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

2. 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

3. 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

4. Law

5. 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

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

7. The Case
Ethics
PPD
Clinical Communication Skills

8. 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?

9. 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?

10. 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

11. Back to the case…

12. 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!

13. 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

14. 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

15. 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)

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

17. PPD

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

19. 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

20. 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

21. “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. 

22. 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

23. 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

24. Clinical communications

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

26. 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

27. Clinical communications: key resources
The iBook!
Lectures?
Sally

28. 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

29. 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

30. Okay so lots of information…. now what?
Sally

31. How to prepare:
sally

32. 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

33. 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

34. 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

35. 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
with any other Qs