Fitness to Practice Nadia Anderson David Tatham Ramesh

Fitness to Practice Nadia Anderson David Tatham Ramesh Mehay www.bradfordvts.co.uk

Introduction What is fitness to practice? Why is it important? Is there any published guidance? And where can I find it? How does it relate to us now as trainees? What does it mean in the future?

Plan Small group work Min-lecture Quiz Mini-lecture Inter-active session What is fitness to practice? Why is it important? What areas of our work does it cover? What guidance is there and where can we find it? How does fitness to practice affect us as trainees? Tea & Biscuits Mini-lecture Mini fitness to practice committees! Revalidation Cases (& how to avoid hot water)

Small Group Work 10-15 mins 3 questions What is “fitness to practice”? Where can we find guidance? What parts of our work does it cover?

What Is Fitness To Practice? To practise safely, doctors must be competent in what they do. They must establish and maintain effective relationships with patients, respect patients’ autonomy and act responsibly and appropriately if they or a colleague fall ill and their performance suffers. But these attributes, while essential, are not enough. Doctors have a respected position in society and their work gives them privileged access to patients, some of whom may be very vulnerable. A doctor whose conduct has shown that he cannot justify the trust placed in him should not continue in unrestricted practice while that remains the case. The Meaning of Fitness to Practice GMC 2005

Fitness to practice is about being a good doctor . .and being a good doctor is about good medical practice . .which is the title of the guidance document issued by the GMC that we must all follow.

“Duties Of A Doctor” http://www.gmc-uk.org/guidance/good medical practice/index.asp

Quiz In groups, 5 minutes to list the duties of a doctor as listed in the GMC guidance, “Good Medical Practice” There’s a prize!

Duties Of A Doctor Make the care of the patient your first concern Protect and promote the health of patients and the public Provide a good standard of practice and care Keep your professional knowledge and skills up to date Recognise and work within the limits of your competence Work with colleagues in the way that best serve patients’ interests Treat patients as individuals and respect their dignity Treat patients politely and considerately Respect patients’ right to confidentiality Work in partnership with patients Listen to patients and respond to their concerns and preferences Give patients the information they want in way they can understand Respect patients’ right to reach decisions with you about their treatment and care Support patients caring for themselves to improve and maintain their health Be honest and open and act with integrity Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk Never discriminate unfairly about patients or colleagues Never abuse your patients trust in you or the public’s trust in the profession

Why Is Fitness To Practice Important? Because “Serious or persistent failure to follow this guidance will put your registration at risk” But even more importantly it’s about patient safety It encompasses everything we do as a doctor (and some aspects private life) It’s important to GMC (so hence must be to us) Needed for Appraisal (currently) and Revalidation (soon) and we need to get the box ticked!

How Does This Affect Us As Trainees? 1) We are all registered medical practitioners and as such must follow the GMC’s principles of good medical practice 2) We have to tick a box on the Eportfolio!

Competency Area

How Can We Tick The Box? We admit it is difficult And everybody seems to struggle with this one But there are lots of resources available Bradford VTS Website RCGP E-portfolio

How Can We Tick The Box? Use the Bradford VTS Website http://www.bradfordvts.co.uk/MRCGP/cbd.htm

How Can We Tick The Box? Use The RCGP Website http://www.rcgp.org.uk/docs/nMRCGP %20blueprint%202007.xls Microsoft Office Excel Worksheet

How Can We Tick The Box? Can demonstrate this through CbD and entries in the learning log that your trainer can map to the competency, eg. make a point to document issues with chaperones, discussing options with patients, choose a case with a shared management plan Make sure you take your holidays! Any suggestions? ?Upload a picture of your gym membership! Any suggestions? Significant event analysis Significant event analysis Present at practice meeting ?with suggestions to change practice or policy

Examples of things that you should add under ‘fitness to practise’ Here are some examples of stuff some of our trainees put on: Clinical Things: Making sure you make an enquiry into the red flag areas for most symptoms e.g. suicidal risk assessment for depressed, MI symptoms/signs for chest pains, intracranial lesions for headaches etc. Difficult areas e.g. under 16 and asking for the oral contraceptive pill Personal Dilemmas “I was asked by a relative to prescribe something for him. I never considered the implications of this. Therefore.” “I was in a real dilemma the other day. I felt quite ill but also felt the difficulties ringing in sick would have on my colleagues. Therefore, I decided to do xxx because.” “I was always turning up late for surgeries and my trainer had raised this a couple of times. I knew it was because of some difficult things I was experiencing at home. So, my trainer and I had a discussion about some of these things: a) looking after 3 children b) studying for my AKT, and my unsupportive husband.One thing that we decided to do is change surgery times and that has helped a lot” “My work-life balance has been getting me down. I just cannot get the right balance and so had a discussion with my programme director.”

Small other ideas Some of us might not be keen to put personal things on for fear of consequences? Examples include: personal illness, mental health, issues with trainer. But seriously – you needn’t worry. This is the sort of stuff they really like to see. Writing it down will really make you think about your situation and help you see light at the end of the tunnel compared with just mulling it over in your mind Your problem will not go away unless you seriously consider it and talk to someone about it. Get it written down, talk to someone, and don’t worry about who will see it. Trainers have been trained to acknowledge these sort of things.

Revalidation In response to Shipman Inquiry Latest guideline suggest should be in the form of an electronic portfolio (Don’t all cheer at once)

Revalidation Revalidation is a process where doctors will be required to “periodically demonstrate their continued fitness to practice (DH 2007: 6). Revalidation has two elements:

Relicensing will be required for all who hold a license. All doctors wishing to practice in the United Kingdom will require a license issued by the General Medical Council every 5 years,( starting in 2009) The process will be based on: Satisfactory completion of annual appraisal Supported by an independent 360 feedback (multisource feedback) Any concerns known to the doctor’s employing organisation Recertification will be required for doctors who are on the GMC’s specialist register and GP register. Recertification will be led by the Medical Royal Colleges who will need to provide a ‘positive statement of assurance’ to the General Medical Council. It is hoped that revalidation will identify those that require further identification or remediation in doctors whose practice is or maybe impaired. The vast majority of doctors are practicing medicine to a high standard. Revalidation should be a process that will support continuous quality improvement in standards and practice for both doctors and patients alike.

Appraisal Annual appraisal throughout career. Five forms. Form 1 Personal details Form 2 Current medical activities Form 3 Based around the headings of good medical Practice Form 4 the formal summary/actions agreed Form 5 Optional confidential record of the appraisal

Form 3 Good Clinical Care eg audits, out of hours log Maintaining good medical practice; reflective diaries, course certificates, pdp Relationships with patients; thank you cards, complaints, patient surveys Working with colleagues Management activity Teaching training and assessing Probity and health

Appraisal Allows identification of areas of success, and future needs Sets an action plan to meet those needs, involving the individual Is confidential to appraisee & appraiser

Fitness To Practice Panels Three groups Each allocated the details of a case Discuss What “fitness to practice” issues does it raise? Which of the “duties of a doctor” are breached? What should happen to the individual concerned?

Case1 A E Doctor develops relationship The doctor was employed in the Accident & Emergency (A&E) Department of a hospital. He examined a female patient who had presented with a knee injury. During the third consultation the doctor gave the patient his personal mobile telephone number. They sent text messages which were flirtatious in manner. When the patient returned to the A&E Department on a further occasion, the doctor engaged in flirtatious conversation with her during the examination of her injured knee.

Case 1 continued On more than one occasion the doctor suggested to the patient that they should meet up. For a 12-month period the doctor pursued a sexual relationship with the patient and was also sexually intimate with her whilst on duty at the A&E Department, During the course of their sexual relationship the doctor acted or purported to act in a professional capacity in relation to the patient. He signed a statutory sickpay form for her, as her doctor at the hospital. He also provided her with a letter, as her doctor, confirming that she was fit to return to work. In that letter he also stated that he was ‘Acting Consultant in Emergency Medicine’.

Case 1 Discuss Areas of breach of duties of a doctor What do you think the consequences should be? Could this happen to you, how would you deal with this situation?

Case 1 Panels view Looked at by GMC panel fitness to practice engaging in flirtatious text messaging and conversation with her, whilst being a medical practitioner responsible for her clinical care, was inappropriate and an abuse of his position as a registered medical practitioner. The Panel noted its responsibility to protect the public interest, with particular reference to maintaining public confidence in the profession and upholding proper standards of conduct and behaviour. The public are entitled to expect that doctors will be honest and trustworthy at all times. The GMC’s Good Medical Practice (2001 edition) states at paragraph 20 that: ‘You must not allow your personal relationships to undermine the trust which patients place in you. In particular, you must not use your professional position to establish or pursue a sexual or improper emotional relationship with a patient or someone close to them.’ and at paragraph 51 that: ‘You must be honest and trustworthy when writing reports, completing or signing forms You must not write or sign documents which are false ‘

Case 1 Verdict Due to lack of insight and remorse. Risk of establishing inappropriate relationships again Incompatible with remaining on the register

Case 2 Not Available To Work GP who worked for OOH service to provide GP services to a nursing home privately Twice absented herself from her OOH post whilst on a night shift Calls had to be put through to other doctors Once found asleep at her desk Twice failed to respond to requests for a visit to nursing home When a visit was made claimed she couldn’t stay and refused to see the patient Privately treated a mole with a laser the wasn’t suitable for the job. Continued to do so despite being told by a plastic surgeon to stop Refused to acknowledge her mistake Falsified documentation about laser treatment at the FTP hearing

Case 2 Breaches Of Duties Of A Doctor Inadequately trained to use laser “Recognise and work within the limits of your competence” “Make the care of your patient your first concern” Falsified documentation “Be honest and open and act with integrity”

Case 2 Verdict Removed from medical register Failure to show insight into shortcomings Deep-seated attitudinal problems

Case 3 Delay In Treatment 32 year old driving instructor Unwell for 4/7 with flu-like symptoms Seen by OOH at 22:30 Temp 36 Clammy ?viral chest infection or pneumonia Didn’t record specific chest findings Seen again by OOH at 02:00 Tachypnoeic Cyanosed Signs consolidation left base Admitted Died at 07:00 on ICU from LLL pneumonia

Case 3 Breaches Of Duties Of A Doctor ‘an adequate assessment of the patient’s conditions, based on the history and symptoms and, if necessary, an appropriate examination’. ‘keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decision made, and the information given to patients and any drugs or other treatment prescribed’.

Case 3 Outcome Case settled by MPS

Case 4 Sick partner While looking for the practice accounts in your partner's room, you find under a bundle of papers a medical report about your partner. It is dated last month and discusses his recent medical problems which seem to centre around his infection with hepatitis C. This comes as a shock to you as you knew nothing about this. What do you do now?

Case 4 Discuss Discuss issues regarding infection Do you talk to the partner directly or involve a third party ?

Case 4 Read it thoroughly to ascertain facts, has he been diagnosed and treated? Risk to patients? Is he carrying out any exposure prone procedures. How did he acquire this infection? Drug use, needlestick? Support needed.

Case 4 Learning points The GMC guidance on serious communicable diseases says you must always take action to protect patients if you feel a colleague's health may put them at risk. Before breaching this confidence, discuss it with a partner, LMC member or your medical defence society How can doctors be reassured that their treatment is confidential? Good Medical Practice says that doctors whose health may put patients at risk should seek independent advice All doctors should be registered with a GP outside their own practice

References/ Further Reading RCGP Guide to Revalidation for GP’s April 2009 The Shipman Inquiry 5th Report Safe guarding patients: Lessons from the past proposals for the future

Any questions?

Take Home Messages Duties of a doctor Importance to trainees Ideas for portfolio entries Useful resources Aware of appraisal GPs work independently so have to be especially mindful of fitness to practice issues.