Fitness to Practice

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Fitness to Practice

• Nadia Anderson
• David Tatham
• Ramesh Mehay
• Bradford VTS 2009

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Introduction

• What is fitness to practice?
• Why is it important?
• Is there any published guidance?
• And where can I find it?
• How does it relate to us now as trainees?
• What does it mean in the future?

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Plan

• What is fitness to practice?
• Why is it important?
• What areas of our work does it cover?
• What guidance is there and where can we find it?
• How does fitness to practice affect us as
  trainees?
• Revalidation
• Cases ( how to avoid hot water)

Small group work Min-lecture Quiz
Mini-lecture Inter-active session
Tea Biscuits
Mini-lecture
Mini fitness to practice committees!
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Small Group Work

• 10-15 mins
• 3 questions
• What is fitness to practice?
• Where can we find guidance?
• What parts of our work does it cover?

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What Is Fitness To Practice?

• To practise safely, doctors must be competent in
  what they do. They must establish and maintain
  effective relationships with patients, respect
  patients autonomy and act responsibly and
  appropriately if they or a colleague fall ill and
  their performance suffers.
• But these attributes, while essential, are not
  enough. Doctors have a respected position in
  society and their work gives them privileged
  access to patients, some of whom may be very
  vulnerable. A doctor whose conduct has shown that
  he cannot justify the trust placed in him should
  not continue in unrestricted practice while that
  remains the case.
• The Meaning of Fitness to Practice
• GMC 2005

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• Fitness to practice is about being a good
  doctor.
• .and being a good doctor is about good medical
  practice.
• .which is the title of the guidance document
  issued by the GMC that we must all follow.

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Duties Of A Doctor
http//www.gmc-uk.org/guidance/good_medical
_practice/index.asp
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Quiz
In groups, 5 minutes to list the duties of a
doctor as listed in the GMC guidance, Good
Medical Practice
Theres a prize!
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Duties Of A Doctor

• Make the care of the patient your first concern
• Protect and promote the health of patients and
  the public
• 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 way that best serve
  patients interests
• Treat patients as individuals and respect their
  dignity
• Treat patients politely and considerately
• Respect patients right to confidentiality
• Work in partnership with patients
• Listen to patients and respond to their concerns
  and preferences
• Give patients the information they want in way
  they can understand
• Respect patients right to reach decisions with
  you about their treatment and care
• Support patients caring for themselves to improve
  and maintain their health
• 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 about patients or
  colleagues
• Never abuse your patients trust in you or the
  publics trust in the profession

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Why Is Fitness To Practice Important?

• Because Serious or persistent failure to follow
  this guidance will put your registration at risk
• But even more importantly its about patient
  safety
• It encompasses everything we do as a doctor (and
  some aspects private life)
• Its important to GMC (so hence must be to us)
• Needed for Appraisal (currently) and Revalidation
  (soon) and we need to get the box ticked!

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How Does This Affect Us As Trainees?

• We are all registered medical practitioners and
  as such must follow the GMCs principles of good
  medical practice
• We have to tick a box on the E-portfolio!

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Competency Area
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How Can We Tick The Box?

• We admit it is difficult
• And everybody seems to struggle with this one
• But there are lots of resources available
• Bradford VTS Website
• RCGP E-portfolio

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How Can We Tick The Box?
Use the Bradford VTS Website
http//www.bradfordvts.co.uk/MRCGP/cbd.htm
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How Can We Tick The Box?
Use The RCGP Website

• http//www.rcgp.org.uk/docs/nMRCGP_20blueprint20
  2007.xls

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How Can We Tick The Box?
Can demonstrate this through CbD and entries in
the learning log that your trainer can map to the
competency, eg. make a point to document issues
with chaperones, discussing options with
patients, choose a case with a shared management
plan
Make sure you take your holidays! Any suggestions?
?Upload a picture of your gym membership! Any
suggestions?
Significant event analysis
Significant event analysis Present at practice
meeting ?with suggestions to change practice or
policy
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Examples of things that you should add under
fitness to practise

• Here are some examples of stuff some of our
  trainees put on
• Clinical Things
• Making sure you make an enquiry into the red flag
  areas for most symptoms e.g. suicidal risk
  assessment for depressed, MI symptoms/signs for
  chest pains, intracranial lesions for headaches
  etc..
• Difficult areas e.g. under 16 and asking for the
  oral contraceptive pill
• Personal Dilemmas
• I was asked by a relative to prescribe something
  for him. I never considered the implications of
  this. Therefore.....
• I was in a real dilemma the other day. I felt
  quite ill but also felt the difficulties ringing
  in sick would have on my colleagues. Therefore,
  I decided to do xxx because....
• I was always turning up late for surgeries and
  my trainer had raised this a couple of times. I
  knew it was because of some difficult things I
  was experiencing at home. So, my trainer and I
  had a discussion about some of these things a)
  looking after 3 children b) studying for my AKT,
  and my unsupportive husband......One thing that
  we decided to do is change surgery times and that
  has helped a lot
• My work-life balance has been getting me down.
  I just cannot get the right balance and so had a
  discussion with my programme director.......

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Small other ideas

• Some of us might not be keen to put personal
  things on for fear of consequences?
• Examples include personal illness, mental
  health, issues with trainer.
• But seriously you neednt worry. This is the
  sort of stuff they really like to see.
• Writing it down will really make you think about
  your situation and help you see light at the end
  of the tunnel compared with just mulling it over
  in your mind
• Your problem will not go away unless you
  seriously consider it and talk to someone about
  it.
• Get it written down, talk to someone, and dont
  worry about who will see it. Trainers have been
  trained to acknowledge these sort of things.

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(No Transcript)
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• Revalidation
• In response to Shipman Inquiry
• Latest guideline suggest should be in the form of
  an electronic portfolio (Dont all cheer at once)

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Revalidation

• Revalidation is a process where doctors will be
  required to periodically demonstrate their
  continued fitness to practice (DH 2007 6).
• Revalidation has two elements

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• Relicensing will be required for all who hold a
  license.
• All doctors wishing to practice in the United
  Kingdom will require a license issued by the
  General Medical Council every 5 years,( starting
  in 2009)
• The process will be based on
• Satisfactory completion of annual appraisal
• Supported by an independent 360 feedback
  (multisource feedback)
• Any concerns known to the doctors employing
  organisation
• Recertification will be required for doctors who
  are on the GMCs specialist register and GP
  register. Recertification will be led by the
  Medical Royal Colleges who will need to provide a
  positive statement of assurance to the General
  Medical Council.
• It is hoped that revalidation will identify those
  that require further identification or
  remediation in doctors whose practice is or maybe
  impaired.
• The vast majority of doctors are practicing
  medicine to a high standard. Revalidation should
  be a process that will support continuous quality
  improvement in standards and practice for both
  doctors and patients alike.

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Appraisal

• Annual appraisal throughout career.
• Five forms.
• Form 1 Personal details
• Form 2 Current medical activities
• Form 3 Based around the headings of good medical
  Practice
• Form 4 the formal summary/actions agreed
• Form 5 Optional confidential record of the
  appraisal

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• Form 3
• Good Clinical Care eg audits, out of hours log
• Maintaining good medical practice reflective
  diaries, course certificates, pdp
• Relationships with patients thank you cards,
  complaints, patient surveys
• Working with colleagues
• Management activity
• Teaching training and assessing
• Probity and health

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Appraisal

• Allows identification of areas of success, and
  future needs
• Sets an action plan to meet those needs,
  involving the individual
• Is confidential to appraisee appraiser

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Fitness To Practice Panels

• Three groups
• Each allocated the details of a case
• Discuss
• What fitness to practice issues does it raise?
• Which of the duties of a doctor are breached?
• What should happen to the individual concerned?

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Case1AE Doctor develops relationship

• The doctor was employed in the Accident
  Emergency (AE) Department of a hospital.
• He examined a female patient who had presented
  with a knee injury.
• During the third consultation the doctor gave the
  patient his personal mobile telephone number.
  They sent text messages which were flirtatious in
  manner.
• When the patient returned to the AE Department
  on a further occasion, the doctor engaged in
  flirtatious conversation with her during the
  examination of her injured knee.

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Case 1 continued

• On more than one occasion the doctor suggested to
  the patient that they should meet up. For a
  12-month period the doctor
• pursued a sexual relationship with the patient
  and was also sexually intimate with her whilst on
  duty at the AE Department,
• During the course of their sexual relationship
  the doctor acted or purported to act in a
  professional capacity in relation to the patient.
  He signed a statutory sickpay form for her, as
  her doctor at the hospital.
• He also provided her with a letter, as her
  doctor, confirming that she was fit to return to
  work. In that letter he also stated that he was
  Acting Consultant in Emergency Medicine.

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Case 1Discuss

• Areas of breach of duties of a doctor
• What do you think the consequences should be?
• Could this happen to you, how would you deal with
  this situation?

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Case 1Panels view

• Looked at by GMC panel fitness to practice
• engaging in flirtatious text messaging and
  conversation with her,
• whilst being a medical practitioner responsible
  for her clinical care, was inappropriate and an
  abuse of his position as a registered medical
  practitioner.
• The Panel noted its responsibility to protect
  the public interest, with particular
• reference to maintaining public confidence in
  the profession and upholding proper standards of
  conduct and behaviour. The public are entitled to
  expect that doctors will be honest and
  trustworthy at all times.
• The GMCs Good Medical Practice (2001 edition)
  states at paragraph 20 that
• You must not allow your personal relationships
  to undermine the trust which patients place in
  you. In particular, you must not use your
  professional position to establish or pursue a
  sexual or improper emotional relationship with a
  patient or someone close to them.
• and at paragraph 51 that
• You must be honest and trustworthy when writing
  reports, completing or signing formsYou must not
  write or sign documents which are false

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Case 1Verdict

• Due to lack of insight and remorse. Risk of
  establishing inappropriate relationships again
• Incompatible with remaining on the register

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Case 2Not Available To Work

• GP who worked
• for OOH service
• to provide GP services to a nursing home
• privately
• Twice absented herself from her OOH post whilst
  on a night shift
• Calls had to be put through to other doctors
• Once found asleep at her desk
• Twice failed to respond to requests for a visit
  to nursing home
• When a visit was made claimed she couldnt stay
  and refused to see the patient
• Privately treated a mole with a laser the wasnt
  suitable for the job.
• Continued to do so despite being told by a
  plastic surgeon to stop
• Refused to acknowledge her mistake
• Falsified documentation about laser treatment at
  the FTP hearing

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Case 2Breaches Of Duties Of A Doctor

• Inadequately trained to use laser
• Recognise and work within the limits of your
  competence
• Make the care of your patient your first
  concern
• Falsified documentation
• Be honest and open and act with integrity

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Case 2Verdict

• Removed from medical register
• Failure to show insight into shortcomings
• Deep-seated attitudinal problems

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Case 3Delay In Treatment

• 32 year old driving instructor
• Unwell for 4/7 with flu-like symptoms
• Seen by OOH at 2230
• Temp 36
• Clammy
• ?viral chest infection or pneumonia
• Didnt record specific chest findings
• Seen again by OOH at 0200
• Tachypnoeic
• Cyanosed
• Signs consolidation left base
• Admitted
• Died at 0700 on ICU from LLL pneumonia

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Case 3Breaches Of Duties Of A Doctor

• an adequate assessment of the patients
  conditions, based on the history and symptoms
  and, if necessary, an appropriate examination.
• keep clear, accurate, legible and
  contemporaneous patient records which report the
  relevant clinical findings, the decision made,
  and the information given to patients and any
  drugs or other treatment prescribed.

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Case 3Outcome

• Case settled by MPS

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Case 4Sick partner

• While looking for the practice accounts in your
  partner's room, you find under a bundle of papers
  a medical report about your partner.
• It is dated last month and discusses his recent
  medical problems which seem to centre around his
  infection with hepatitis C.
• This comes as a shock to you as you knew nothing
  about this. What do you do now?

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Case 4Discuss

• Discuss issues regarding infection
• Do you talk to the partner directly or involve a
  third party ?

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Case 4

• Read it thoroughly to ascertain facts, has he
  been diagnosed and treated?
• Risk to patients? Is he carrying out any exposure
  prone procedures.
• How did he acquire this infection?
• Drug use, needlestick?
• Support needed.

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Case 4Learning points

• The GMC guidance on serious communicable diseases
  says you must always take action to protect
  patients if you feel a colleague's health may put
  them at risk.
• Before breaching this confidence, discuss it with
  a partner, LMC member or your medical defence
  society
• How can doctors be reassured that their treatment
  is confidential?
• Good Medical Practice says that doctors whose
  health may put patients at risk should seek
  independent advice
• All doctors should be registered with a GP
  outside their own practice

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References/ Further Reading

• RCGP Guide to Revalidation for GPs
• April 2009
• The Shipman Inquiry
• 5th Report Safe guarding patients Lessons from
  the past proposals for the future

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Any questions?
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Take Home Messages

• Duties of a doctor
• Importance to trainees
• Ideas for portfolio entries
• Useful resources
• Aware of appraisal
• GPs work independently so have to be especially
  mindful of fitness to practice issues.