Common queries from foundation doctors

Dr Ellie Mein shares some of the most common reasons foundation doctors call the MDU, and explains what you can do if you find yourself in a similar situation.

We have previously issued advice on responding to requests for Coroner’s reports, dealing with an adverse incident and complaints handling. Here we look at some of the other medico-legal dilemmas raised by members.

Raising concerns in the workplace

If you are concerned that a colleague’s health may be posing a threat to patient safety, the GMC's guidance states that all doctors have a duty to raise concerns where they believe that patient safety or care is being compromised. This duty overrides any personal or professional loyalties. For example, you may be concerned that a colleague is coming to work under the influence of drugs or alcohol. Raising concerns would also be in your colleague’s interests as they can then be offered treatment and support. .

This is a difficult situation, particularly if you need to raise concerns about a more senior colleague. The MDU can provide you with specific support, but consider taking the following steps:

  • Consider approaching the colleague directly to discuss your concerns, encouraging them to leave work and to talk to their supervisor and/or GP.
  • Make it clear to your unwell colleague that you will take action if they continue to work while clearly unfit to do so.
  • If you do not feel able to approach your colleague directly or have had tried to do so unsuccessfully, for example because the person did not take such discussions seriously, reacted angrily or refused to accept help, follow your hospital's established procedures for raising concerns. This would usually require concerns to be raised in writing but in acute situations, it is better to speak to the designated person in the relevant department straight away.
  • The GMC expects doctors to keep a record of their concerns and the steps they have taken to resolve them.
  • In the unlikely event that no action is taken and the doctor remains a serious threat to patients, then you should escalate your concerns. This would mean contacting a more senior manager within the trust, a postgraduate dean at your Local Education and Training Board or the GMC.

Having acted on concerns, avoid any departmental gossip about the unwell colleague: they are entitled to the same degree of sensitivity and confidentiality about their health as any other patient.

Further advice on raising concerns can be found here.

Working in an understaffed department

The GMC advises that if doctors consider their working conditions unsafe then they should try to work with colleagues to establish a way to provide the safest care possible to patients. If you have such concerns raise these directly with a senior colleague or ask someone else to on your behalf.

Doctors should be aware of who to contact when they have concerns and how to do so. Keep a written record of what action has been taken. If you raise concerns by phone, follow this up with an email referring to the conversation, so both parties have a record of what was discussed and agreed.

The guidance highlights that employers are responsible for ensuring that working environments are safe and that the appropriate supervision and support are provided.

In summary, when doctors feel that staffing arrangements pose a patient safety issue they are advised to follow the GMC’s guidance Raising and acting on concerns, keep a record of the steps they have taken and be able to justify their actions if necessary.

The GMC has further advice on this topic in their blog.

Private work and prescriptions

When thinking about taking on private medical services, bear in mind that if you are a Foundation Year 1 doctor you only have provisional GMC registration which means you are not permitted to undertake any kind of service post, other than an approved UK foundation year 1 programme.

Foundation year 2 doctors are fully registered with the GMC however there are still barriers to them providing private services as they are still required to practice in an Approved Practice Setting (APS).

The GMC are clear that if you are working under APS restrictions then you are not limited to only working within their designated body. You can work in other organisations provided you remain connected with the designated body. However, locum work can only be undertaken if the locum agency is also a designated body

The GMC stipulates that doctors who are on a UK training programme and who wish to practise outside of their substantive employment must make their educational supervisor aware of such work. You would also need to comply with any reporting requirement set by your training body or Responsible Officer (RO)

Foundation year 2 doctors can write private prescriptions while under APS restrictions subject to compliance with appropriate GMC guidance. Foundation year 1 doctors cannot write private prescriptions

However, as we explain below, it will rarely be appropriate for foundation doctors to write a private prescription for a relative, friend or acquaintance. Wherever possible, you must also avoid self-prescribing.

Medical advice for friends and family

Even before doctors qualify they may have experienced friends or relatives asking them for medical advice. It may be tempting to offer help to those close to you however it is best avoided. The GMC make this clear in Good Medical Practice (2013):

16. In providing clinical care you must… wherever possible, avoid prescribing medical care to yourself or anyone with whom you have a close personal relationship.

It is still best to avoid advising even distant relations or friends of friends because you may not be as objective as you would when seeing a patient. Bear in mind you do not have full knowledge of their medical history or medications and you do not have access to their medical notes to make a comprehensive record of what information was given to you and what your advice was. You also need to consider how your relationship may be affected if a problem arises from your involvement and the likelihood that you may not be indemnified for advice offered to friends and relations should the individual make a claim against you.

It is advisable when approached for medical advice, in a non-emergency situation, to direct the person to their own GP who will be best placed to help them.

Reflections

Formal reflective writing is an increasingly important part of medical training and ongoing development. However, following the Dr Hadiza Bawa-Garba case, it is understandably also a cause for concern among many doctors. We get enquiries about to how to frame reflective documents given the potential for them to later be used against doctors.

The Academy of Medical Royal Colleges, the Conference of Postgraduate Medical Deans (COPMeD), the GMC and the Medical Schools Council have jointly issued a short guide on this topic called The Reflective Practitioner. This publication covers why reflection is important, how to approach it and the disclosure of reflective notes.

The guidance confirms that the GMC will not ask a doctor to disclose reflective notes to assist in their investigations unless the doctor wants to disclose the note in order to demonstrate insight. However, they explain that these notes can still be required by a court. As such, reflective notes ‘should focus on the learning rather than a full discussion of the case or situation. Factual details should be recorded elsewhere.’

The joint guidance is clear that if you are asked by courts to disclose part of your learning portfolio then you should seek advice from your ‘employer, legal adviser, medical defence organisation or professional association.’ If you have any concerns about such requests then please contact us for advice.

When patients don’t want information noted in their records

Sometimes patients or their relatives find it easier to confide in junior doctors than more senior clinicians. Unfortunately this can extend to patients or their family providing you with medical information and then asking for this to be kept ‘off the record’ or ‘just between us’ with the result that the doctor can find themselves in an awkward position.

In your professional role, if anyone says they want to tell you something ‘off the record’ then it is appropriate to warn them that you cannot guarantee that this will be the case. It will then be for the person to decide if they share the information with you in the knowledge that what they say may be documented or disclosed to others if necessary.

If a patient tells you something clinically relevant but then asks that it is not recorded explain to them that doctors are obliged to record any clinically relevant information in the notes to ensure that they are an accurate reflection of what was discussed. This often arises when patients reveal drug or alcohol misuse problems but can also occur with other types of sensitive information.

This guidance was correct at publication 22/07/2019. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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