Being a GP

Hugh McGuire

1

Hugh McGuire

Clinical Methods Walker Hall and Hurst 1990 NCBI

All Doctors need a License to Practice a prerequisite to which is the obligation to adhere to the principles and guidance of the GMCs Good Medical Practice

Everything you do as a Doctor should be justifiable and defensible with reference to the 79 statements in Good Medical Practice. Or else your License to Practice might be revoked.

There may be rapidly time-expiring definitions of what is or makes a GP – including some pointers to attributes of a good or even excellent GP but if you stick to the spirit and detail of GMP (put the patient first, treat them with respect, know your stuff, don’t abuse drugs or engage in immoral activity) you’ll be reasonably safe and a good doctor to boot whatever the context within which you work. You might even have a rewarding, fulfilling and prosperous long-term career.

Salaried GPs and others might question just how prosperous that future might be and what the opportunities are given the Elders have been busy both selling off whilst trying to preserve the Crown Jewels – undermining and commodifying the value and cost of high quality medical manpower whilst trying to grab a piece of the action. We are worth it, important and busy – you are a commodity
Nevermind also they’ve also helped kill off the NHS itself (for better or worse) as of 21/3/2012 through their zero-sum game – wrong for the right reasons or right for the wrong reasons – you choose

Being A GP is value neutral or agnostic and no more or less than what you do, how you act, and how that is perceived by the patient.

No medical/surgical speciality has a monopoly on or can lay claim to special expertise in holism, patient-centred care or whatever simply by dint of their title. The patient is often ignorant of the context within which they seek care – they just want help, advice and treatment from a competent and visibly caring practitioner.

Medical students and junior doctors nowadays are taught good behaviour and communication skills whether they go on to become Primary Care Physicians or Orthopaedic Surgeons. They always were of course but as time goes by whether due to working in relative isolation or whatever slippage may occur.

The essence of being a good doctor is being competent and visibly caring – at all times

Traditionally patients have been willing to excuse failings in competence if the practitioner appeared to be nice/caring or conversely willing to excuse a lack of social niceties (but mishaps maybe less so) if the practitioner was clearly very competent or gave the impression of being so or had a good reputation.

This may changing due to better informed patients/consumers/service users and reduced opportunities for building up a prior bank of goodwill. In any case the need to demonstrate caring competence is ever more pressing. Focussed attention to Good Medical Practice is a win-win zero-plus game for patient and clinician – ensuring and embedding safe efficient and rewarding experiences for both.

RCGP Commission on generalism

Promoting continuity of care in general practice pdf

The ACRRM Position on the Specialty of General Practice

Future of primary healthcare education: current problems and potential solutions J Lord 2003

Good Medical Practice

Good Medical Practice / Duties of A Doctor

Revised GMP and Appraisal/Revalidation Framework Oct 2011 (draft)

Good Medical Practice

Patients must be able to trust doctors with their lives and health.

To justify that trust you must show respect for human life and you must

1 Make the care of your patient your first concern

2 Protect and promote the health of patients and the public

3 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 ways that best serve patients’ interests

4 Treat patients as individuals and respect their dignity

Treat patients politely and considerately

Respect patients’ right to confidentiality

5 Work in partnership with patients

Listen to patients and respond to their concerns and preferences

Give patients the information they want or need in a way they can understand

Respect patients’ right to reach decisions with you about their treatment and care

Support patients in caring for themselves to improve and maintain their health

6 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 against patients or colleagues

Never abuse your patients’ trust in you or the public’s trust in the profession.

You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

In Good Medical Practice the terms you must and you should are used in the following ways:

You must = overriding duty or principle.

You should is used where the duty or principle will not apply in all situations or circumstances, or where there are factors outside your control that affect if or how you can comply with the guidance.

Serious or persistent failure to follow this guidance will put your registration at risk. GMP CMC 2006

These are clearly not fashionable post-modern mores or PC dictats but rules on how to act and behave to be a good Dr and retain your licence and livelihood.

More specific details and examples as to what constitutes Good Medical Practice is defined by the GMC in 79 individual statements covering 7 areas.

1 Good Clinical Care
2 Maintaining GMP
3 Teaching Training Appraising Assessing
4 Relationship with patients
5 Relationships with Colleagues
6 Probity
7 Health

GPs criticise plans for GMC regulation of doctors’ private lives Pulse Sep 2011

Success as a doctor

Success and survival as a GP
Clinical Knowledge and Skills	the value proposition
Communication skills	patients colleagues and everyone else – includes presentation skills
Caritas	enough to keep you going and remind yourself why plus ability to know your personal limitations
Technical Skills	particularly special differentiating expertise – to survive and prosper in the new health economy
Personal Hygeine	in the Greek sense – work life balance, family and interests etc

What makes a good doctor

helen jacques

lancet

morethanmedicine

good = wrt patients, the profession, colleagues and the doctor’s family.

a truly good doctor ticks all boxes but maybe some very good but less balanced examples may have been guilty of putting their patients first before other considerations

interestingly many current job adverts from APMS organisations refer to adequate rather than good or even excellent wrt the qualities below in their person specs – ditto considerations from the the GMC where “good enough” seems to set a low barrier for patients and practitioners alike, whilst some of the de facto good-thing personal attributes do have a hint of prurient political correctness and subjectiveness about them.

whatever – here are the rules – understand these are rules not suggestions or ideals for living –

your career and livelihood depends on adhering to them.

Professional qualities

A good doctor follows the profession’s code of practice, as laid down by the GMC in Good Medical Practice.

The doctor makes his patients his first concern and is respectful of the patient’s primacy.

The doctor is honest, trustworthy and ethical.

He maintains his patient’s confidentiality and establishes a relationship that is based on trust.

He obtains appropriate informed consent and decides on treatments that are in his patient’s best interests.

The doctor does not abuse his position in society.

He maintains his financial and personal integrity (probity).

A good doctor is also a safe doctor he recognizes the limits of his competence and does not put his patients at risk.

He continues to improve his knowledge, skills, attitudes and professional values

He actively learns from his work and keeps up to date.

He does not engage in unethical research.

Personal qualities

Good doctors are sensitive, caring empathetic, understanding, patient-centred and approachable.

Self-awareness

a good doctor has insight into his own motives, needs and feelings.

He is able to ask for help.

He is able to challenge his assumptions and knowledge without being defensive and resistant to change.

Good interpersonal skills

He is able to contribute to and appreciate the value of team work.

He demonstrates leadership skills and is able to support other members of the group.

He has good communication skills he is able to listen and respond appropriately.

He analyses well, marshals his facts, argues a case and establishes priorities.

He has a good sense of humour, is conscientious, tolerant, flexible and affable.

He is motivated, enthusiastic and committed to his work.

He is able to achieve a good balance between his professional and private life.

He is personally well organized and able to set good boundaries.

Leader and team player

He listens to and respects the views of all team members.

He is skilled at motivating the quieter members of the team to contribute and skilfully moderates the more voluble.

He is a skilled negotiator who provides a clear and detailed vision of what the team requires and encourages team members to work towards these goals.

What society expects

Society expects doctors to keep the patient at the focus of the consultation, to put the needs of the patient first, to be patient-centred.

Doctors can achieve patient-centredness by:

reducing sapiential authority: sapiential authority is possessed by virtue of the person’s special knowledge, expertise and experience.

Historically, the authority of doctors grew because they knew more about disease and treatments than their patients.

Patients did not question the doctors and doctors rarely admitted that they did not know the answers.

Doctors can reduce their sapiential authority by facilitating their patients’ access to

information, by explaining the treatment options in simple language and allowing patients to make the choice that suits them best, reducing moral authority: moral authority is possessed by virtue of the person’s concern for the afflicted individual.

Society expects doctors to work in the best interests of their patients. In the aftermath of the Bristol scandal and the Shipman murders, public confidence in the ‘inherent good’ of doctors has waned.

Clinical governance, with its emphasis on transparency, accountability, and cultural openness is perhaps an attempt by the profession to show society that doctors are acting in the patients’ best interests rather than in their own, reducing charismatic authority: charismatic authority is possessed by virtue of the afflicted person’s faith that the doctor will be of help.

A doctor was seen as having the healing power that was given by God to a chosen individual.

There is a general social trend towards informality and openness.

The priestly white coat has disappeared from general practice. Patients are more questioning of their doctors.

http://www.youtube.com/watch?v=zzT4lg-JW4c

http://www.youtube.com/watch?v=xCw_5GgU7JE

RCGP core statements

GMP as applied to General Practice (after Moore and Curtis, Rughani and others)

RCGP curriculum has 15 sections – 16 if one counts 15.x “things we forgot”

250 Textbooks/ Hacking Medicine has 52 sections/chapters in an attempt to remedy any oversights/look further whilst remaining usefully aligned to the RCGP framework.

The RCGP “Core Statement – Being a GP” applies 10 domains to the curriculum – any item in the curriculum or any clinical or other situation can be examined from the perspective of these 10 viewpoints /considerations. Don’ t try too hard to reconcile the maths. Nor dwell too much on Clinical Skills appearing to come 10th in the RCGP version. There may be an assumption that such skills go without saying or a need to emphasis other clearly important areas of clinical practice.

Clinicians’ core business remains dealing with people with ill-health and ahem illness – a holistic, multidisciplinary, preventive, societal approach to the same should not overlook this. See also Daniel Sokok BMJ Dec 2011 How not to get sued.

Simple frameworks are great – more complex ones cause brain-ache which and divert attention from clinical decision-making, wholism, and patient care . The map is not the terrain (though in fact thats what we’re trying to make it) KISS.

RCGP Core statement
6 Core Competencies = broad areas of expertise
1	Primary care management
2	Person-centred care
3	Specific problem-solving skills
4	A comprehensive approach
5	Community orientation
6	A holistic approach
3 Essential Attributes = “Application Features”
1	Contextual
2	Attitudinal
3	Scientific
Psychomotor skills
1	Practical/Clinical skills

Meanwhile the GMC describe 7 broad areas (Domains) of good medical practice

GMC 7 Domains of Good Medical Practice
1	Good clinical care
2	Maintaining good medical practice
3	Relationships with patients
4	Working with colleagues
5	Teaching training appraisal
6	Probity
7	Colleague Health and Performance

These were whittled down to four GMC domains wrt appraisal/revalidation but have since been expanded back up to 12 more “things” = attributes of a good GP … that your revalidation evidence needs to be mapped to

GMC Attributes of a Good GP
1.1	professional performance
1.2	knowledge and experience
1.3	records
2.1	Patient protection & improved care
2.2	risk management
2.3	own health
3.1	communication
3.2	colleagues & delegation
3.3	patient partnerships
4	Patient Protection/Improved Care
4.1	respect for patient

GMC guidance on specfic areas

General Medical Council’s ethical guidance

A-Z guide

0-18 years

Accountability in Multi-Disciplinary Teams

Appointments

Audio and Visual Recordings

Confidentiality

Conflicts of Interest

Consent

Duties of a doctor

End of life care

Expert witnesses

Good Medical Practice

Pandemic influenza

Maintaining Boundaries

Management

Personal Beliefs and Medical Practice

Prescribing

Raising Concerns

References

Reporting Convictions

Research

Professionalism

http://www.youtube.com/watch?v=5niE-DayNxw

Doctors (and medical students) are expected/required to adhere to the tenets of professionalism in their actions and in their behaviours. 24/7/365.

Appraisal revalidation and relicensing introduces the an additional requirement to demonstrate adherence and provide evidence of the same

From Liverpool VTS : Registrars should leave training with positive attitudes and values including

1. A willingness to seek self understanding and be self critical
2. A commitment to continuing professional development including continuing education
3. A willingness to make a contribution to a wider professional life and society as a whole
4. A willingness to teach others
5. A willingness to contribute to research and the furtherance of understanding where appropriate
6. A willingness to review and evaluate his work with a commitment to change where indicated
7. A willingness to work within an accepted ethical framework

Facebook and social media

hacking-medschool/social-media

social media profile can doctors have? BMJ Feb 2012

License To Practice

Licensing GMC

To practise medicine (on patients) in the UK all doctors are required by law to be both registered and hold a licence to practise.

Only doctors who are registered with a licence to practise can, for example:

Work as a doctor in the NHS

Write prescriptions

Sign death or cremation certificates

Licences will require periodic renewal by revalidation. When revalidation begins licensed doctors will be required to demonstrate to the GMC that they are practising in accordance with the generic standards of practice set by the GMC

Licensed doctors on the Specialist or GP register will in addition be required to recertify against the standards that apply to their specialty or area of practice, set by the relevant medical Royal College or Faculty and approved by the GMC

Appraisal and revalidation

Revalidation RCGP

Revalidation GMC

Regular, continuous, systematic, iterative, formative review of past achievements and constructive planning of future progress.

Appraisal relates to the doctor’s professional development within their working environment.

Revalidation involves assessment against fitness to practise standards, in line with GMC’s Good Medical Practice e

GMC 7 Domains of Good Medical Practice
1	Good clinical care
2	Maintaining good medical practice
3	Relationships with patients
4	Working with colleagues
5	Teaching training appraisal
6	Probity
7	Colleague Health and Performance

Data collected for the purposes of appraisal should satisfy the requirements of revalidation.

Appraisal portfolio

Structured record of achievement with supportive documentation. Content should reflect the role and responsibilities of the doctor.

Completion of necessary paperwork prior to the appraisal discussion is an essential prerequisite for constructive dialogue between the doctor and appraisal facilitator.

Description of activities should be succinct and accurate.

There is no need for exhaustive detail though necessary supportive documentation should be included.

The appraisal discussion will provide an opportunity for explanation and fuller account

Form 1	current demographics and cv
Form 2	brief factual description of current medical activities
Form 3	documentation in line with GMP 7
Form 3A	Good clinical careMaintenance of core clinical competenciesDoctor patient communication Premises Patient access to services Integrity of medical records Use of equipment Appropriate use of investigations Prescribing Structured approaches to chronic diseases Emergency care
Form 3B	Maintaining good medical practiceKeeping up to datePersonal and practice development planning Audit Significant event analysis Awareness of local and national health initiatives Health and safety regulations and employment matters.
Form 3C	Relationships with patientsinformation about servicesconsent to treatment Confidentiality Discrimination and prejudice against patients Complaints and formal enquiries.
Form 3D	Working with colleaguesCommunication within the practiceTeamwork and staff development Defined roles and responsibilities Referrals.
Form 3E	Teaching and training, appraising and assessinghonesty and objectivity in appraisal and assessment of colleagues.Those involved in teaching have an obligation to maintain and develop their skills
Form 3F	Probity and HealthAccuracy of published information about servicesHonesty in writing reports and signing documents Integrity of research Financial and commercial dealings Conflicts of interest Doctors are requested to consider whether or not aspects of their own health influence their ability to care for others.
Form 3G	An opportunity is provided for the doctor to share his or her insights to reflect on the achievements of the appraisal period, to consider present developmental needs and to identify constraints to progress.Form4
Form 4	Accurate summary of both the appraisal submission and issues identified in discussionAn outline of the doctor’s learning and developmental strategy over the subsequent twelve months will be included.The doctor and the appraiser will each retain a copy of Form 4.
Form 5	Declaration of satisfactorily completion of Appraisal. The appraisal facilitator will send a copy of the signed document to the central Appraisal OfficeThe doctor may be assured that the submission and content of the appraisal discussion will be treated as confidential. The appraiser will send the second copies to the relevant Appraisal Coordinator, who will undertake a learning needs analysis and forward the data to the GP Appraisal Unit.All records will be held on a secure basis and access complies fully with the requirements of The Data Protection Act.

Doctors health stress and burnout

Doctors support network

Sick Drs Trust

Practitioner Health Programme

British Doctors and Dentists Group

National Clinical Assessment

Invisible Patients DH

Drs mental Health DH review

The Goldberg Files – Combating MedSchool Stress

The Pressure Point MPS Sep 2011

Alcoholics Anonymous

Narcotics Anonymous

Workplace Bullying BMA 2006

Suicide in Doctors BMA Oct 2011

Doctors Heath BMA.org

BMA Doctors for Doctors Telephone Counseling and Support Service 08459200169 020 7383 6739

Why this matters – nevermind any faux-pastoral concerns re the welfare of the medical workforce – Ill health is a major contributor to impaired performance, inefficiency and risks to patient safety.

4 stages of burnout
overwork
frustration
resentment
depression

Signs of stress & burnout
Emotional Lability	irritibility anger apathy fatigue cynicism low self-esteem
Decreased productivity	lateness poor time keeping falling behind with paperwork, missing deadlines and overlooking tasks, poor clinical deciscions and communication
Sickness	Repetitive absences (often short notice) alcohol or drug misuse

As stress increases, productivity increases until it peaks. Beyond this, further loading on the individual leads to decreased performance (often depicted as bellshaped curve as below but the downslope is more acute and sudden like the failure of a spring or wire beyond its elastic limits).

http://www.youtube.com/watch?v=XkMth4paNko

Poorly performing doctors

Support service to NHS primary care, hospital and community trust, the prison health service and the defence medical services, when they are faced with concerns over the performance of an individual doctor.

Protecting patients

All doctors have a duty to maintain good practice

Patients must be protected from poor practice

Dysfunctional doctors should be helped back to practice wherever appropriate

Openness about doctors’ performance is essential to public trust

Prevalence of poorly performing doctors

6 % senior hospital workers in any 5 year period.

3 – 5 GPs per health authority area.

Why does it occur?

Problems with:

Doctor’s health

Knowledge Skills Attitudes

General clinical competences

Organisation and system failures

Causes of stress and illness

Patients

Complaints or litigation

Increased workload (increased numbers or expectations)

GP – Patient communication

Lack of consultation skills

Poor emotional housekeeping

Unnecessary interruptions to consultations

Doctors Themselves

Unrealistic expectations of themselves (the demon of perfection)

Lack of intellectual stimulation

Poor time management or organisation skills

Health issues

Home issues (finance, relationships, dependants etc)

Practice factors

Increased actual workload (increasing list size or increasing patient expectations)

Decreased GP numbers (maternity leave, sick doctor, holidays)

Resource input not keeping pace with increasing demand

Poor organisation

Poor peer or professional support

Dysfunctional partnership

Organisational causes of poor quality medical care

A provider orientated service

Emphasis on speed of access to service over quality

Self accountability and paternalism

Waiting for the damage to be done

Lack of coordination of all involved in regulation

How to identify and investigate allegations of poor performance.

‘Good Medical Practice’ requires ALL doctors to take steps if they believe that the health, conduct or performance of a colleague, may be putting patients at risk of harm.

There are multiple methods to do so following a single incident, or more significantly, a pattern of repeated poor performance.

Who does this?

Practice P.C.T. N.C.A.S. G.M.C.

Practice

Concerns about performance are often expressed and incidents uncovered long before the individual self discloses, is referred to the PCT, NCAS, GMC etc or GP partners intervene. Early intervention at this stage, however traumatic for the Practice, can avoid significant events and provided a better outcome for the doctor concerned.

PCT

Different ways an allegation is made/ brought to attention

An NHS complaint An independent panel review

Health authority disciplinary inquest Ombudsman’s enquiry

GMC inquiry Performance procedures

Conduct procedures Health procedures

Inquest Claim for negligence

Police enquiry Clinical governance review

Analysis of PACT data by PCT Healthcare commission review

Employer’s investigation Internal and public enquiries.

The PCT may assess a doctor and consider referral to their performance assessment team which comprise clinical and lay members e.g. Practice Managers

Competences needed by assessment team members:

Information gathering

Communication skills

Team working skills

Leadership skills

Good track record in own professional field.

Possible flow of an investigation

PCT INFORMATION GROUP

Gather data and process allegations

Appoint case manager

Receives report of case

Advises Chief Executive on possible actions

POSSIBLE REPONSES (NOT EXCLUSIVE)

No action

Continued surveillance

Dialogue with clinician or practice

Referral to a local Performance Assessment Team

Referral to NCAS

Referral to GMC

Exclude from practice pending inquiry

Occupational health assessment.

POSSIBLE TREAMENTS

No action,

Health intervention

Educational intervention

Principles governing PCT performance procedures.

European law

Proportionality

Equality and respect for fundamental rights

Legitimate expectations

Legal certainty.

Natural justice

Hear the other side

Rule against bias

Follow procedures

Must look for mitigating circumstances.

Follow code of practice for confidentiality.

Components of NCAS assessments

Occupational health assessment

Behavioural assessment

Basic knowledge screen

Review of information provided by the GP and the referring organisation prior to assessment

Check of practice equipment

Views of colleagues about doctor’s performance

Patients views of practice and satisfaction with consultations

Direct observation of practice

Medical record review

Practice based discussion clinical and managerial.

Referring organisation follow up after NCAA assessment.

can have review in 6 12 months if planned

G.M.C. Referral/ Investigation

If GMC referral usual follows very severe allegations against a doctor or if the doctor is referred from PCT or NCAA.

The GMC will review the complaint carefully to see if there are issues that they need to investigate. If they decide that they do not need to investigate, then they may pass the complaint back to the doctor’s employer so that it can be handled locally.

If they do decide to investigate, they will need to show the doctor the full details of the complaint. Once they have received his or her comments, the complainant will be given a chance to respond.

Once they have collected the information they need, the case will be considered by two case examiners (one is medical, the other nonmedical) who are senior GMC staff.

They will consider whether the concerns are serious enough for the doctor to attend a hearing. If they are, a panel will decide at the hearing if the doctor is fit to practice. A Fitness to Practice Panel hearing is the final stage of GMC procedures.

Investigation is in two parts

Investigation

Adjudication

After a hearing the GMC may

Issue a warning

Put conditions on the doctor’s registration so that they are only allowed to do medical work under supervision or so that they are restricted to certain areas of practice

Agree undertakings, for example they agree to retrain, or work under supervision

Suspend the doctor’s name from the register – so that they cannot practice during the suspension period

Remove the doctor’s name from the register.

The doctor can appeal to the High Court to challenge the outcome.

DH Annual Report of the Chief Medical Officer Sir Liam Donaldson 2002

Traditional Barriers

High tolerance of deviant behaviour among doctors.

The fact that whistleblowing can be seen as disloyal.

Ambiguity of where to draw the line between acceptable and unacceptable.