Sally Barker and Lydia daniels, 4th Year FOCP Exam Lydia Sally Barker and Lydia daniels, 4th Year

Tutorial Outline General information Law The Case Revision tips Exam tips The Case General ethical arguments Key ethical themes and questions Key PPD themes and questions Key Clin Comms themes and questions Preparing your 20 pages Lydia We’ve picked out some potential questions You can use this as a structure for spotting other potential questions

General Exam Information Exam Length: 2 hours 45 minutes 10 Essay Questions based on the pre-released Case Ethics Clinical Communication PPD 30 Law SBA’s Look over the essay questions, then do the law SBA’s, then go back to answer the essay questions. Sally. (1hr, 1hr 45) Remember it is better to answer ALL of the questions rather than trying to make 8/11 perfect. DIVIDE YOUR TIME WELL BETWEEN ETHICS/CC/PPD (and LAW!) – the are all worth roughly the same and CC/PPD are easy marks

Law

Law: Revision Tips The Medical Law E-lectures on Blackboard are golden. Take note of the specific examples. Review your lectures on MedLearn. Condense your notes as much as possible. Lydia

Law: exam tips Read every part of the question: Sally

The Case Ethics PPD Clinical Communication Skills

General ethical arguments FOUR PILLARS The principle of autonomy The principle of beneficence The principle of non-maleficence The principle of justice Can we treat everybody equally? What about when autonomy conflicts with non-maleficence? Lydia. Autonomy: Dworkin:  the ability to act out of genuine preference or character or conviction or a sense of self.  - Does it show respect for the patient and their right to make decisions? Benificence: a medical professional should always do good for their patients. Does it benefit the patient? Non-maleficence: one person should not cause harm to others. Does it harm the patient? Justice: equality for all. Are there consequences in the wider community? Who defines the best interests and how?

General ethical arguments continued… Honesty vs confidentiality Paternalism Deontological Consequentialism Utilitarianism Virtue-based What is the greater good? Sally. Paternalism: when someone in authority restricts the freedom and responsibilities of another Deontological: the moral approach that certain things are right or wrong regardless of the consequences  Consequentialism: to judge whether an action is ethically right or wrong by the consequences it produces  Utilitarianism: the moral action is the one that provides the greatest overall happiness (a version of consequentialism) Virtue- based: “virtue is a character trait human being needs to flourish/live well” – Aristotle  Are the consequences 100% predictable?

You can use these to frame your answers: ETHICAL PRINCIPLE GENERAL QUOTE GENERAL PROS GENERAL CONS CASE EXAMPLE Deontology “Always recognize that human individuals are ends, and do not use them as means to your ends” Immanuel Kant Promotes a patient-centered approach. In alignment with GMC guidelines/Hippocratic Oath. By ignoring consequences, not in alignment with evidence-based medicine. It was the duty of the healthcare team to ensure Mrs Begum had an ITU bed for best possible care. However this ignores the probability of her recovery and shortage of resources. etc Sally

Back to the case…

Ethics: key themes: Confidentiality Autonomy vs Best interests Resource allocation Good practice regarding prescribing (Capacity and competence) Lydia These are the key themes that we’ve been able to pick out from reading the case. You might want to go through and label/highlight the relevant parts of the case. Be aware that they might extrapolate the case in the exam!

Ethics potential questions Confidentiality Do family members have a right to know patient information? Autonomy vs Best interests Was the use of paternalism valid in this situation? Who’s interpretation of the patient’s best interests are more valid in this case, the medical professional’s or the family’s? Resource allocation Should the patients age be a factor in the allocation of ITU beds? What are the ethical arguments for and against the withdrawal of IV fluids from a palliative patient? Good practice regarding prescribing Was Dr Mirza right to prescribe antidepressants for his aunt? Lydia

Should the patient’s age be a factor in the allocation of ITU beds? YES NO Consequentialist- younger patients have a greater likelihood of recovery to full health and, once healthy, have longer and better opportunities to usefully contribute to society- John Harris, source 2. Counter-consequentialist: it is impossible to know the lifespan of any patient or their future contribution to society- as described as the “anti-ageist” argument by Shaw, source 3. Paternalism: the medical professionals know the condition of each patient much better than the patients themselves. Therefore they would have final say on who receives maximal treatment and, generally, younger patients are more likely to responds well to intensive therapy. As discussed by Raw and Fletcher, source 1. Deontology- “Always recognize that human individuals are ends and do not use them as a means to your ends”- Kant. The duty of the doctor is to care for their patients as their first concern- GMC guidelines. This should not depend on the doctor’s personal view of the worth of that patient. Utilitarianism- younger people are more likely to have children dependent on them, therefore greater happiness is achieved by saving their lives. Justice- older people deserve better care because they have already served society throughout adulthood- “fair inning argument” from e-lectures. Conclusion:…. Sally

Should Drs prescribe for themselves and family? YES NO Autonomy - doctors have competence in prescribing– should recognise their ability to treat themselves for minor illnesses. Doctors not trusted to treat themselves and close family ~ mistrust in the profession Non-maleficence/consequentialist – risk that the medication prescribed could fuel addictions. Serious consequences if the person has been misdiagnosed. May lead to gaps in medical notes ~ future difficulties. Beneficence - In cases of emergency, GMC permits prescribing to self or someone close if i) necessary to save a life ii) avoid serious deterioration in health, or iii) alleviate otherwise uncontrollable pain or distress. Beneficence – some argue that a doctor is unable to view themselves/family objectively, so medical advice should be sought from an unrelated doctor – more balanced tx Utilitarian - Saving of time and NHS resources i.e. family member having to visit out-of-hours service Utilitarian - unfair if the doctor is manipulating NHS resources – may result in less availability of medications for patients (abuse of privilege) Conclusion:…. Dr Mirza had been prescribing antidepressants Source 7 (+ read GMC guidance)

Important: Consider both sides Be clear and concise No bullet points allowed Conclusions are important Sally

PPD

PPD key themes: The role of the medical student The existence of professional hierarchy Error Sally

PPD example questions: The role of the medical student What should the medical student do next in this situation? What can the medical student do to exercise resilience? The existence of professional hierarchy Is the professional hierarchy beneficial to medical practice? Error How did medical error contribute to the hospitalisation/lack of care/final outcome of Mrs Begum? Sally

Key resources: GMC guidelines for MEDICAL STUDENTS To recognize and work within limits of competence Respect the decisions and rights of patients Behave with courtesy Report any concerns they have about patient safety to the appropriate person… GMC guidelines for DOCTORS Care of the patients is the first concern Respect the patients right to confidentiality Never abuse the patient’s trust in you… The iBook! Lydia https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/professional-behaviour-and-fitness-to-practise

“You felt bullied by Dr Jones and went on to report the experience to your personal tutor, who advised you to talk to Dr Jones about it the next day. ” What are the benefits of this course of action? FOR THE PATIENT: GMC guidelines for medical students: “Work with colleagues in the ways that best serve patients’ interests.” FOR THE STUDENT: May reduce the cycle of vindicate role-modelling. Haglund et al 2009 indicate such experience can grow the resilience of the medical student, but this requires reflection with a mentor. Similarly,  Timm et al, source 6,  found in a survey….. nursing students were much more likely to discuss their experience with a lead nurse, and correspondingly found the experience less traumatic. Timm et al also noted that failure to resolve the issue resulted in students avoiding that clinician, missing out on valuable learning opportunities.  FOR THE DOCTOR: By discussing Dr Jones’ behaviour with her, it may aid her awareness of Johari’s window…. Sally: there a multiple ways to strcuture this type of question. Could do by source OR could considor the benefits for the medical student, the dr and the patient in turn, as attempted here. 

Considering it from a HCP perspective: Bullying Source 5 Impact of Bullying Barriers to reporting Lower job satisfaction Concern that nothing would change Intentions to leave work Targets labelled as troublemakers Poorer psychological health Seniority of the bully affecting career progress ‘depression, helplessness, anxiety and despair’ ‘suicide ideation; psychosomatic and musculo-skeletal complaints; risk of cardiovascular disease Uncertain how policies implemented/how it would be managed Lydia See also Source 6 – more specific to medical students

How did medical error contribute to the hospitalisation/lack of care/final outcome of Mrs Begum? General example but the message is; it’s useful to know on error framework you can reference to.  SallySWISS CHEESE MODEL: Every step in a process has potential for failure, to varying degrees. Ideal system is analogous to a stack of Swiss cheese slices. Consider the holes to be opportunities for a process to fail, and each of the slices as “defensive layers” in the process. An error may allow a problem to pass through a hole in one layer, but in the next layer the holes are in different places, and the problem should be caught. Each layer is a defence against potential error impacting the outcome. Although many layers of defense lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident to occur. SWISS CHEESE MODEL Reason 1991

Clinical communications

Clinical communications: key themes: Effective handovers Explaining procedures Cross-cultural communication Lydia

Clinical communications: example questions: Effective handovers What constitutes an effective handover? telephone - SBAR Explaining procedures Cross-cultural communication What factors should be taken into account in cross-cultural communication? What skills are needed in cross-cultural communication i.e. to use an interpreter effectively in a consultation? Lydia

Clinical communications: key resources The iBook! Lectures? Sally

What factors should be taken into account in cross-cultural communication? Sensitivity to cultural diversity, stereotyping and prejudice Recognise impact of your professional background General skills of good communication Specific skills to negotiate communication barriers Be patient and show interest, establishing concerns Simplify language Use diagrams Use of interpreters (see Figure 3 in Source 8) Lydia Exploring Iceberg Model Benefits Dr interpretations of patient’s needs = better sharing of info = more effective outcome

Explaining a procedure “Explains the procedure, as well as possible risks and expected recovery time” Provide the correct amount and type of information Determine pt’s ICE Organized info so it’s logical, clear and easy to follow Ask pt how much info they want to know & gauge how much pt knows already “a good starting point is for you to tell me what you already know” Relate explanation to pt’s initial ICE Maynard’s Interactional alignment: greater chance of Mr B accepting if Dr aligns with his ideas Give Procedural – what happens before/during/after OR Emotional – more focused on how they will feel during and after. Use categorization/signposting (Ley) e.g. ‘I have 3 things to tell you.’ Aiding accurate recall and understanding Ensure pt knows they can ask questions throughout the discussion Regularly check pt’s understanding → ask them to summarise what you have said (chunk & check)*** Avoid jargon/explain it Use aids e.g. draw diagrams, give leaflets Achieving a shared understanding Address concerns, expectations, discuss fears (ICE) Ensure pt understands risks & benefits of procedure, and why it needs to be done Planning shared decision-making Give them sufficient time to decide Make sure they’re informed so they can give consent/a rational decision Sally What patient will want to know about a procedure: what is it in lay terms, when it will take place, where it will happen, what preparation is necessary, how long it will last, how painful it will be, will I be awake, who will do it, who else will be present, risks if any, side/after effects, any alternatives, when will results be available and how

Okay so lots of information…. now what? Sally

How to prepare: sally

On your own: Do the law e-lectures Continually condense notes Do the recommended (and extra reading) Condense the key facts into small paragraphs for your notes Make a table of the core ethical arguments for your notes Sally

In a group: Go through the case together and come up with as many questions as you can – don’t just rely the one’s we’ve covered today! Divide them up between you and set a date for everyone to complete answers on a shared document Remember – the sources give clues for potential questions! Once completed, incorporate into your notes Lydia

So your notes… 20 pages including: Colour code! Structure! Ethical themes table Possible questions and answer frameworks A couple of pages of law notes And a couple of pages of recommended reading summaries Colour code! Structure! Practise using your question plan in timed conditions Know your notes as well as you can… Both

Thank you for listening & good luck! You are a medical student coming out of a long, tiring day at St Peter’s. Your colleague spots some coffee that has most likely been left over from a conference that day, but you are unsure whether students are allowed to take the remains. Your colleague says it's "probably fine" and starts pouring a cup. Rank in order the following actions in response: A. Fill out a clinical incident form. B. Use passive-aggressive communication skills to remind your colleague that the Hippocratic Oath requires doctors to aspire to a rigorous code of ethics in all aspects of their life, both beverage-related and non-beverage-related, and that by taking this coffee he risks bringing the profession into disrepute. C. Remind your colleague that his professional duties extend to evidence-based medicine. By taking a cup of coffee he would cause the supplies to run out sooner, forcing the researchers into a state of caffeine withdrawal. This would set their work back, thereby depriving future generations of valuable research, and posing a major threat to patient safety. D. Call hospital security immediately ± sedation E. Ask the nurse to bleep your consultant, who is currently attending to a deteriorating patient in resus, and ask her to come to the education centre and publicly reprimand your colleague. F. Take some coffee yourself, and ask if anyone has seen any biscuits lying around. Please fill in feedback so the slides can be released! bit.ly/muslimmedics Email LED15@ic.ac.uk with any other Qs