Professional Documents
Culture Documents
HANDBOOK
An essential handbook
for anaesthetic trainees
FOREWORD CONTENTS Please click on the buttons to view
Welcome to the eleventh edition
of the Group of Anaesthetists in
Training Handbook. The Association of Anaesthetists of Great Britain
and Ireland & Group of Anaesthetists in Training 6
Australia and GASACT
Canada
59
61
The Royal College of Anaesthetists 8 New Zealand 62
Medical recruitment, training and working patterns have undergone
KATE O’CONNOR The General Medical Council 9
major change in the last few years, and our speciality has not
GAT Honorary Secretary The British Medical Association 10
emerged unscathed. Thankfully, due to the innovative approach
and the already well-organised training structure in anaesthesia,
we have been better prepared to weather these storms than many The consultant post 64
other medical specialties. Evolution continues however, with the Ten top tips for your first year as a consultant 65
establishment of the Faculty of Intensive Care Medicine (FICM) Anaesthetic training, competencies
overseeing single and dual CCT training in ICM, the Shape of and assessments 13
Training Review investigating changes to postgraduate medical Less Than Full Time training 16
education and the establishment of Local Education and Training Applying for training in England 18
Getting started in research 66
Boards (LETBs) to replace the traditional deanery structure in parts Applying for training in Wales 19
What is an academic clinician? 67
of the UK; and all this is taking place against a backdrop of great Applying for training in Scotland 20
economic austerity and health policy reform. Applying for training in Northern Ireland 20
Applying for training in Ireland 21
CLAIRE GILLAN
GAT Elected Committee
The aim of this handbook is to help trainees negotiate their way Out of Programme Training / Research 22
Member along the many and varied paths available in anaesthesia - from Anaesthesia training and the armed forces 23 Conduct an audit 71
appointment at CT1 or ACCS level to their CCT, and finally to a Logbooks, confidentiality, security Design a study 72
consultant appointment in their chosen field. There is a wealth of and data protection 25 Write a paper 73
well-researched information and advice contained within these Logbooks – a trainee’s opinion 26 Please the editor 74
pages, written by those who have been there and done it before. Annual Review of Competency
Whether you want to conquer the world of academic anaesthesia Progression (ARCP) 27
or work among refugee populations on the other side of the globe, The FRCA examination 28
you will find advice in this resource to aid you on your journey. Keeping out of trouble 77
The pregnant anaesthetist 78
The handbook is moving with the times and this year will be Training with a long-term illness 81
produced as a fully functional online resource for the first time - Returning to practice following a prolonged absence 82
Core Training 31
please take a look at www.aagbi.org/professionals/trainees. Members’ wellbeing 83
Acute Common Core Stem (ACCS) 32
The use of social media 84
We hope you find this collection of articles valuable; as ever,
the GAT Committee appreciates your comments and feedback.
Good luck with the challenges that lie ahead, and we hope that this
Acknowledgements:
will help you on your way to a happy and fulfilling career. ENT, head and neck & difficult airway 34
Bariatrics 35 Medical protection organisations 86
We would like to thank the Medical Protection
Society (MPS) for their generous support Cardiothoracics 36 Consent and UK legislation 87
as sponsors of this publication. MPS is Best wishes, Day surgery 38
the leading provider of comprehensive Intensive care medicine 39
professional indemnity and expert advice to KATE O’CONNOR Leadership and management opportunities 41
doctors, dentists and health professionals GAT Honorary Secretary
around the world. MPS has a wealth of Medical education 42 What consultants really earn and how do they do it 90
experience and expertise in helping doctors Medico-legal expert 44 Financial planning and pensions 91
and other healthcare professionals with CLAIRE GILLAN Neuroanaesthesia 44
ethical and legal problems that arise from GAT Elected Committee Member Obstetrics 46
their practice. As a responsible organisation, Ophthalmics 47
MPS believes in the value of education
and risk management. It is an integral part
Paediatrics 48 Abbreviations 94
of the development of every healthcare Pain medicine 49
professional. Plastics and burns 50
Pre-hospital emergency medicine 52
www.medicalprotection.org/uk Regional 53
Transplant 55
Trauma 56
Vascular 57
Every effort was made to ensure that the information in this book was accurate
at the time of going to press, but articles (particularly those to do with the
organisation of training) have a tendency to go out of date, so you are advised
to check with the appropriate organisation for the most up-to-date information.
The AAGBI pursues these objectives with vigour and enthusiasm The membership fees are extremely good value, particularly The GAT Committee represents the views and perspectives
on behalf of both anaesthetists and the general public. Current WHAT EXACTLY DOES THE AAGBI DO? for trainees, who enjoy a tiered subscription rate. Some of the of anaesthetic trainees on the Council of the AAGBI, its sub-
membership stands at over 10,000, accounting for approximately benefits of membership are: committees and working parties. We maintain a firm presence
90% of anaesthetists in the UK. Trainees make up more than A large amount of the work of the AAGBI is in education and on other national bodies, such as the RCoA Trainee Committee
3500 of these and are represented by the Group of Anaesthetists development within the specialty. Three scientific meetings are • Up to £1 million of free personal injury and life insurance and the Anaesthetic Subcommittee of the Central Consultants
in Training (GAT) Committee. The headquarters of the AAGBI organised each year: Annual Congress3 is the largest and takes cover for patient transfer and Specialists Committee and the Junior Doctors Committee
are at 21 Portland Place, an elegant, 18th century Grade II* place each September at a venue in either the United Kingdom • Free subscription to Anaesthesia, the renowned international (JDC) of the BMA.
listed building on London’s ‘Grandest Street’. The AAGBI’s or Ireland. The WSM (or Winter Scientific Meeting)4 in London monthly journal
Patron, HRH The Duke of York, officially opened the building in is held every January and includes a Core Topics day. The • Free monthly newsletter Anaesthesia News Over the past year we have established a network of trainee
November 2003. It houses meeting rooms of various sizes, a GAT Annual Scientific Meeting5 is held in the summer and the • Free fortnightly e-newsletter that keeps all grades of links across the country to improve information gathering and
restaurant and a museum, together with the busy administrative venue rotates around the country to provide equality of access anaesthetists up to date with current developments and dissemination. After raising training and political issues with
staff of the AAGBI. to trainees. This is on top of the popular Core Topics days6, upcoming events the relevant organisations, we feed back information to our
held regionally and the numerous seminars that take place at • Free access to the Association’s guidelines membership via the many avenues available to us: direct through
Portland Place throughout the year. All events are open to all • Special rates for AAGBI Scientific meetings including the the trainee network links, through the @AAGBI e-newsletter,
anaesthetists, but members of the AAGBI enjoy discounted rates. GAT ASM the AAGBI website, and through regular articles in Anaesthesia
GAT also holds several in-house seminars on topics relevant to • Special rates for seminars at Portland Place News.
trainees and those approaching consultancy. • Access to the GAT Handbook
• Free professional advice and information
The AAGBI has a number of working parties in progress at any • Opportunities for prizes, grants and awards THE HISTORY OF GAT
one time, to set standards and address pertinent concerns within • Representation at Westminster and the Department of
the specialty. Recommendations and guidelines are produced Health Trainee anaesthetists were first permitted to become
as a ‘glossy’ publication. The ‘glossies’ are available on the • Free access to ‘members only’ areas on the new AAGBI associate members of the AAGBI in 1956. However, they
website7 or as hard copies from Portland Place. website including new podcasts and other upcoming web- had no representation and no voting rights. In 1967, under
based education the Association presidency of Dr Pinkerton, the Associates
In 2008 the AAGBI, together with the RCoA, the journals • 20% discount on textbooks from both Oxford University in Training Group was established, and a constitution drawn
Anaesthesia and the British Journal of Anaesthesia, formed the Press and Wiley-Blackwell Publishing up. The elected committee of five trainees met twice a year to
NIAA, which is now the main source of funding for anaesthetic • Discounted subscripts rates for FRCAQ represent less than 100 members and initially had non-voting
research in the UK. The NIAA has been awarded Partnership • AAGBI subscription is on the HMRC-approved list of representation on Council. In 1970, the constitution changed:
status by the National Institute for Health Research (NIHR). This professional organisations for tax relief two members of the trainees’ committee were admitted to
means that many studies funded by the NIAA Research Council Council with full voting rights, and all trainee members were
grants are adopted onto the NIHR portfolio and are eligible To join, contact the AAGBI membership department: given full voting rights within the Association. The name also
The activities of the AAGBI are co-ordinated by a Council. Voting for support from the NIHR Comprehensive Local Research Tel: 020 7631 8801 Email: members@aagbi.org changed to the Junior Anaesthetists Group (JAG). In the early
members of Council are the Executive Officers, Vice-Presidents, Networks. The AAGBI also bestows numerous grants and 1990s, as juniors became known as trainees, JAG became GAT
elected members and also the GAT Chairman and Honorary awards upon its members for research and travel through the We would like to acknowledge Chris Meadows (GAT Committee and the number of elected members rose to ten. In the 21st
Secretary. Council also has a number of non-voting co-opted Research & Grants Committee8. Chair 2007-2009) for authoring the chapter on which this one is century, GAT has around 3500 members, all of whom have voting
members (Presidents of the UK and Irish Colleges, Convenors based. rights within the Association. An annual postal ballot of all GAT
of the Scottish and Irish Standing Committees, armed forces Anaesthesia, Europe’s leading anaesthetic journal, is the monthly members is held to elect the committee of twelve and we meet
representative, Editor of Anaesthesia News, Chairman of the SAS scientific journal of the AAGBI and is circulated to all members. RICHARD PAUL four times a year. We have been representing trainees since
Committee and others). The voting members of AAGBI Council With Anaesthesia comes Anaesthesia News, the newsletter of the GAT Committee Chair before the formation of the RCoA and our work, and breadth of
meet ten times a year. Association. It aims to keep members up-to-date with specialty Cardiothoracic Anaesthesia Fellow, Royal Brompton Hospital representation, has grown enormously. We have representatives
news as well as taking a more light-hearted look at our specialty. from all over the UK and links with anaesthesia trainee bodies
Branching out from the central strategic body are the As of 2013, the AAGBI has launched an online resource – ANDREW HARTLE in Canada, Australia, New Zealand and Europe. We strive as a
numerous working committees of the Association. These include Anaesthesia Cases9 – to allow anaesthetists to upload interesting AAGBI Immediate Past Honorary Secretary group to maintain transparency and accuracy through our work,
Education, Standards, Safety, Wellbeing and Support and case reports and to share their knowledge and experiences. Consultant in Anaesthesia & Intensive Care, Imperial College allowing trainees to make their own informed opinions on issues
a number of working parties tasked with producing national Healthcare NHS Trust (St Mary’s Hospital) that will affect them as professionals, both at the current time,
equipment, pharmacological and safety guidance popularly and in their future.
“Put simply ‘good enough’ is not good to the GMC specialist register and allows anaesthetists to work
as a consultant in the UK Occasionally, remedial action has
been necessary, and methods for identifying this need varied
•
•
Legal framework for practice
Information technology
enough. Rather, in the interests of the health considerably between regions and were poorly validated. In
recent years, it has been increasingly recognised by the College
For further information please see www.rcoa.ac.uk
to excellence.”
changes in the specialist registrar (SpR) training programme, Foundation Years 1 & 2
and an increase in the length of SpR training from four to five Many doctors will pass through anaesthetic departments for a
years following the Calman reforms. All anaesthetic trainees few months as part of their foundation training (FT) programme,
are now trained in this way and an understanding of these basic but their numbers are limited. Some of them may return to
Professor Sir John Tooke, Aspiring To Excellence principles should help to maximise your training opportunities anaesthesia in the future having achieved valuable competencies
and avoid any potential pitfalls. during time spent in other specialties.
In order to apply for an ST3 post you must have achieved a pass
USEFUL RESOURCES in the Primary FRCA. Previously candidates could be offered a THE INTERVIEW PROCESS Training in anaesthesia in Ireland is administered by the CAI.
1. www.welshschool.co.uk position pending successful completion of the Primary exam but The structure of training has recently moved from a seven year
2. www.westmidlandsdeanery.nhs.uk this is no longer the case. Candidates who are shortlisted will be offered one interview. programme, consisting of two years basic specialist training
3. www.walesdeanery.org These interviews will be conducted by trained selectors against with five years as a specialist registrar, to a six year run-through
The pressures of achieving a pass in the FRCA Primary within the criteria set in the personal and job specifications, and last programme. All new trainees as of July 2012 will have entered
a two-year window has meant that some past trainees have not about 30 minutes. Candidates are scored and ranked from this new training scheme. The six years of anaesthesia training
been able to progress to ST3. There is some provision from NES these results. is based in accredited hospitals recognised by the College.
Scotland for trainees in this position to undertake an additional Training is structured to maximise opportunities for learning
year whilst completing exams in order to be eligible to apply for The interview format may change as national recruitment evolves, and to provide a broad range of experience in different types of
APPLYING FOR TRAINING IN SCOTLAND hospitals and of different sub-specialties in anaesthesia including
an ST3 post. but it has previously consisted of:
• Document check paediatric anaesthesia, intensive care and pain medicine.
CORE
• Workplace Based Assessment Tools: high standard and are offered by most Deaneries. The
- Anaesthesia Clinical Evaluation Exercise (A-CEX): 5 majority of trainees find these very helpful, and indeed
- Case Based Discussion (CbD): 8 essential for the OSCE / SOE component. Trainees should
TRAINING
- Direct Observation of Procedural Skill (DOPs): 6 book revision courses early as places are competitive.
• e-Learning Anaesthesia1 (e-LA) is an excellent online
On completion of a successful novice period, including a resource to aid FRCA revision, utilising 20 minute e-learning
minimum of 19 workplace based assessments, an ‘Initial sessions, complete with self-assessment.
Assessment of Competency Certificate’ (IACC) is awarded. • Simulation courses are great fun.
This deems the trainee safe to practice with some autonomy for
appropriate cases with Consultant guidance. LOUISE YOUNG
StR, Wessex
The remainder of the first year of training focuses on gaining
more experience and confidence, building on the knowledge
and skills outlined above, and preparing for the FRCA Primary USEFUL RESOURCE
Examination. 1. www.e-LA.org.uk
OVERSEAS TRAINING
“An NHS framework for international
development should explicitly recognise the
value of overseas experience and training for
UK health workers and encourage educators,
employers and regulators to make it easier to
gain this experience and training.”
Lord Nigel Crisp, Global Health Partnerships – The UK contribution to health in developing
countries
From http://www.anzca.edu.au/training/2013-training-program/program-overview
THE
allows you access to certain online resources prior to registration. fees (reimbursed by the DHBs) are kept low by NZ legislation that nearest NZ High Commission or Embassy before doing this!
Basic training includes six months of initial introductory training prevents patients from taking direct legal action against medical Your prospective employer will issue a supplementary form to
and a formal sign off is required (Initial Assessment of Anaesthetic practitioners. Cases of medical negligence are referred to the support your application.
CONSULTANT
Competence) before passing onto less supervised practice. Health and Disability Commission and recommendations may
The Primary exam needs to be completed prior to commencing range from an apology to being struck of the register. Affected KATHRYN HAGEN
patients will be classified as having a ‘treatment injury’ and their Trainee Representative
POST
advanced training. The Final exam must be completed before
your can move onto a PF position. Your ‘letters’ are only awarded welfare will be handled by the Accident and Compensation New Zealand Society of Anaesthetists (NZSA)
at the end of training and not immediately after completion of the Commission. Criminal practice will however attract the attention
Final exam. of the police.
REFERENCES
If applying while halfway through training in the UK/Ireland, some 1. www.anzca.edu.au
training time may be accredited. Completion of only the RCoA WORK ENTITLEMENTS 2. Contact details can be found at www.healthcareers.org.nz/
Primary does not exempt one from sitting the ANZCA Primary. rmo under the ‘Current RMOs apply now’ tab
Completion of the RCoA Primary and Final exams (before being All district health boards (DHBs) currently employ junior doctors 3. To view the list of accredited departments, go to http://www.
granted the CCT or equivalent) may allow exemption from the under the Multi-Employer Collective Agreement (MECA) which anzca.edu.au/trainees/hospital-accreditation/new-zealand-
ANZCA Primary but not the Final exam. Completion of all British is negotiated between the Resident Doctors Association (RDA, hospitals
training requirements (exams and CCT in Anaesthesia) allows our union) and the DHBs. The RDA was formed 25 years ago 4. www.mcnz.org.nz
registration in NZ as a specialist, usually requiring an interview during a time when it was thought the New Zealand Medical 5. www.immigration.govt.nz
with the medical council and ANZCA. With the new curriculum Association wasn’t effectively defending the interests of junior
(see below), it would strongly pay to apply and register with the doctors. Although the junior doctor workforce is highly unionised
College prior to starting your position in New Zealand. This (98%), it is not compulsory to join the RDA. Non-RDA members
will allow you to get any retrospective time accredited and will retain the option of negotiating their own contract with individual
mean you won’t commence your time in NZ in introductory DHBs. Most DHBs will still offer you the MECA and you pay a
training. Check out the ANZCA website1 for further information negotiation fee equivalent to one year’s subscription to the RDA.
on registration. In its current form, the MECA entitles junior doctors (including
those on a work visa) to the following:
NEW 2013 CURRICULUM
• Paid meals while on duty
ANZCA has recently rolled out a new curriculum. Leaning • 30 days, (i.e. six weeks) of annual leave
heavily on the UK for inspiration, the 2013 curriculum includes • Full reimbursement of the cost of your Annual Practicing
a new suite of Workplace Based Assessments (WBAs) as well Certificate from the medical council
as the previously existing exams. The basis of the curriculum • Full reimbursement of annual medical indemnity insurance
fee
ACADEMIC
National Institute of Academic Anaesthesia Chair PROS AND CONS OF A RESEARCH CAREER
That’s enough of the past – what about now? Fortunately, there
are real signs that the DoH has become aware of the near demise Academic medicine is an interesting and rewarding career but is
ANAESTHESIA
of clinical research within the NHS and the real damage that not without drawbacks and is not for everyone.
this has caused; they are determined to reverse it. An example USEFUL RESOURCES
of their commitment is the creation and generous funding of 1. NIHR Research Training Scheme www.nccrdpcf.nhs.uk Pros Cons
the National Institute for Health Research (NIHR), funding that Opportunity to make new
remains remarkably unscathed in the recent spending review. Lack of financial security and fierce
scientific discoveries and change
competition for research funding
This is a good time to be involved with research; the future is medical practice
more promising than it has been for some years. Intellectually stimulating and
Prolongs training time
varied
Getting started may not be easy but it is definitely achievable
Interesting work with researchers Hard work to perform good quality
if you are pro-active and committed. Here are some top tips: across disciplines research and maintain clinical skills
• Find a mentor: This could be anyone who is involved with, Opportunities for international Administration, grant applications
travel for research collaborations
or has experience of, research; ideally, an enthusiastic and conferences
etc. are time-consuming and limit
the available time for practical
consultant. research
• Have realistic ambitions: Don’t try to cure cancer in High degree of autonomy
your first study. Make sure that your project is simple, well
designed and achievable. Despite the difficulties of a career in academic medicine, it
• Get involved with established teams: Are there any active remains an attractive career primarily because of the opportunity
research teams on your patch that need a pair of hands? to make a long term impact on health care.
This could be commercial or non-commercial research.
• Consider working in the laboratory: Are there any local
opportunities here? Laboratory work is very demanding TRAINING IN ACADEMIC ANAESTHESIA
and satisfying; it can be scheduled more easily than clinical
research. 1. Integrated Academic Training Path
• Apply for a local research fellowship: Most centres have Prior to 2007, there were no structured training programmes in
academic medicine and individual researchers carved out their
own career paths. The Walport report of 2005 identified this lack
Figure 2 Options for research involvement outside the integrated academic career path.
68 THE GAT HANDBOOK 2013-2014 THE GAT HANDBOOK 2013-2014 69
HOW TO...
CONDUCT AN AUDIT ETHICS COMMITTEE APPROVAL
THE AUDIT CYCLE Careful planning is the key to finishing an audit project
successfully. Any aspect of healthcare delivery can be a suitable
Clinical audit is a cyclical process where standards are agreed subject for an audit. You may choose to start a new audit project
and data collected. Analysis of this data shows whether the from scratch. Alternatively there may be an opportunity to join
standards are being met. If not, changes are planned and in an existing audit project that is already in progress in the
implemented and data collected for a second time and analysed department in which you are working or are planning to join. You
to see if any improvements have resulted from these changes may consider taking over from a colleague who is moving on to
[Figure 1]. It is important to realise that data is collected and another hospital and is perhaps unable to complete the project
analysed on two occasions. A single data collection exercise that they have started, or you may choose to re-audit a subject
does not constitute audit. The first data collection is to establish that has been looked at in the past. Your first port of call should
the current position and the second is to see if any improvements be the clinical lead for audit within the department. This may
have been made. not necessarily be a medical doctor but he or she will have the
support of the department as a whole and will have been given
responsibility to co-ordinate and monitor audit projects within the
department. They may be able to suggest a possible subject
that needs looking at, perhaps something that needs auditing or
re-auditing which has been of concern to the department. They
will also ensure that, should you have a subject in mind, it is not
already in the process of being audited nor already been audited
by someone else recently. The other group of people to talk to
are the permanent members of staff in the department who will
be familiar with what has been done over the recent months or
years and may have suggestions for what needs to be audited.
HOW TO...
UNDERTAKING THE AUDIT
“We believe that involvement in academic You have to carry your colleagues with you. This is especially
important if the likely outcome is going to have an impact on their
practice. Keep the project simple and stay focused. Do not be
activity is a cornerstone of anaesthetic training WHY SHOULD I DO AN AUDIT? distracted by irrelevancies and minutiae. There is a tendency to
collect far too much irrelevant data. This is counter-productive,
wasteful and slows everything down. Confine data collection to
and this leads to improved clinical care at
Best practice and best outcome should be the goal of every
clinician. Voluntary critical self-appraisal of one’s performance what is pertinent to the audit project. Select a topic that is relevant
is a useful way of ensuring this. Clinical audit enables one to and exhibits potential benefit to the patients, to the department
both a local and national level.” achieve these goals. All consultant contracts in the NHS have or to the hospital. If the topic falls within your area of interest or
clinical audit as part of their job descriptions, hence it is a good expertise, so much the better. High risk, high turnover, high cost
idea to get into the habit early. There is now a clear expectation practices are particularly good to audit as improving them can
that trainees will complete yearly audit project during their training have a profound impact on the quality of care or the quality of
National Institute of Academic Anaesthesia and that permanent clinical staff will undertake continuing audit service and can at times make a real difference. Do not tackle
during their NHS careers. a topic where the likelihood of improvement is questionable or
beyond control of yourself or the department. You should try
and work within a given time frame. Innumerable audit projects
AUDIT OR RESEARCH? are started which are never finished resulting in a waste of time,
effort and resources. If you feel that a project cannot be finished
There is a difference between audit and research. Research by you, e.g. because you have to move on to a different hospital
is a process that tries to find out what you should be doing to as part of your rotation, recruit a colleague to take over so that
your patients. Audit is a process that tells you whether you are the project can be completed.
actually doing what you are supposed to be doing. Research
seeks new knowledge or refines existing knowledge and audit
reviews current practice to stimulate change.
Your manuscript will then be reviewed by a number of people, 2. CONSTRUCT YOUR PAPER WELL
depending on the journal. For some journals, the editor-in-chief I won’t go on here about what to say in each section of the
will screen all manuscripts first and reject the hopeless, unethical manuscript; go and take a look at Anaesthesia’s Guidelines for
and intelligible ones at this stage. For others, they’ll all be Authors.1 Or you could look at any other journal’s guidance; they
reviewed by two or more editors and/or external reviewers, with all tend to say the same thing. We’ve tried to make our guidance
the final verdict made by the editor-in-chief, taking the others’ helpful too, rather than just prescriptive. Remember, the aim of
opinions into account. This process can be lengthy if: the paper your writing is to explain clearly to the editor/reviewer/reader
is complicated; there are only a few experts in the topic to ask what you did and why it might be important; if it’s not clear then
for an opinion and they’re all busy; the external reviewers are that in itself can be a reason for rejection, or at best it’ll lead to
slow to provide an opinion; the reviewers disagree and it has to a request(s) to clarify various aspects of your work. The best
go for a further opinion(s); the editorial office is dealing with a papers are simple and easy to follow; they avoid complicated
large backlog or even a crisis, (e.g. technical); or your email (or sentence structures and refer to the groups and outcomes in
the one to/from reviewers) gets lost in the ether. Most journals the same order throughout the text, so the reader doesn’t get
should be able to give you a verdict within a one to two months confused where they are.
“Wellbeing requires four components: a good rearrange service cover to make sure that patients are protected
and that you are given the chance to recover.
who make honest mistakes.
working environment and work arrangements, However, looking after yourself goes beyond just making sure that
you are fit to work on a particular day. It extends to developing
DON’T GET PROUD
A wise man (my father-in-law) once told me: “never, ever think
support for staff to maintain good physical
a lifestyle that means that you are as fit as you can be all the
time. You need enough sleep, a reasonable amount of exercise, you are the best anaesthetist in the world, just be very grateful
time for friends and family, a good diet, a passion outside of indeed that you are not the worst – there will always be people
and mental health, good working relationships medicine and a lifestyle free from drugs, smoking and anything better and worse than you are”. Even if you are very good indeed,
more than a modest amount of alcohol. These may seem like there will be days when nothing goes right – when it feels like you
trite recommendations, but a visit to the GMC’s website, and in are wearing boxing gloves and none of the lines will go in. Don’t
and good personal support; we can all particular the judgements of the Fitness to Practise panel, will
show you that many of the doctors who go off the rails ignore
get proud – get someone else to help you. The person you ask
to help you doesn’t always have to be more experienced than
you. I have often had difficulty putting a line in and have asked
these seemingly trite recommendations. Your health and sanity
contribute to this.” is very much conducive to the wellbeing of your patients. If you
find yourself failing to live up to these recommendations, I would
a trainee to help, only to watch the trainee put it in at their first
attempt. This is good for the trainee and good for the patient
strongly advise you to seek help of some sort, even if it is talking and, after a while, your pride will get immune to the odd dent,
which will do it a deal of good.
Nancy Redfern, Chair of the Support and Wellbeing Committee, AAGBI to a sympathetic friend who knows you well enough to support
you and point you in the right direction.
REFERENCES
1. Pregnancy and work: What you need to know as an PSYCHO-SOCIAL CONSIDERATIONS
employee. Department for Business, Innovation and
Skills, 2010. (http://www.direct.gov.uk/prod_consum_dg/ • Serious illness can be very isolating. Despite the events
groups/dg_digitalassets/@dg/@en/@employ/documents/ in your life the world around you carries on, apparently
digitalasset/dg_078787.pdf) seamlessly, without you. This happens at a time when you
MEDICO-LEGAL
• Alcoholics Anonymous www.alcoholics-anonymous.org.uk
Tel: 0845 769 7555
• Narcotics Anonymous www.ukna.org
References
1. Gaba D. Human error in dynamic medical domains.
In:Bogner MS, ed. Human Error in Medicine. New Jersey:
“the practice of medicine can generate a
Lawrence Erlbaum Associates, 1994.
2. Kain ZN, Chan KM, Katz JD et al. Anesthesiologists and spectrum of medico-legal and ethical issues
within everyday work, some of which are far
acute perioperative stress: a cohort study. Anesth Analg
2002; 95: 177-183.
3. 3 Kluger MT, Townend K, Laidlaw T. Job satisfaction,
Medical protection organisations patients in assessing the technical competency of a doctor. They One step beyond ‘It is a general legal and ethical principle that valid consent must
will, therefore, frequently judge the quality of clinical competence be obtained before starting treatment, physical investigation, or
by their experiences of personal interactions. In medicine it may seem that all a doctor needs are expertise, providing personal care’ for a patient.1 Health professionals who
Medicine is a risky business. No matter how skilled, experienced knowledge and technical competence. Yet all of these hard- carry out procedures without valid consent are liable to legal
or conscientious you may be, unfortunately, things will Failings in interpersonal skills, which may eventually convince won skills and knowledge, vital as they are, are not sufficient in action by the patient and investigation by the GMC or equivalent
occasionally go wrong. When an adverse incident occurs, a patient to sue, can be separated into two distinct categories: themselves to make a good doctor and avoid complaints and professional bodies.
you will need specialist advice and support. Membership of a predisposing factors and precipitating factors. claims.
medical defence organisation will give you access to invaluable Consent is an important part of the process of discussion and
independent advice and assistance with non-NHS indemnified The former includes rudeness, inattentiveness and apathy, while The vital ingredient is good communication and this, like all decision-making by patients and their doctors. You should ‘share
problems which arise from your professional work, such as a the latter can be borne out by adverse outcomes, mistakes and skills, has to be acquired through hard work, experience and information in a way the patient can understand and, whenever
GMC inquiry, disciplinary or police investigation. failure to provide adequate care. Precipitating factors are unlikely application. Taking the time to talk and listen to patients, while possible, in a place and at a time when they are best able to
to lead to litigation in the absence of predisposing factors, juggling the demands of work, is not time wasted and proves, understand and retain it’.2 When deciding how much to disclose
The practice of medicine can generate a spectrum of medico- however. ultimately, to be highly rewarding. to individual patients you should take account of their wishes
legal and ethical issues within everyday work, some of which are but ensure all relevant information and the nature and level of
far from clear-cut, especially when one ethical principle seems Patients will be dissatisfied if their expectations have not been Gareth Gillespie risks are included to enable them to make an informed decision.
to conflict with another. Life can be made much simpler with the met. Of course, many patients’ expectations are unrealistic – that Publications Manager – MPS In addition, it is good practice to provide written information
benefit of advice on the legal and ethical framework to which you you have unlimited time and availability, will solve all the issues leaflets for patients prior to admission for elective surgery and
should adhere, as well as the opportunity to talk through a thorny at once and all treatments will be 100% effective and risk free. Angelique Mastihi anaesthesia. Doctors should check patients have understood
situation with a fellow professional. It is important to remember Medicolegal Adviser – MPS all the information and encourage them to ask questions, which
that a medical protection organisation is not just there to pick up should be answered fully and honestly.
the pieces after things have gone wrong, but is also ready with Body talk
advice to help members avoid problems or criticism in the future. REFERENCES Valid consent implies that a competent and informed person
The words we use are of less importance than the tone of voice, 1. Beckman HB, Markakis KM, Suchman AL, Frankel RM, The gives it voluntarily and not under duress. All adults should be
Any uncertainty you may have about your duties and or our body language. Letting patients tell their full story also doctor–patient relationship and malpractice: lessons from presumed to have capacity to consent unless there is contrary
responsibilities in a situation can be easily clarified by a quick allows you to gauge their emotional distress; and, as patients do plaintiff depositions, Arch Intern Med 154:1365-70 (1994) evidence. To have capacity for consent, the patient must be
call to your medical protection organisation. Proactivity rather not present problems in order of clinical importance, the longer able to comprehend and remember the information provided,
than just reactivity is the key. you delay interrupting, the more likely you are to discover the full weigh up the risks and benefits of the proposed procedure,
spread of concerns the patient wants to discuss. Eye contact is and consider the consequences of not having the procedure
One of the most common causes of complaints and claims that critical in demonstrating interest and understanding. in order to make a balanced decision. They must also be able
MPS sees is a problem related to communication. Here we offer to communicate this decision.3,4 Doctors must respect patient
some advice to clinicians on how to improve their communication autonomy and their right to be involved in decisions that affect
skills. A margin for error them. You must respect a patient’s decision regarding treatment
even if you think it is irrational or unwise and ‘may result in death
Despite the best of intentions, there will be occasions when of the patient (and/or the death of an unborn child, whatever the
Why communication matters patients or their relatives will be dissatisfied with the care you have stage of the pregnancy)’.1, 5
provided, or with the outcome they have experienced. This may
Developing good interpersonal and communication skills be due to human error, systems failure or unmet expectations. Consent may be expressed, as either written or verbal, or implied,
improves your clinical effectiveness as a doctor and reduces Complaints feel personal, hurtful and sometimes unfair. Your e.g. holding out one’s arm for a blood test. At present a separate
your medico-legal risk, leaving you with a satisfied patient and best course of action initially is to discuss the situation with an formal written consent form for anaesthesia is not required if part
a considerably less stressful consultation. This is easier said experienced colleague or your medical defence organisation. of another treatment, but anaesthetists should record details of
than done however. It is when you are busy, stressed and doing their preoperative discussion with patients in the medical record,
your best to cope with the multiple demands of current clinical The senior doctor responsible for the care of the patient should ‘noting what risks, benefits and alternatives were explained’6.
practice that you are most likely to find effective communication be the person who advises the patient on what has occurred.
a challenge. Above all, try to retain your professionalism, making sure that
you: PATIENTS WHO LACK CAPACITY
But communication – along with partnership and teamwork – is
one of the four domains in the GMC’s guidance Good Medical • Acknowledge what has occurred The treatment of patients who lack capacity is governed in
Practice (2013) and is integral to safe practice. Paragraphs • Find out the facts; discuss them as they become known to England and Wales by the Mental Capacity Act 2005 (MCA)4,
31-32 say: ‘You must listen to patients, take account of their you and in Scotland by the Adults with Incapacity (Scotland) Act
views, and respond honestly to their questions. You must give • Provide an explanation 2000.7 In Northern Ireland decision making for these patients is
patients the information they want or need to know, in a way • Apologise currently governed by common law, requiring decisions to be
they can understand. You should make sure that arrangements • Identify what can be done to prevent similar issues arising made in the patient’s best interests.
are made, wherever possible, to meet patients’ language and • Adopt those lessons into your future practice
communication needs.’ In the MCA there is a two stage test of capacity, namely:
There should also be a decision made on whether an incident 1. Does the person have an impairment of the mind or brain
With research showing that 70% of litigation is related to poor report should be filed and if there should be a sentinel event or is there some sort of disturbance affecting the way their
communication following an adverse event, the benefits review. mind or brain works, whether temporary or permanent?
of making simple adjustments to your approach cannot be 2. If so, does that impairment or disturbance mean the person
overstated. A summary of communication behaviours that reduce medico- is unable to make the decision in question at the time it
legal risk is set out below: needs to be made?
Great expectations • Being available (returning phone calls, making and keeping If the patient lacks capacity, then it is lawful for treatment to be
appointments), especially if something has gone wrong given if it is in the patient’s best interests. The definition of ‘best
Patients will frequently judge the quality of clinical competence • Giving the impression that you have sufficient time for the interests’ is assumed not be limited to best medical interests, but
by their experience of their personal interactions with a doctor. patient (which can be done without taking up much extra considered to include welfare, social, emotional, psychological
While patients want doctors to have good clinical and technical time, and is achieved by not giving out ‘rushed’ signals) and other interests.
skills, they rate interpersonal skills as more important. This is • Soliciting and understanding the patient’s viewpoint
likely to be due to there being understandable difficulties for • Demonstrating empathy
FINANCE
aagbi.org/sites/default/files/consent06.pdf
Young adults over the age of 16 years are presumed competent 7. Adults with Incapacity (Scotland) Act 2000
in law to give consent for any treatment without obtaining 8. MDU guidance and advice. The Mental Capacity Act 2005.
separate consent from a parent or guardian. However you should February 2008 http://www.themdu.com/guidance-and-
encourage young people to involve their parents in making advice/latest-updates-and-advice/the-mental-capacity-act-
important decisions. If the young person is not considered
competent, (e.g. has learning difficulties) then in England, Wales
2005#Proposed%20changes
9. GMC 0-18 years: guidance for all doctors. 2007 http:// “Whichever you choose, if any, take sound
and Northern Ireland a parent may give consent until 18 years www.gmc-uk.org/guidance/ethical_guidance/children_
old, but in Scottish law the concept of parental responsibility
ceases at 16 years old.
guidance_index.asp
10. Children’s Act 1989
financial advice, don’t live beyond your
means, and remember that all good things
11. Gillick v West Norfolk and Wisbech AHA [1986] AC 112
Children under 16 years old who demonstrate the ability to fully 12. Department of Health. Seeking consent: working with
appreciate the risks and benefits of the planned intervention, children 2001 http://dera.ioe.ac.uk/9286/
can be considered competent to give consent – so called ‘Gillick
competency’.11 If a child lacks the capacity to consent, you should
ask for consent from a person with parental responsibility or from
13. Re W (a minor) (medical treatment) [1992] 4 All ER 627
can come to end”
the court.9 The decision of a competent child to accept treatment
cannot be overridden by a person with parental responsibility.12 Andrew Hartle, President Elect, AAGBI
Children with capacity, and young adults who refuse treatment,
may have their decision overridden in the courts ‘if it would in
all probability lead to the death of the child / young person or
to severe permanent injury’.1, 13 If a competent child refuses
treatment, the courts have said that, in exceptional cases,
persons with parental responsibility may consent on their behalf
and the treatment can lawfully be given. For young adults the
law on parents overriding young people’s competent refusal is
complex and you should seek legal advice.9
The annual allowance is potentially more of a concern for all In the event of your death your NHS pension also provides your
ages of doctor. The annual allowance limits the amount of tax family with some excellent additional benefits such as a death in
allowable pension benefits you can accrue and the method of service lump sum of twice your pensionable pay, plus a short-
calculating this in the NHS Pension scheme is complex. The term pension of six months pensionable pay. If you have more
annual allowance limit was reduced from £255,000 to £50,000 on than two years’ pensionable service your spouse, partner and
1.4.11 and is to be reduced further to £40,000 on 1.4.14. Whilst a dependant children will also subsequently be entitled to a long-
tax charge for a doctor in training is not common currently when term pension, which can be invaluable. If you are not in a legally
the allowance reduces in 2014 those individuals who receive an recognised relationship (i.e. marriage or civil partnership) and
increment, or promotion will need to check their position far more want to ensure your partner receives these benefits it is essential
carefully. From October 2013 it is expected that the NHS Pension that you complete a nomination form and register this with the
scheme will inform any member who exceeds this allowance so NHS pension scheme as this entitlement is not automatic.
they can incorporate this information on their self assessment
tax return. It is possible to utilise any unused allowance from up Whilst these benefits are excellent will they be enough?
to three previous years and for the vast majority of trainees this A quality financial adviser will calculate the financial value of the
should cover any excess and as a result avoid a tax charge. If above benefits and discuss and determine with you whether
however anyone is in the position where they have incurred a tax these are sufficient to maintain your lifestyle in the event of an
charge of £2,000 or more, which is unaffordable, they can opt to illness, or even death.
have this tax charge taken form their future pension benefits at
retirement. This should not be a decision that is taken lightly as It is often necessary to protect yourself further, and equally
there are punitive interest charges applied. as important to consider protection needs for your spouse or
partner, even if they are not working themselves.
ABRA Association of Burns and Reconstructive Anaesthetists IRC International Relations Committee
ACCS Acute Care Common Stem JDC Junior Doctors Committee (BMA)
APA Association of Paediatric Anaesthetists LETB Local Education and Training Board
ANZCA Australian and New Zealand College of Anaesthetists LTFT Less Than Full Time
ASCAB Armed Services Consultant Advisory Board MCAI Membership of the College of Anaesthetists of Ireland
BLTC Basic Level Training Certificate NASGBI Neuroanaesthesia Society of Great Britain and Ireland
BOAS British Ophthalmic Anaesthesia Society NIMDTA Northern Ireland Medical and Dental Training Agency
CT/CAT Core Training/ Core Anaesthetic Training OOPE/T/R Out of Programme Experience/Research/Training
DMAP&CC Department of Military Anaesthesia, Pain and Critical Care RA-UK Regional Anaesthesia UK
FCAI Fellowship of the College of Anaesthetists of Ireland SOBA Society for Obesity and Bariatric Anaesthesia
FFPMRCA Fellowship of the Faculty of Pain Medicine at the RCoA ST Specialty Trainee
GMC General Medical Council CSAF Clinical Supervisor’s End of Unit Assessment Form
www.medicalprotection.org/uk
USEFUL ADDRESSES
AAGBI www.aagbi.org
GAT gat@aagbi.org
www.aagbi.org/professionals/trainees