Vocational Studies

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

Accident and Emergency Unit

 The first thing in A&E is triage
 This involves the triage nurse and the named nurse
 The most commonly used triage system consists of 5 categories :
1 = immediate resuscitation – patients in need of immediate treatment for
preservation of life
2 = very urgent – patients with major illness or injury needing urgent
attention, need to be seen within 10-15 mins
3 = urgent – patients with serious problems but are stable enough to be seen
60 mins within arrival
4 = standard – patients not in immediate, need to be seen within 120 mins
5 = non urgent – in no danger, seen within 240 mins
 The triage nurse immediately assesses patients on arrival, documenting the
complaint, medical history, vital signs, allergies, medications and any other
important information
 This allows them to determine the patients’ priority
 They also often have to administer first aid
 They have to continually monitor the condition of the patients and keep
family/friends updated
 The named nurse organises an appropriate treatment area for the patient and
conducts a secondary evaluation of the patient
 They help co-ordinate the patient care with other medical staff
 They also develop a plan for the patient’s discharge
Non-acute Hospital Settings
 GP referrals for a specialist opinion go to an out patient clinic
 Acutely ill patients are usually admitted directly from a hospital ward or via A&E
 The main providers of health care working with acute hospitals are primary health
care, health boards, the Scottish Ambulance Service and local authorities

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

Chest and Heart Examination

 Stages of examination are :
-introduction
-inspection
-palpation
-percussion
-auscultation
-summary
 In introduction, wash hands, say your name, check patient’s name, seek permission
to examine them, check they know what is involved, give an accurate explanation,
ask if they are comfortable and check they aren’t sore in the area you are going to
examine
 For inspection, make sure the patient is properly positioned and the area can be
seen well, know what you are looking for, comment on any negative findings (eg if
they look ill, sore, breathless, thin, fat, anaemic, have a rash, finger clubbing,
cyanosis, jaundice, tremor etc)
 In palpation, the areas to be concerned with are chest expansion, palpating the
trachea and tactile vocal fremitus among others. Work systematically and know what
you are looking for
 For chest expansion, apply palms laterally, stretch the patient’s skin so that thumbs
come together in the midline but don’t let the thumbs touch the skin, ask the patient
to take a deep breath and your thumbs will move away from each other allowing you
to demonstrate the degree of movement on the chest wall
 Percussion involves the tapping of different parts while asking the patient to breathe
in and out of their mouth
 Auscultation is the use of a stethoscope, to compare both sides. Listen to the heart,
demonstrate vocal resonance (‘111’) and listen for bronchial breathing
 Always thank the patient and wash hands
Non-Verbal Communication
 Consists of any aspects of communication which do not involve the spoken word
 Such messages are often subconscious but a very important part of human
communications
 Emotions tend to be expressed non-verbally
 Channels of non-verbal communication include :
-dress and appearance (everyone makes assumptions about other people
from their dress and appearance – these are often made quickly)
-facial expression (basic emotions including sadness, happiness, disgust, fear
and anger seem to be expressed by similar facial expressions throughout the
world despite cultural differences)
-gaze and eye contact (during conversation, each person will look at the
other for about half the time and there will be mutual eye contact for about
25% of the time – the amount depends on many factors, including anxiety
and depression reducing eye contact and intimacy increasing mutual gaze)
-gestures (used to demonstrate and punctuate what is being said – they also
convey emotions, such as nervous tapping of feet or anger of clenched fist)
-posture (may reflect status, attitudes and emotions – has considerable and
cultural variations – relaxed position may indicate dominance and leaning
forward may indicate empathy)
-proximity (sets context of communication between 2 people – tends to be
divided into 4 zones :

 Seating positions round a table facilitates various types of interaction :

  Body contact and touch are the most basic forms of non-verbal communication
 Paralinguistics is the term given to those aspects of vocalisation, such as the speed,
loudness and pitch of the voice – these may convey information about emotions,
attitudes or personality
 Non-verbal communication is highly complex and can convey much information
 Most people are skilled at controlling it but “leakage” can occur so that non-verbal
signals can convey information which the person is trying to hide or suppress
 Doctors need to be skilled at reading patients’ non-verbal signals and to be able to
manage their own non-verbal communication
 There are two techniques that can be used :
-mirroring
-pacing
 Mirroring is reflecting observable behaviours such as body posture, hand
movements and facial expressions
 This usually improves rapport
 It can also apply to speech patterns and the language used when communicating
with patients
 Pacing allows you to lead another person from a particular state of mind
 If someone is agitated and is speaking rapidly, adopting the same rate of speech and
then slowing down can often lead the other person to become calmer too
 This can be physical or verbal
 Finally there is congruence
 This is matching what the rest of the communication signs such as body language say

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 :

 Managing risks involves :

-identification of risky situations and identification of errors
-evaluation of these situations
-subsequent control of risks in order to reduce the impact
-monitoring
Right Thing To Do
 Adults with capacity have the right to decide whether to accept any proposed
medical treatment – they may decline it if that is what they want
 No one can give consent on behalf of an adult with capacity
 Proxy consent is when a person with capacity delegates the right to consent to
medical treatment to another person
 There is presumption of capacity unless there are substantive reasons to doubt it
 The Adults with Incapacity Act 2000 allows proxy consent where the patient (prior to
losing capacity) has nominated a welfare guardian to make decisions on treatment
that benefity the patient
 In genuine emergency situations, if a patient lacks capacity to authorise treatment
(eg. Unconsious) then it is lawful to provide life-saving treatment
 Excpetions to providing life saving treatmenet for adults in these cirucmstances are
when they have unambiquously specified in advance that they don’t wish to receive
it (eg. DNR)
 In scotland, parental responsibilty applies until the age of 16
 However, minors can have capacity to make their own medical deiciosn depending
on their level of undertsanding and the nature of the medical treatment
 Whether or not a patient has attained the age of legal capacity, and whether or not
the patient has capacity, doctors have a duty of confidentiality not to discolse
personal information of patients to third parties unless it is necessary for medical
treatment or if there is a specific legal obligation to do so
 If a patient who has capacity does not wish to know all of the relevant informaton
concerning their proposed treatment, then the consent given is still lawful when the
associated risks have been explained

Ethical Issues with Alcohol

 If someone suspected of being drunk is taken to A&E, the staffs’ primary tole is to
care for them but forensic (medico-legal) matter must also be considered
 Their life threating injuries should be dealt with first
 It is dangerous to assume that they are simply suffering from effects of alcohol –
difficult and uncooperative patients maye be hypoxic, hypovalaemic, hypoglycamic,
hypothermic, in pain and frightened among other things
 Alcohol misuse not only makes diagnosis and treatmenet difficult but the long term
effects of heavy drinking can lead to illnesses (eg. Liver, gut, pancreasm heart and
brain) which account for up to 20% of admissions to hospital
 The clinical effects of alcohol vary with the plasma concentration :
-mild intoxication (0.5-1.5g/l) emotional liabiltity, impaired muscle
coordination and reaction time
-moderate intoxication (1.5-3.0g/l) visual impairment, slurred speech
-severe intoviation (3.0-5.0g/l) marked impairment of motor skills, blurred
vision, hypothermia, occasionally hypoglycaemia and convlusions
-coma (5.0g/l) repiratory depression, hypotension, depressed reflexes –
death may result from aspiration (inhaled vomit) or cardiac and respiratory
failure
 In terms of prevention, attendance at hospital with an alcohol related accident can
provide oppurtunity for change
 It is in the interest of hopistal stafff to provide a woord of advide back up by
documents and follow up arrangement to assist rehabikkitation
 The early recognition of harmful drinking in a patient can be made easier with
questionaires such as the CAGE test :
-C = out to CUT down
-A = ANNOYED about advice
-G = GUILT about drinking
-E = the need for an EYE opener
 The following shows effects of varying blood alcohol concentrations :

 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

Autonomy, Capacity and Consent

 Respect for autonomy is fundamental to patiented-centred health care
 It is the recongition that a person has the atttribute of being self-governing and and
self-determining
 Adults with capacity have the right to exercise their choice of treatment options
available
 It might be thought that when a patient seeks care of a doctor, there is implicit
consent to treatment the doctor considers necessary but this cannot be known
unless verified with the patient
 Even if patients confirm they would prefer doctors to make decisions on their
treatment options, this is not an authenic choice as it conflicts with their staturs as
adults with capacity
 If patients do exercise autonomy in their choice of treatment options, they must
have all the relevant information
  Consent is not ‘once-and-for-all’ and is only valid for the specific treatment proposed
 It is an on going process and patients can withdraw their consent at any time

 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

Confidentiality, Disclosure and Medical Records

 Health care professionals have both an ethical duty and a legal obligation to main
confidentiality
 The relationship between doctor and patient is founded on trust
 Patients are expected to share information about themselves that they would not
discuss with anyone else
 In order to maintain this trust, patients must be assured that the infomration they
share will not be improperly discussed with others
 There are cirumstances where disclosure with consent of the patient is required
 For example, medical reports concerning patients that are supplied to a third party
by a doctor for emplyment or insurance purposes
 These would requrie patients’ consent
 There are situations where disclosure is obligatory without consent of the patient
  For example where a patient is unfit to drive but continues to do so against medical
advice – it must be disclosed to the medical adviser of the DVLA
 There are also sitiuations where it is necessary :
-colleagues assissting with patient care
-information required by police
-information requried by a court
-discloure that is justified in public interest
 The Data Protection Act 1998 states that disclosure of patients’ information in order
to deliver care and treatment must be necessary for medical purposes

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

 Questions may come from :

-case studies
-clinical visits
-own experience
 The PICO framework can be used to formulate some types of questions
 PICO stands for :
-people or patients
-intervention
-comparison
-outcome of interest
 The pre-requirements for a randomised trial are that :
-there must be genuine uncertainty
-there must be informed consent
 The features of a randomised controlled trial include :
-an appropriate sample of a represntative study population
-participants are selected randomly to treatment group
-the double-blind design (triple-blind if possible_
-there is an objective measure of outcome
-the follow-up of particpants is complete
-there is no comparison of ‘like-with-like’ in every respect other than
exposure to the intervention
 Random sampling is the process of allocating study participants to two or more
groups so that everyone has an equal chance of being selected – this allows the
random sample to be as similar to those of the population as a whole
 Random allocation is the process of allocating study participants to two or more
groups – groups selected in this way may not be identical but any differences that
occur cannot be attributed to bias
 RCT advantages :
-they are interventional and are the gold standard to assess cause and effect
 -subjects are randomly allocated to control or intervention groups
-study groups are closely matched for factors that might affect the outcome
 RCT disadvantages :
-they are costly and difficult to set up and run
-they are time consuming
-recruits many not be typical patients – selection bias
-limit applicability – many important issues cannot be assessed in this way
(eg. Role of diet in heart disease)
-trials are necessariy limited to people who consent to take part and who do
not have the exclusion criteria
-results may not be applicable to all patients
-small trials may lead to false negative conclusions
 Design of a RCT :
 Definitions of words :
-utility
-futility
-treatment
-cure
-palliation
-paternalism
-benefience
-non-malefience
-rerspect for autonomy
-justice
-consent
-capacity
-incapacity
-confidentiality
-disclosure
-Data Protection Act 1998
-truth-telling
-Abortion Act 1967
-rights
-personhood
-autonomy