1. Consulting Others & Medicolegal Risk Reduction Max Brinsmead MB BS PhD May 2015

2. Consultation advice for JMOs First know how to find your consultant First know how to find your consultant When to consult depends upon… When to consult depends upon… The experience of the JMO The experience of the JMO The wishes of the consultant The wishes of the consultant In the beginning report EVERYTHING In the beginning report EVERYTHING And this will change with time And this will change with time Thereafter in life, if in doubt, CONSULT Thereafter in life, if in doubt, CONSULT Always record consultation in the notes Always record consultation in the notes If you want the consultant to come then ask unequivocally and write that in the notes If you want the consultant to come then ask unequivocally and write that in the notes If the consultant does not come then ask again If the consultant does not come then ask again

3. Who to Consult? Out of courtesy, consult first with your line manager Out of courtesy, consult first with your line manager Thereafter consult the person most likely to be able to help Thereafter consult the person most likely to be able to help This can occur at any time… This can occur at any time… At the end of the day or week At the end of the day or week From the bedside From the bedside From an operating theatre From an operating theatre And by any means… And by any means… Phone Phone Letter Letter E-mail E-mail

4. Preparing for Consultation First ask yourself these three questions… First ask yourself these three questions… What is the problem What is the problem What do you want from the consultation? What do you want from the consultation? What information is relevant? What information is relevant? Then make sure that you have all relevant information ready… Then make sure that you have all relevant information ready… History, examination, tests History, examination, tests Significant negative facts Significant negative facts Find a suitable time and place to make the consultation Find a suitable time and place to make the consultation

5. How to Consult Courtesy is of the essence Courtesy is of the essence Identify yourself and the consultant Identify yourself and the consultant Ask if you can proceed with a consultation Ask if you can proceed with a consultation Put the problem up front… Put the problem up front… Summarise in one sentence and with one breath Summarise in one sentence and with one breath Indicate the degree of urgency Indicate the degree of urgency Then give background as requested Then give background as requested Don’t tell the consultant what you want him to do Don’t tell the consultant what you want him to do This is a consultation, not an order This is a consultation, not an order If possible, have your own management plan ready for discussion If possible, have your own management plan ready for discussion

6. Consulting with another Discipline Obtain consent Obtain consent From your line manager From your line manager From the patient From the patient Follow local protocol… Follow local protocol… But courtesy suggests that you consult first with your peer But courtesy suggests that you consult first with your peer

7. Medicolegal Risk Reduction during Patient Consultation Review previous notes Review previous notes Privacy Privacy Interruptions Interruptions Empathy Empathy Making assumptions Making assumptions Boundaries in the therapeutic relationship Boundaries in the therapeutic relationship A second opinion? A second opinion?

8. Examination Obtaining consent Obtaining consent Specific advice Specific advice Privacy Privacy Chaperone Chaperone Boundaries Boundaries

9. Consent to Procedure General and specific risks General and specific risks Dealing with patient’s specific concerns Dealing with patient’s specific concerns Options discussed Options discussed Relatives welcome Relatives welcome Diagrams and brochures Diagrams and brochures Patient to feedback Patient to feedback Documentation Documentation Who signs the form? Who signs the form?

10. In Theatre Check equipment Check equipment Check with the staff Check with the staff Check the patient Check the patient Position the patient Position the patient Check the notes Check the notes Supervising juniors Supervising juniors

11. Postoperative care Following protocol Following protocol Patient told what to expect Patient told what to expect Patient knows what to do if something goes wrong Patient knows what to do if something goes wrong Role delineation Role delineation Surgeon Surgeon Anaesthetist Anaesthetist Review the patient before discharge Review the patient before discharge Special circumstances e.g. patient to travel Special circumstances e.g. patient to travel

12. Medications Explain risks and side effects Explain risks and side effects Patient must know what to do if questions or problems arise Patient must know what to do if questions or problems arise Review notes before prescribing Review notes before prescribing Monitor response to therapy Monitor response to therapy Review medication regularly Review medication regularly

13. Difficult Patients Personality disorder Personality disorder Psychiatric disorder Psychiatric disorder Those with unrealistic expectations Those with unrealistic expectations Communication difficulties Communication difficulties Low intelligence Low intelligence Language Language Cultural Cultural You have bad news You have bad news

14. Colleagues and Staff Roles and responsibilities delineated Roles and responsibilities delineated Working collaboratively Working collaboratively Don’t undermine Don’t undermine Make yourself available for consultation Make yourself available for consultation All staff to understand privacy and confidentiality All staff to understand privacy and confidentiality A multidisciplinary approach to complex problems A multidisciplinary approach to complex problems Requires good communication Requires good communication

15. Antenatal Care and Delivery Explaining care plan and tests Explaining care plan and tests Written guidelines for midwives Written guidelines for midwives Reviewing a CTG Reviewing a CTG Labour review Labour review Review all available data Review all available data Record the time Record the time Document any differences to midwife obs. Document any differences to midwife obs. Document your advice Document your advice Involving the patient in the decisions Involving the patient in the decisions Documenting special cases Documenting special cases

16. General measures Ensuring patient follow up Ensuring patient follow up Communication with others Communication with others Dealing with tests Dealing with tests Normal Normal Abnormal Abnormal Medical Records Medical Records “If it isn’t written down it didn’t happen” “If it isn’t written down it didn’t happen”

17. When things go wrong… Timely response Timely response Empathy but not liability Empathy but not liability Make contemporary notes in detail Make contemporary notes in detail Review protocols Review protocols Root cause analysis Root cause analysis Have a mechanism for handling complaints Have a mechanism for handling complaints