Good Medical Practice Good Practice in Psychiatry

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Good Medical PracticeGood Practice in Psychiatry

• Dr. Nikolaos Patelis

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Introduction

• What is Good Medical Practice?
• Principles of Good Practice
• Good practice in Psychiatry

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What is Good Practice?

• Discussion (5)

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Definition of Good Practice

• Giving a definition and setting universal
  guidelines is almost impossible as the above are
  not always acceptable to any practicing doctor,
  granted that there are as many types of practices
  as there many types of doctors.

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Definition of Good Practice (2)

• A possible definition could be
• All medical actions and decisions that can be
  supported scientifically and can be justified
  whenever there is a question or doubt raised
  about them, are called
• Good Practice.

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What are the ingredients to GP?

• Professional integrity
• Communication skills
• Ethical behavior
• Treating patients with dignity
• Being a team player

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Principles of Good Practice
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Principles of Good Practice

• The doctor as a person
• The doctor and the practice
• The doctor and the patient
• The doctor as a team player
• The doctor and the employer
• The doctor in solo practice
• The doctor in institutional and public practice
• The doctor in dilemma

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1. The doctor as a person

• 1.1.Trust
• Be polite and honest
• Respect patients dignity and privacy
• Respect the right of patients to a second opinion
• Be readily accessible to patients and colleagues
  when you are on duty
• Respect the right of patients to decline to take
  part in teaching or research and ensure that
  their refusal does not adversely affect your
  relationship with them

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1. The doctor as a person

• 1.2.Communication
• Listen to patients and respect their views
• Use simple language that patients understand.
• Protect confidential information. Share
  information only if the patient gives consent.

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2. The doctor the practice

• Recognize the limits of your professional
  competence
• Keep clear, accurate, legible and contemporaneous
  records
• Prescribe drugs only where you have adequate
  knowledge of the patient's health and medical
  needs
• Make efficient use of the resources available to
  you
• Keep your professional knowledge and skills up to
  date
• Make sure that your personal beliefs do not
  prejudice your patients care
• Act quickly to protect patients from risk
• Avoid abusing your position as a doctor

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3. The doctor the patient

• The patient who seeks medical help is in an
  anxious frame of mind. So the patient makes many
  personal sacrifices. He surrenders his
  individuality and privacy to the doctor, exposing
  his innermost secrets and personal problems to
  the doctor who is a total stranger. The doctors
  only claim to this privilege is his education and
  training as a compassionate healer.
• Be attentive and a good listener
• Be polite and friendly. Avoid being business-like
• Be gentle during the examination when possible
  always use a chaperon
• Be clear and discreet when discussing possible
  diagnosis
• Give relevant options for treatment
• End this relationship based only on professional
  criteria

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4. The doctor as a team player

• You must treat your colleagues fairly and you
  must not discriminate between colleagues
• You must not make malicious judgment or unfounded
  criticism of colleagues
• Respect skills and contribution of colleagues
• Be readily accessible to colleagues when you are
  on duty
• Be willing to consult colleagues
• Make sure that your patients and colleagues
  understand your professional status and
  specialty, your role and responsibilities in the
  team and who is responsible for each aspect of
  patients care

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5. The doctor the employer

• The doctor must remember his primary professional
  responsibility to patients when operating under
  financial constraints
• If the doctor manages finances, he must make sure
  that the funds are used for the purpose for which
  they were intended and are kept in a separate
  account from personal finances
• Before taking part in discussions about buying
  goods or services, the doctor must declare any
  financial or commercial interest which he or his
  family might have in the purchase

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6. The doctor in solo practice

• The doctor in solo practice often has financial
  obligations, having to bear rentals of
  facilities, leasing, staff salaries and other
  expenses. Such a doctor may be vulnerable to
  demands by patients or by employers.
• The doctor should not compromise professional and
  ethical rules to accommodate unfair demands by
  such persons for financial rewards or benefits
• The doctor must not tout nor canvass for
  patients, nor lobby with employers or other
  colleagues

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7. The doctor in public practice

• The doctor practicing in an institutional or
  public facility has to constantly keep in mind
  that health resources generally are costly,
  precious and finite
• The fundamentals of patient care by doctors are
  universal and apply equally whether the doctor is
  in public or in private practice
• In hospitals with wards with classes, the doctor
  must remember that the class refers to the
  comfort facilities in the rooms and not to the
  standard or level of medical care.
• Patients newly admitted to the ward should be
  seen as soon as possible, examined and treatment
  commenced without delay
• Patients need to be attended regularly, and
  rounds conducted at least once a day, and more
  frequently in ill patients

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8. The doctor in dilemma

• A patient who complains about his treatment has a
  right to expect a response. The doctor has a
  professional responsibility to deal with
  complaints constructively and honestly without
  being prejudiced to the patients further
  treatment
• If a patient has suffered serious harm, the
  doctor should act immediately to put matters
  right. The patient must receive a proper
  explanation and the short and long term effects.
  When appropriate the doctor should offer an
  apology
• If a patient has died, the doctor should explain,
  to the best of his knowledge, the reasons for,
  and the circumstances of, the death to the
  next-of-kin
• The doctor must co-operate fully with any formal
  enquiry.

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Good Practice in Psychiatry
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What are the special characteristics of Good
Practice in Psychiatry?

• Discussion (5)

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Special characteristics of GP in Psychiatry

• The psychiatrist should
• Be able to communicate with patients with
  learning disabilities, drug alcohol abusers,
  children, adolescents and families as a whole
• Know in detail the legal framework of patients
  consent and disclosure of information (Abarbanel
  study)

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The Abarbanel Study

• The study was conducted in Abarbanel Mental
  Health Center among 113 patients and the article
  is published in Harefuah Medical Journal by Prof
  S. Tyano and Dr. R. Finzi.
• Conclusion Almost two thirds of the patients
  where unfit to give their informed consent. The
  patients consent to hospitalization was very
  problematic and probably resulted from their
  submission to family pressures or from the reason
  for their hospitalization.
• The problem occurred to disclosure of
  information, as well. It was the psychiatrists
  decision whether to or not to share information
  with the patients next-to-kin.

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Skills for all psychiatrists

• Knowledge of the differing presentations of
  mental health problems in young persons, those
  with learning disability, older adults and those
  with physical health problems
• Knowledge on substance misuse and its effect on
  physical and mental health
• Skills in the assessment of psychiatric disorder
  complicated by or associated with substance
  misuse
• Skills in the immediate management of these
  conditions
• Sufficient knowledge of management strategies and
  local services to access the appropriate care for
  these conditions
• Knowledge and skills in these areas will need to
  be maintained and updated.

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Good practice within various aspects of psychiatry

• Child and adolescent psychiatry
• Psychiatry of learning disability
• Psychiatry of old age
• Psychotherapy
• Rehabilitation psychiatry
• Psychiatry of substance misuse

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1. Child Adolescent Psychiatry

• having a detailed understanding of the
  developmental, psychological, behavioral,
  systemic, physical and social factors in the
  presentation of child and adolescent mental
  disorders
• being able to engage, communicate and effectively
  intervene with children, adolescents and adults
  individually and in families balancing the needs
  of children and parents in families, and acting
  in the best interests of children/young people
• balancing the maintenance of confidentiality and
  the need for child protection gaining the
  childs consent to assessment and treatment and,
  where necessary, considering the use of the most
  appropriate legal orders to assess and/or treat
  the child/young person
• having a detailed knowledge of the relevant
  legislation relating to children, and being aware
  of and following local child protection
  procedures assessing parenting skills and
  planning for the management and treatment of
  identified deficits
• prescribing with due care, having regard for the
  age and wishes of the child, parents wishes,
  side-effects and the overall treatment plan.

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2. Psychiatry of learning disability

• treating people with learning disabilities with
  respect
• enabling effective and reciprocal communication
  with people with communication impairments and
  with their families and carers
• being prepared to advocate on behalf of people
  with learning disabilities, and encouraging them
  in self- advocacy
• having the specific knowledge and competence
  required for the assessment and treatment of
  psychiatric and behavioral problems in people
  with learning disabilities
• understanding the complex interplay between the
  learning disability, other developmental disorder
  (such as autistic-spectrum disorders), social
  disadvantage and adverse experiences, abnormal
  brain development (including disorders such as
  epilepsy) and mental illnesses.

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3. Psychiatry of old age

• an avoidance of stereotyping, regardless of
  patients age or disability
• being skilled in the assessment of confusional
  states and in communicating with patients who
  have confusional states
• recognition that the needs and wishes of patients
  and their families are not always similar
• being cognisant of the interrelationship of
  biological, psychological and social factors in
  the etiology, presentation and management of both
  functional and organic mental illness in old age
• understanding how treatments developed for
  working-age adults may be adapted for an older
  population

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4. Psychotherapy

• paying particular attention to boundaries, time
  and place, and being sensitive to the
  psychological implications of transgressing
  boundaries, e.g. through touch and/or
  self-revelation
• being especially sensitive to issues of
  confidentiality
• being aware of the extent and limitations of
  psychotherapy training, and staying within the
  limits of competence
• respecting the different models operating within
  both psychiatry and psychotherapy
• being well-versed in the evidence base underlying
  psychological therapies, and not undertaking
  treatments for which there is no established
  clinical or scientific evidence
• recognition of the particular psychotherapeutic
  needs of minority groups (identified by
  ethnicity, gender, sexual orientation, age and
  disability)

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5. Rehabilitation psychiatry

• identifying the biological, social and
  psychological components that contribute to
  disability
• making assessment of change within the mental,
  social, cultural and psychological state
• assessing and evaluating the social needs of a
  person with chronic mental illness, and being
  familiar with the processes that lead to better
  housing, social support, benefit matters and
  occupation

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6. Psychiatry of substance misuse

• awareness of the need for careful assessment and
  advocacy for this patient group, who tend to
  encounter particular forms of stigma
• knowledge and awareness of the types and
  prevalence of legal and illegal drugs, alcohol,
  prescribed drugs and over-the-counter medications
  with misuse potential
• recognition that substance misuse problems affect
  all age groups and all sections of society
• knowledge and skills to assess those with complex
  physical problems and substance misuse
• knowledge and specific competence to manage
  complex drug and alcohol dependencies, using
  pharmacological and psychological approaches in a
  variety of settings
• recognition of the high risk of substance misuse
  within the medical profession, and competence to
  treat it