely fashion. If a deficiency in one or other of these systems damages patients, physicians should seek improvements.

Excellent managerial and interpersonal skills, with personal, financial and intellectual probity.

Health care spend related to outcome—different countries can spend the same amounts with very different outcomes, as shown in this graph, where health care expenditure is plotted against health care system performance

(From The World Health Report 2000: health systems: improving performance)

Hippocratic oath and the modern perspective

High ethical and moral standards are an imperative for good practice – the Hippocratic oath and its modern successors aim to codify behaviour. They are guidelines to best behaviour, although medicine is more complex than implied by such phrases. However, regardless of phrasing, the implication that physicians should have the highest ethical, moral and technical standards stands. Society respects physicians, and consequently physicians face social as well as other penalties if performance is poor.

Health-care systems

Health-care systems are imperfect compromises among society’s aspirations, wealth, humanity and individual needs (see figure above and Table 1.1). It is vital to understand how any system works, so that it can be used in a patient’s best interests. If individual or organizational failure occurs, this should be highlighted to the appropriate responsible individuals, agencies or, rarely, the media.

Table 1.1 The three fundamental objectives of health systems.

How to learn

Becoming a doctor means acquiring a set of skills, knowledge and values. How this is best done depends on the individual and the medical school. However, concentrating on one area/skill to the exclusion of others is counterproductive. Facts alone do not make a physician, and nor do learning or technical skills alone. It is the right combination of the above list that ‘maketh the physician’. Students need to determine the right balance for themselves, bearing in mind their individual aptitudes, and their medical school’s doctrine. A reasonable approach is the ‘patient-centred’ one, approached in a ‘problem-based’ fashion, supplemented by dedicated learning sessions (e.g. seminars, lectures, etc.); students should:

See patients, so learning communication skills.

Ascertain symptoms and signs, so learning clerking and examination skills.

Formulate a diagnosis or differential diagnosis, so learning diagnostic skills. The first part of this book aims to aid in diagnosis, i.e. the turning of symptoms and signs into diseases with names.

Present findings to attending physicians, so learning presentation skills.

Formulate investigation and treatment plans, so refining diagnostic and therapeutic skills. The second part of this book aims to help here.

Observe patients’ progress, so determining whether the original diagnosis and therapy were correct. This feedback is an essential component in improving diagnostic and therapeutic skills.

Deficiencies in knowledge and technique are identified at each stage and corrected using information/skills training obtained from books and libraries, electronic resources, physicians, other health-care professionals, patient groups, skills workshops, learning sessions, etc.

Some medical schools have a structured approach to this process, with substantial guidance at each stage; others are less formalized – which appeals more depends largely on you. Which is better is unclear.

How to behave on the wards

It is particularly important when performing ward work to:

Introduce yourself to the ward staff as well as the patient, so that they know who you are and why you are there.

Respect patients’ privacy, and their right to refuse to see you.

Ask for consent before seeing a patient.

If you undress a patient to examine him or her, help him or her to dress again once you have finished.

Be courteous to nurses and other members of staff (e.g. physiotherapists, ward cleaners, cooks, etc.) at all times.

Be punctual in attending teaching sessions – you will find that your teachers, who are often busy clinicians, are often late; this is not deliberately done to infuriate you, rather it reflects how hectic their lives are. It is reasonable to wait c. 10 min, before ‘bleeping’ to remind them of the session.

Write in the notes: different medical schools have different policies on this. Often, however, senior medical students are expected to write in the notes. This is a legal document, so write legibly, never use pejorative phraseology, and sign your name, along with your status as student, legibly at the end. Never amend the record at a later time, unless you clearly identify who you are and when the alterations occurred.

Enjoy yourself!

Chapter 2

Patient confidentiality

The duty to respect patient confidentiality stems mainly from two ethical principles. The first is ‘respect for autonomy’, or the right for an individual to have control over his own life, or in this context to have control over who has access to personal information about him. The second is based on the idea that there is a duty to act to bring about the best consequences, which in the context of medical confidentiality means maintaining public trust in the medical profession. Breaching patient confidentiality could result in a loss of trust, resulting in patients feeling less inclined to be open about their condition and symptoms and ultimately leading to a lower standard of health care.

From a legal perspective, patient confidentiality is generally seen from a public interest perspective rather than from a private interest perspective. Although the Human Rights Act 1998 indicates that there is also a private right to confidentiality, in practice this makes little difference because of the considerable weight given to the public interest in maintaining patient confidentiality. The legal duty to respect patient confidentiality however is not absolute, and making decisions about whether or not to breach patient confidentiality involves balancing the consequences of breaching confidentiality with the consequences of not breaching confidentiality: i.e. balancing the public interests.

Confidentiality has not been breached if the patient has given valid consent for the release of the information. If the patient has not given consent and could be identified, either by being named or as a result of information being divulged, then there has been a breach of confidentiality.

Consent to disclosure of confidential information (see Chapter 3)

There are some circumstances where consent to sharing a patient’s medical information can be implied. For example, it is generally accepted that information about care of a patient will be discussed within the medical team. Express consent would not normally be required. However, information discussed within a medical team should be on a need to know basis.

In most other circumstances, express consent should be obtained unless there is a legal obligation to disclose the information, or unless the medical professional believes that the public interest in disclosing the information requires it (see below).

If an adult patient is incompetent to give consent, doctors should act in the patient’s ‘best interests’. In the case of a minor, if he is over 16 years he would generally be assumed to be competent to give or refuse consent for disclosure of information. Minors below 16 are assumed not to be competent to give or refuse consent unless they are assessed as being ‘Gillick competent’ (see Chapter 3). It would normally be the case that doctors should inform parents of medical treatments for those under 16 years. However, if the child refuses consent to inform parents and is ‘Gillick competent’ and it is in his best interests not to inform parents, then the doctor may withhold information from the parents.

Handling patient’s medical records and data

Patient’s medical records should normally only be released with the consent of the patient or in response to a court order. The police do not have an automatic right to look at medical records, which should only be released in response to a court order or if the medical professional considers it to be an acceptable breach of confidentiality (see below). A coroner, however, does have the right to access a dead patient’s records in order to go about their duties.

When using patients as case studies in publications such as clinical papers or textbooks, consent should be sought from the patient where possible. If this is not possible, extra care should be taken to ensure that the patient cannot be identified.

Breaches of patient confidentiality

Unacceptable breaches of patient confidentiality

The most common situation in which medical professionals wrongfully breach confidentiality is as a result of carelessness. For example discussing famous patients at dinner parties or leaving patient notes on buses. The General Medical Council would regard such breaches of confidentiality as serious professional misconduct.

Situations where there is a legal obligation to breach patient confidentiality

Some examples of situations where there is a legal obligation for the medical professional to breach patient confidentiality are in the context of:

Notifiable diseases.

Termination of pregnancy.

Births.

Deaths.

Details of anyone alleged to be guilty of an offence under the Road Traffic Act 1988 (on request by police only).

Court orders.

However, these breaches should only be made to the relevant authorities.

Situations where the medical professional may but is not obliged to breach patient confidentiality

These situations involve weighing up the public interest in disclosure versus non-disclosure. The General Medical Council offers detailed guidance in this area and this guidance carries a lot of weight with the courts (see www.gmc-uk.org). Three key points from the guidance are as follows:

1. Disclosure of confidential information without consent would normally be justified in order to prevent risk of death or serious harm. (Note that this will usually be limited to harm to people, not property for example.)

2. Disclosure should only be made to an appropriate authority.

3. The patient should normally be informed before disclosure of their information.

Further reading

Hope, A., Savulescu, J. & Hendrick, J. Medical Ethics and the Law. The Core Curriculum, 2nd edn. Elsevier, Oxford, 2008.

Chapter 3

Consent

In modern health care, it is acknowledged that patient consent is required before any medical intervention is carried out. This would normally be express consent. However, in certain circumstances consent can be implied, for example when a patient holds out his arm for blood to be taken. The importance of consent stems from the ethical concept of autonomy: the right to have control over our own lives. This concept has been incorporated into English law as three criteria that must be met for consent to be valid. These criteria are:

1. That the patient has been informed as to the purpose, nature, risks and benefits of the medical procedure.

2. That the patient is competent (has capacity) to understand this information.

3. That the patient has given voluntary consent, i.e. the patient has not been coerced.

In order to maximize autonomy, patients should be as much in control as possible throughout the course of any medical intervention. This also means that they can withdraw consent at any time. This is important legally in relation to the consent form. The consent form is not a contract. Therefore it is illegal (battery – see below) to proceed with a medical intervention if the patient withdraws his consent, even if he has previously signed a consent form.

For patients to be ‘informed’, they should be given general information about the purpose and nature of the proposed course of action. Failure to do this could result in the patient making a claim for battery (touching a person without consent). Information should also be given about any reasonable alternatives, risks and benefits, including common and serious side effects, otherwise a claim could be made for negligence. Even if a patient prefers to know nothing about the proposed procedure, it would be unwise to proceed without informing him or her of the key aspects of the treatment. The General Medical Council offers guidance on the provision of information to patients on their website www.gmc-uk.org.

In English law, a person over the age of 16 is assumed to have capacity, i.e. be competent, unless it can be shown to the contrary.

Mental Capacity Act 2005

The Mental Capacity Act 2005 outlines the procedure for determining capacity and how to act when a patient over the age of 16 lacks capacity. Under the Act (Part 1 Section 3(1)), a person lacks capacity if he is unable to:

understand the information relevant to the decision, or

retain that information, or

use or weigh that information as part of the process of making the decision, or

communicate his decision (by any means).

If a patient is shown to lack capacity, then those caring for him must attempt to enhance his capacity insofar as this is practical (Part 1 Section 1(3)). Note that ‘capacity’ refers to the ability of the patient to make a specific decision, not to the patient as a whole. In addition, a patient does not lack capacity simply because he makes an unwise decision (Part 1 Section 1(4)).

Under the Mental Capacity Act, patients who lack capacity (and have not appointed a Lasting Power of Attorney or made an Advance Decision – see below) should be treated in their ‘best interests’ (Part 1 Section 4). The Act specifies some factors that should be taken into account in making a decision about their best interests. The General Medical Council also offers guidance as to how to determine ‘best interests’ (see www.gmc-uk.org).

Under the Mental Capacity Act (Part 1 Section 9), a Lasting Power of Attorney can be appointed by a person who has capacity to make medical and non-medical decisions on his behalf at a future time when he no longer has capacity. The Act also allows Advance Decisions to be made, by persons aged 18 or over who have capacity, to refuse treatment at a future time when they lack capacity (Part 1 Sections 24–26). An Advance Decision can relate to life-sustaining treatment if it is in writing and specific to that effect and if it is appropriately signed and witnessed.

In Scotland, although the approach to determining capacity and treatment of those without capacity is similar, the law differs slightly and is covered by the Adults with Incapacity (Scotland) Act 2000.

Consent and minors (<18 years old)

When dealing with minors and consent, it is important to remember that in an emergency situation when the minor and/or those with parental responsibility cannot or will not give consent, the medical professional should normally act to prevent death or serious harm to the patient.

Minors aged 16 or 17 years are presumed to have capacity to consent to medical treatment unless it can be shown otherwise. Those with parental responsibility (usually the parents) can also give consent. If valid consent for the relevant procedure has been given either by the minor or by any person with parental responsibility then the doctor has consent to proceed (without risk of battery). Doctors (and those with parental responsibility) have a legal obligation to act in a minor’s best interests. If neither the patient concerned nor a person with parental responsibility consents, and the doctor judges that the treatment is in the patient’s best interests, then advice should be sought from the courts.

Children aged less than 16 are presumed not to have capacity to consent unless they demonstrate that they are ‘Gillick competent’, i.e. have reached a level of intelligence and understanding sufficient to understand what is being proposed. The criteria on this are vague and if there is doubt it would be wise to obtain consent from a person with parental responsibility. The legal position for refusal of treatment by Gillick-competent children is the same as for competent 16 or 17 year olds.

Consent should be obtained from at least one person with parental responsibility for minors below the age of 16 who are not Gillick competent. If no one with parental responsibility gives consent and failure to carry out the procedure would be significantly against the child’s best interests then doctors should apply to the court for a ‘specific issue order’. In an emergency, doctors should act to save the child from death or serious harm.

Further reading

Hope, A., Savulescu, J. & Hendrick, J. Medical Ethics and the Law. The Core Curriculum, 2nd edn. Elsevier, Oxford, 2008.

Chapter 4

Relationship with the patient

Your relationship with your patient is the key determinant of your effectiveness as a clinician. Why is this? You need the patient to give you all the information necessary for diagnosis. You must then communicate this decision and any uncertainty surrounding it, to the patient in language they understand, and you must convince them that the treatment you recommend is appropriate and effective. None of this will occur unless you have established an effective relationship with your patient. Different patients require different techniques to develop relationships; with some you can be informal and quite chatty, with others you may need to be much more formal, and keep to the point, some appreciate humour, and others find it unprofessional. Develop your style, but modify it for individual patients. So, how do you develop such a relationship? In many ways, though some tips include:

Listening to your patient, largely letting them do the talking, albeit guided by yourself to elaborate on certain areas and to move on from others.

Engaging in eye contact.

Appropriate use of non-verbal gestures, such as smiling.

Appropriate use of asides – ‘isn’t it sunny today’, etc. – in a culturally sensitive manner.

Minimizing the chance of interruptions and other distractions (such as bleeps going off).

Where relevant, asking a relative (in the presence of the patient) to comment on their views of the patient’s illness.

Dressing appropriately; in years gone by, most patients expected consultants to wear suits. This era has largely passed – consultants attending patients in the middle of the night not infrequently wear jeans, so do adjust your attire according to the setting and time. However, you should be certain your clothes are smart and clean, and that you follow the dress code of your institute (in the UK National Health Service this includes no jewellery and only short sleeve shirts) which is there to minimize your risk of transmitting hospital-acquired infection.

When meeting a patient, establish their identity unequivocally (ask for their full name and confirm with their name band, ask for their date of birth, address, etc.) and be certain that all records, notes, test results, etc. refer to that patient, as not infrequently results find there way into the wrong patient’s notes.

Often you may wish to shake their hand, ‘My name is Dr Davey and you are …’? Or ‘Your name is …’? ‘Your date of birth is …’?, ‘Your address is …’? Tell them your name, your title and job and what you are about to do. For example:

I am Dr Davey, a consultant specializing in heart medicine and I’ve been asked to try and work out whether your heart is working properly. I’m going to spend about half an hour talking to you about your medical problems, and then I’ll examine you thoroughly. After that I’ll explain to you what I think the matter is and what we need to do to help you.

Or you could say, ‘I am Patrick Davey, a medical student, and I’d like to ask you some questions about your illness if I may’.

Always be polite, be respectful and be clear. Remember the patient may be feeling anxious, unwell, embarrassed, scared or in pain. If you detect these emotions, ask the patient to elaborate on their fears – unless you know what is really worrying them, you will not have a satisfactory consultation.

You should be gathering information and observing the patient as soon as you meet them: history taking and examination are not distinct, sequential processes, they are ongoing. Your best clues to the presence of thyroid disease, acromegaly, Cushing’s syndrome, alcohol dependency and many other conditions, is found from the patient’s appearance in the first few seconds of the consultation, so start thinking diagnostically the moment you see the patient, not just at certain times in the consultation.

Sequence of the consultation

Though your diagnostic processes will be working continuously throughout the consultation, the usual order is history, examination, explanation to the patient of their illness and then, crucially, to ask the patient if they have questions they wish addressing.

Privacy

Ensure that there is privacy (this is not always easy in busy hospital wards: make sure curtains are properly closed; see if the examination room is free).

Language

Establish whether the patient is fluent in the language you intend to use and, if not, arrange for an interpreter to be present. Often a family member will be willing to interpret, but, on grounds of confidentiality, you should establish that the patient is happy to discuss their problems via this relative.

Relatives, friends and chaperones

Establish who else is with the patient, their relationship with the patient and whether the patient wishes for them to be present during the consultation. Ask if the patient wishes for a chaperone to be present during the examination; this may be appropriate in any case.

Remember that the patient is the most important person in the room! Remember that all information you gain from your patient or anyone else is confidential. This means that information about the patient should only be discussed with other professionals involved in the care of that patient. You must ensure that patient discussions or records cannot be overheard or accessed by others.

Some guidelines for the use of chaperones

A chaperone is a third person, (usually) of the same sex as the patient and (usually) a health professional (not a relative).

When asking a patient if they would like a chaperone to be present, ensure they know what you mean; for example, ‘We often ask another member of staff to be present during this examination, would you like me to find someone’?

If either the patient or the doctor/medical student wishes a chaperone to be present then the examination should not be carried out without one.

Record the presence of a chaperone in the notes – this is vital if you are to fully protect yourself medicolegally.

A chaperone must be present for intimate examinations by doctors or students examining patients of the opposite sex (vaginal, rectal, genitalia and female breast examination).

Hand washing and hospital-acquired infection

In modern health-care systems there is considerable and appropriate concern about hospital-acquired infection; the hands of staff are the commonest vehicles by which microorganisms are transmitted between patients and hand washing is the single most important measure in infection control. So, always ensure your hands are washed, whether using alcoholic rubs or medicated soap is less important than that the hands are actually washed. Hands should be washed before each patient contact, and also between wards.

You should also ensure that you minimize the risk of your clothes transmitting infection by not wearing jewellery, long-sleeved shirts or a tie, and ensuring that your stethoscope is disinfected regularly.

Chapter 5

History of presenting complaint

The history of the presenting complaint is the most important part of the history and examination. It not only provides the information necessary to create the differential diagnosis but it also provides vital insight into the features of the complaints most important to the patient. It should receive most time during a consultation.

The history obtained should be recorded and presented in the patient’s own words, not be masked by medical phrases such as ‘dyspnoea’, ‘myocardial infarction’, etc., which may disguise the true nature of the complaint and important nuances. As you listen to the presenting complaint, continually ask yourself ‘what does this tell me about the diagnosis?’ Remember it is the patient’s problems that you are trying to understand and record in order to establish diagnoses. Do not force or overinterpret what the patient says to fit into a particular diagnosis or symptom, nor simply record what the patient reports other doctors have said.

If a clear history cannot be obtained from the patient then the history should be sought from relatives, friends or other witnesses. It may be appropriate to seek corroboration of features of the history, such as alcohol consumption or details of a collapse, always bearing in mind the principles of medical confidentiality.

Let the patient talk

The presenting complaint should be obtained by allowing the patient to talk without interruption, if possible. This may be initiated by asking an open question such as:

‘Why have you come to see me today?’

‘What’s the problem?’

‘Tell me what seems to be the trouble.’

‘How long have you been ill for, and what have you noticed over this time?’

The patient should always be allowed to talk for as long as possible without interruption. Small interjections such as ‘Go on’ or ‘Tell me more’, may help produce more information from a reticent patient.

It may be possible to enable patients to elaborate on areas of medical interest, without directing the history, by indicating these are areas you are interested in. One way to do this is to repeat the last phrase that a patient has voiced in a questioning way. For example, to ‘I’m finding breathing more difficult’ you would respond ‘Breathing more difficult?’

More specific questioning

After this, open questions should be addressed to reveal more detail about particular aspects of the history. For example, ‘Tell me more about the pain’, ‘Tell me in more detail about your tiredness’ or ‘You’ve said that you’ve been feeling tired?’

More direct questions can then be addressed to gain information about the chronology and other detail of the complaints; for example, ‘When exactly did you first notice the breathlessness?’, ‘Which came first, the chest pain or the breathlessness?’ or ‘What exactly were you doing when the breathlessness came on?’ Sometimes patients find it difficult to accurately recall chronology – in this situation, establish when the patient was last completely well, as this will often tell you for how long they have been ill.

Directed questions can then be addressed to establish diagnostically important features about the complaints; for example, ‘What was the pain like?’, ‘Was the pain sharp, heavy or burning?’, ‘What made the pain worse?’, ‘Did breathing affect the pain?’ or ‘What about breathing in deeply?’

Other aspects of the history (e.g. past medical history or social history) relevant to the presenting complaint, though they are conventionally analysed separately, commonly arise during discussion of the presenting complaint and can receive detailed attention at this point.

In some settings, such as during resuscitation of a very ill patient, very focused or abbreviated questioning may be appropriate.

Premorbid functional status

It is crucial to ascertain this. This information is essential in managing the patient, and also for conveying the patient’s history to colleagues. This is because:

Usually, you aim to restore a patient’s health to that immediately prior to an illness – knowing their premorbid state means that you know what you are aiming to achieve.

Functional status is a most important predictor for life expectancy. If a patient’s premorbid functional status is poor, then the premorbid life expectancy is usually not good. This information can then be factored into how intensively you should investigate and treat their current illness.