Dr Susan GibsonSmith MBChB MRCGP MPhil Doctors in Difficulty httpswwwmaxpixelnetScienceFictionBbcTheTardisDoctorWhoLondon3713712 Aims Explore the variety of difficulties a doctor may find themselves in ID: 1045679
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1. Supporting DoctorsinDifficultyDr Susan Gibson-SmithMBChB MRCGP MPhil
2. Doctors in Difficultyhttps://www.maxpixel.net/Science-Fiction-Bbc-The-Tardis-Doctor-Who-London-3713712
3. AimsExplore the variety of difficulties a doctor may find themselves in.Develop an understanding of the different disciplinary and regulatory processes involved.Equip the appraiser to provide a supportive robust appraisal.
4. Question TimeWhat types of difficulties have you encountered doctors to be facing when conducting appraisals?
5. Types of DifficultiesFAI’s/Claims/Complaints/Ombudsman/SUIGMC InvestigationsHospital Disciplinary ProceduresClinical Support Group InvestigationsHealth
6. Medico-legal DifficultiesComplaintsOmbudsmanClaimsFAI’sSUI’s
7. GMC InvestigationsProvisional EnquiryInterim Orders Tribunal (IOT)Rule 4 Fact finding/expert advice/closedRule 7 Written allegations/28 day response/no action/warning/undertakingsMPTS Hearing Facts/ Impairment/Sanction
8. Hospital Disciplinary InvestigationPCS8 Circular (Under review at present)Preliminary Enquiry /recommendations/case closed.Personal Conduct/Professional Conduct/Professional Competence. Annexe B or Annexe C.
9. Clinical Support Group ReferralsMedical Director by colleagues/appraiser/GMCClinical Support Group consists of Medical Director, Out of Hours Lead, Local Appraisal Adviser, Nurse Lead, Practice Manager Lead, LMC Lead, Prescribing Lead.Doctor referred to Associate Adviser for performance support Agree objectives communication skills/peer video/SEA/prescribing/procedures and clinical governance. Feedback to CSG discharge/monitoring/ more support
10. HealthPhysical/Mental/AddictionsOccupational HealthGPSpecialist support
11. Scenario 1
12. Developmental ProcessAddresses ALL aspects of a doctor’s work - including any private or OOH work, educational management roles, or any non-remunerated roles (e.g. volunteering at the local sports club or school as a doctor)Facilitates reflection on the doctor’s practice and the submitted supporting informationOffers individuals feedback on past performanceCharts and acknowledges continuing progressIdentifies Learning Needs and agrees PDP
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14. Why ReflectionYou must take part in systems of quality assurance and quality improvement to promote patient safety. This includes:regularly reflecting on your standards of practice and the care you provide. (Good Medical Practice paragraph 22b)
15. Appraisal expectations re reflectionAnnual reflection on CPD and learning activities across a balanced range appropriate to your scope of work.Quality improvement activities every year to demonstrate how you review the quality of your work and reflect on the standard of care you provide.Reflection on feedback from colleagues Reflection on feedback from patients Reflection on all complaints involving you personallyReflection on anything else you have been specifically asked to bring to the appraisal.
16. The Reflective Practitioner
17. What is reflective practice
18. 1. What? So what? Now what?Main example given in the joint guidance – Rolfe et alWhat? – What happened? What did I do? What did others do? What did I feel? What was I trying to achieve?So What? – So what is the importance of this? So what is the significance for me? So what is the significance for the future? How did I feel before and after? Now What? – Now what could I do? Now what do I need to do? Now what might I do? Now what might be the consequences of this action?
19. 2. Reflection based on SchonSchon, D.A. (1983) The Reflective Practitioner: How professionals think in action New York: Basic books.Reflection-IN-actionThinking ahead, analysing, experiencing, critically responding (in the moment)What were you thinking at the time?What was influencing that thinking?
20. Schon continuedB. Reflection-ON-action Thinking through and discussing subsequent to the situation.What is your thinking about the event now? Having time to think, discuss, review information etc.The effective reflective practitioner is able to recognise and explore confusing or unique (positive or negative) events that occur during practice.
21. 3. What, Why, How?What do you want to reflect on? Should contain enough information to allow you to recall the event.Why do you want to reflect on it? What do you hope to get out of this reflection – how will it help you?How did you and will you learn from this? How will this affect your practice and make you a better doctor. How have you been affected by this? What are your overall conclusions from this episode. How do you feel about the reflection?
22. 4. Gibbs’ reflective cycleGibbs, G. (1988) Learning by doing. A guide to teaching and learning methods. Oxford Polytechnic: Oxford.Description – what happened? Feelings – what were you thinking and feeling? Evaluation – what was good and bad about the experience? What went well and what went badly? Analysis – what sense can you make of the situation?Conclusion – what else could you have done? Action plan – if it arose again, what would you do?
23. Gibbs’ reflective cycleDescriptionWhat happened?FeelingsWhat were youthinking and feeling?EvaluationWhat was good and bad about the experience?AnalysisWhat sense can youmake of the situation?ConclusionWhat else couldyou have done?Action PlanIf it arose againwhat would you do?Reflective Cycle
24. The Role of Reflection At the MPTS in support of her position part of Dr B-G’s case was that she had “reflected on and addressed her failings” In the determinations of the MPTS when considering whether her failings “were remediable”:“you have undergone significant remediation and reflection… The Tribunal…is satisfied that the risk of you putting a patient at unwarranted risk of harm in the future is low”
25. The Role of Reflection 2Submissions on behalf of Dr B-G , regarding the appropriate sanction being suspension, included:Dr B-G had demonstrated insightShe had reflected on and expressed remorse for the events
26. The Role of Reflection 3The Tribunal accepted that Dr B-G had an unblemished record as a doctor, she was of good character, noted the timescales involved and that the failings occurred in the context of wider systemic failings. BUT“The Tribunal accepted the evidence of Dr A that you had reflected deeply and demonstrated significant and substantial insight in your conversations with him. However, the Tribunal was unable to conclude that you had complete insight into your actions as it did not hear from you directly.”
27. The Role of Reflection 4The Tribunal concluded that Dr B-G did not have complete insight Going forward the Tribunal stated it would be assisted at the review hearing by:“Evidence that you have reflected on the Tribunal’s findings and further evidence of reflection and insight into your actions”
28. Anonymising details in ReflectionThe GMC’s Guidance ‘Confidentiality: good practice in handling patient information ’gives clear direction on anonymisation in the context of using and disclosing patient information for secondary purposes, such as education and training: Para 79: “Anonymised information will usually be sufficient for purposes other than the direct care of the patient and you must use it in preference to identifiable information wherever possible. If you disclose identifiable information, you must be satisfied that there is a legal basis for breaching confidentiality.”
29. Reflective Notes and the GMCThe GMC does not ask a doctor to provide their reflective notes in order to investigate a concern about them. Following a significant event or a serious incident, factual details should not be recorded in reflective discussions but elsewhere, in accordance with each organisation’s relevant policies.Evidence of insight and remediation may reduce the need for the GMC to take action. It plays an important role in how the GMC assesses whether a doctor’s fitness to practise is impaired.
30. In SummaryReflection is a good thing, it empowers doctors to:demonstrate insight by identifying actions to help learning, development or improvement of practice, developing greater insight and self-awareness.identify opportunities to improve quality and patient safety in organisations.Reflective notes should focus on the learning, should not be a full discussion of the case and should be fully anonymised.
31. Supporting DoctorsinDifficultyDr Susan Gibson-SmithMBChB MRCGP MPhil