Fitness to Practice Nadia Anderson David Tatham Ramesh Mehay Bradford VTS 2009.

Fitness to PracticeFitness to Practice

Nadia AndersonNadia Anderson

David TathamDavid Tatham

Ramesh MehayRamesh Mehay

Bradford VTS 2009Bradford VTS 2009

IntroductionIntroduction

• What is fitness to practice?What is fitness to practice?• Why is it important?Why is it important?• Is there any published guidance?Is there any published guidance?

• And where can I find it?And where can I find it?

• How does it relate to us now as How does it relate to us now as trainees?trainees?

• What does it mean in the future?What does it mean in the future?

PlanPlan• What is fitness to practice?What is fitness to practice?• Why is it important?Why is it important?• What areas of our work does it cover?What areas of our work does it cover?• What guidance is there and where can we find What guidance is there and where can we find

it?it?

• How does fitness to practice affect us as How does fitness to practice affect us as trainees?trainees?

• RevalidationRevalidation

• Cases (& how to avoid hot water)Cases (& how to avoid hot water)

Small group workMin-lecture

Quiz

Mini-lectureInter-active session

Tea & Biscuits

Mini-lecture

Mini fitness topractice committees!

Small Group WorkSmall Group Work

• 10-15 mins10-15 mins• 3 questions3 questions

• What is “fitness to practice”?What is “fitness to practice”?• Where can we find guidance?Where can we find guidance?• What parts of our work does it cover?What parts of our work does it cover?

What Is Fitness To What Is Fitness To Practice?Practice?

• To practise safely, doctors must be competent in what To practise safely, doctors must be competent in what they do. They must establish and maintain effective they do. They must establish and maintain effective relationships with patients, respect patients’ autonomy relationships with patients, respect patients’ autonomy and act responsibly and appropriately if they or a and act responsibly and appropriately if they or a colleague fall ill and their performance suffers.colleague fall ill and their performance suffers.

• But these attributes, while essential, are not enough. But these attributes, while essential, are not enough. Doctors have a respected position in society and their Doctors have a respected position in society and their work gives them privileged access to patients, some of work gives them privileged access to patients, some of whom may be very vulnerable. A doctor whose conduct whom may be very vulnerable. A doctor whose conduct has shown that he cannot justify the trust placed in him has shown that he cannot justify the trust placed in him should not continue in unrestricted practice while that should not continue in unrestricted practice while that remains the case.remains the case.

The Meaning of Fitness to PracticeThe Meaning of Fitness to PracticeGMC 2005GMC 2005

Fitness to practice is about being a Fitness to practice is about being a good doctor….good doctor….

…….and being a good doctor is about .and being a good doctor is about good medical practicegood medical practice….….

…….which is the title of the guidance .which is the title of the guidance document issued by the GMC that we document issued by the GMC that we

must all follow.must all follow.

““Duties Of A Doctor”Duties Of A Doctor”

http://www.gmc-uk.org/guidance/good_medical _practice/index.asp

QuizQuiz

In groups, 5 minutes to list the duties of a doctor as listed in the GMC guidance, “Good

Medical Practice”

There’s a prize!

Duties Of A DoctorDuties Of A Doctor• Make the care of the patient your first concernMake the care of the patient your first concern• Protect and promote the health of patients and the publicProtect and promote the health of patients and the public• Provide a good standard of practice and careProvide a good standard of practice and care

• Keep your professional knowledge and skills up to dateKeep your professional knowledge and skills up to date• Recognise and work within the limits of your competenceRecognise and work within the limits of your competence• Work with colleagues in the way that best serve patients’ interestsWork with colleagues in the way that best serve patients’ interests

• Treat patients as individuals and respect their dignityTreat patients as individuals and respect their dignity• Treat patients politely and consideratelyTreat patients politely and considerately• Respect patients’ right to confidentialityRespect patients’ right to confidentiality

• Work in partnership with patientsWork in partnership with patients• Listen to patients and respond to their concerns and preferencesListen to patients and respond to their concerns and preferences• Give patients the information they want in way they can understandGive patients the information they want in way they can understand• Respect patients’ right to reach decisions with you about their treatment Respect patients’ right to reach decisions with you about their treatment

and careand care• Support patients caring for themselves to improve and maintain their Support patients caring for themselves to improve and maintain their

healthhealth• Be honest and open and act with integrityBe honest and open and act with integrity

• Act without delay if you have good reason to believe that you or a Act without delay if you have good reason to believe that you or a colleague may be putting patients at riskcolleague may be putting patients at risk

• Never discriminate unfairly about patients or colleaguesNever discriminate unfairly about patients or colleagues• Never abuse your patients trust in you or the public’s trust in the professionNever abuse your patients trust in you or the public’s trust in the profession

Why Is Fitness To Practice Why Is Fitness To Practice Important?Important?

• Because Because “Serious or persistent failure to follow “Serious or persistent failure to follow this guidance will put your registration at risk”this guidance will put your registration at risk”

• But even more importantly it’s about patient But even more importantly it’s about patient safetysafety

• It encompasses everything we do as a doctor It encompasses everything we do as a doctor (and some aspects private life)(and some aspects private life)

• It’s important to GMC (so hence must be to us)It’s important to GMC (so hence must be to us)• Needed for Appraisal (currently) and Needed for Appraisal (currently) and

Revalidation (soon) and we need to get the Revalidation (soon) and we need to get the box ticked!box ticked!

How Does This Affect Us How Does This Affect Us As Trainees?As Trainees?

1)1) We are all registered medical We are all registered medical practitioners and as such must practitioners and as such must follow the GMC’s principles of follow the GMC’s principles of good medical practicegood medical practice

2)2) We have to tick a box on the E-We have to tick a box on the E-portfolio!portfolio!

Competency AreaCompetency Area

How Can We Tick The How Can We Tick The Box?Box?

• We admit it is difficultWe admit it is difficult• And everybody seems to struggle And everybody seems to struggle

with this onewith this one• But there are lots of resources But there are lots of resources

availableavailable• Bradford VTS WebsiteBradford VTS Website• RCGP E-portfolioRCGP E-portfolio

How Can We Tick The How Can We Tick The Box?Box?

Microsoft Word Document

Use the Bradford VTS Website

http://www.bradfordvts.co.uk/MRCGP/cbd.htm

How Can We Tick The How Can We Tick The Box?Box?

http://www.rcgp.org.uk/docs/nMRCGP_%20blueprint%202007.xlshttp://www.rcgp.org.uk/docs/nMRCGP_%20blueprint%202007.xls

Use The RCGP Website

Microsoft Office Excel Worksheet

How Can We Tick The How Can We Tick The Box?Box?

Can demonstrate this through CbD and entries in the learning log that your trainer can mapto 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 analysisPresent at practice meeting ?with suggestions to change practice or policy

Examples of things that you Examples of things that you should add under ‘fitness to should add under ‘fitness to

practise’practise’Here are some examples of stuff some of our trainees put on:Here are some examples of stuff some of our trainees put on:Clinical Things:Clinical Things:• Making sure you make an enquiry into the red flag areas for most symptoms e.g. 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, suicidal risk assessment for depressed, MI symptoms/signs for chest pains, intracranial lesions for headaches etc..intracranial lesions for headaches etc..

• Difficult areas e.g. under 16 and asking for the oral contraceptive pillDifficult areas e.g. under 16 and asking for the oral contraceptive pill

Personal DilemmasPersonal Dilemmas• ““I was asked by a relative to prescribe something for him. I never considered the I was asked by a relative to prescribe something for him. I never considered the

implications of this. Therefore.....”implications of this. Therefore.....”• ““I was in a real dilemma the other day. I felt quite ill but also felt the difficulties 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 ringing in sick would have on my colleagues. Therefore, I decided to do xxx because....”because....”

• ““I was always turning up late for surgeries and my trainer had raised this a couple of 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. 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 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 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”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 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.......”and so had a discussion with my programme director.......”

Small other ideasSmall other ideas

• Some of us might not be keen to put personal things on for Some of us might not be keen to put personal things on for fear of consequences? fear of consequences?

• Examples include: personal illness, mental health, issues with Examples include: personal illness, mental health, issues with trainer.trainer.

• But seriously – you needn’t worry. This is the sort of stuff But seriously – you needn’t worry. This is the sort of stuff they really like to see. they really like to see.

• Writing it down will really make you think about your situation Writing it down will really make you think about your situation and help you see light at the end of the tunnel compared with and help you see light at the end of the tunnel compared with just mulling it over in your mindjust mulling it over in your mind

• Your problem will not go away unless you seriously consider it Your problem will not go away unless you seriously consider it and talk to someone about it.and talk to someone about it.

• Get it written down, talk to someone, and don’t worry about Get it written down, talk to someone, and don’t worry about who will see it. Trainers have been trained to acknowledge who will see it. Trainers have been trained to acknowledge these sort of things.these sort of things.

• RevalidationRevalidation• In response to Shipman Inquiry In response to Shipman Inquiry • Latest guideline suggest should be Latest guideline suggest should be

in the form of an electronic in the form of an electronic portfolio (Don’t all cheer at once)portfolio (Don’t all cheer at once)

RevalidationRevalidation• Revalidation is a process where doctors will be required Revalidation is a process where doctors will be required

to “periodically to “periodically demonstratedemonstrate their continued fitness to their continued fitness to practice (DH 2007: 6). practice (DH 2007: 6).

Revalidation has two elements:Revalidation has two elements:

RelicensingRelicensing will be required for all who hold a license. will be required for all who hold a license. • All doctors wishing to practice in the United Kingdom will require 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) issued by the General Medical Council every 5 years,( starting in 2009) The process will be based on:The process will be based on:

• Satisfactory completion of annual appraisal Satisfactory completion of annual appraisal • Supported by an independent 360° feedback (multisource feedback) Supported by an independent 360° feedback (multisource feedback) • Any concerns known to the doctor’s employing organisationAny concerns known to the doctor’s employing organisation

• RecertificationRecertification will be required for doctors who are on the GMC’s specialist will be required for doctors who are on the GMC’s specialist register and GP register. Recertification will be led by the Medical Royal 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 Colleges who will need to provide a ‘positive statement of assurance’ to the General Medical Council. General Medical Council.

• It is hoped that revalidation will identify those that require further It is hoped that revalidation will identify those that require further identification or remediation in doctors whose practice is or maybe impaired.identification or remediation in doctors whose practice is or maybe impaired.

• The vast majority of doctors are practicing medicine to a high The vast majority of doctors are practicing medicine to a high standard. Revalidation should be a process that will support standard. Revalidation should be a process that will support continuous quality improvement in standards and practice for both continuous quality improvement in standards and practice for both doctors and patients alike.doctors and patients alike.

AppraisalAppraisal

• Annual appraisal throughout career.Annual appraisal throughout career.• Five forms.Five forms.

• Form 1 Personal detailsForm 1 Personal details• Form 2 Current medical activitiesForm 2 Current medical activities• Form 3 Based around the headings of Form 3 Based around the headings of

good medical Practicegood medical Practice• Form 4 the formal summary/actions Form 4 the formal summary/actions

agreedagreed• Form 5 Optional confidential record of the Form 5 Optional confidential record of the

appraisalappraisal

• Form 3Form 3• Good Clinical CareGood Clinical Care eg audits, out of hours log eg audits, out of hours log• Maintaining good medical practiceMaintaining good medical practice; ;

reflective diaries, course certificates, pdpreflective diaries, course certificates, pdp• Relationships with patients;Relationships with patients; thank you thank you

cards, complaints, patient surveyscards, complaints, patient surveys• Working with colleaguesWorking with colleagues• Management activityManagement activity• Teaching training and assessingTeaching training and assessing• Probity and healthProbity and health

AppraisalAppraisal

• Allows identification of areas of Allows identification of areas of success, and future needssuccess, and future needs

• Sets an action plan to meet those Sets an action plan to meet those needs, involving the individualneeds, involving the individual

• Is confidential to appraisee & Is confidential to appraisee & appraiserappraiser

Fitness To Practice Fitness To Practice PanelsPanels

• Three groupsThree groups• Each allocated the details of a caseEach allocated the details of a case• DiscussDiscuss

• What “fitness to practice” issues does it What “fitness to practice” issues does it raise?raise?

• Which of the “duties of a doctor” are Which of the “duties of a doctor” are breached?breached?

• What should happen to the individual What should happen to the individual concerned?concerned?

Case1Case1A+E Doctor develops A+E Doctor develops

relationshiprelationship• The doctor was employed in the Accident & The doctor was employed in the Accident &

Emergency (A&E) Department of a hospital. Emergency (A&E) Department of a hospital. • He examined a female patient who had He examined a female patient who had

presented with a knee injury.presented with a knee injury.• During the third consultation the doctor gave During the third consultation the doctor gave

the patient his personal mobile telephone the patient his personal mobile telephone number. They sent text messages which number. They sent text messages which were flirtatious in manner.were flirtatious in manner.

• When the patient returned to the A&E When the patient returned to the A&E Department on a further occasion, the doctor Department on a further occasion, the doctor engaged in flirtatious conversation with her engaged in flirtatious conversation with her during the examination of her injured knee.during the examination of her injured knee.

Case 1 continuedCase 1 continued• On more than one occasion the doctor suggested to the On more than one occasion the doctor suggested to the

patient patient that they should meet up. For a 12-month that they should meet up. For a 12-month period the doctorperiod the doctorpursued a sexual relationship with the patient and was pursued a sexual relationship with the patient and was also sexually intimate with her whilst on duty at the also sexually intimate with her whilst on duty at the A&E Department,A&E Department,

• During the course of their sexual relationship the During the course of their sexual relationship the doctor acted or purported to act in a professional doctor acted or purported to act in a professional capacity in relation to the patient. He signed a capacity in relation to the patient. He signed a statutory sickpay form for her, as her doctor at the statutory sickpay form for her, as her doctor at the hospital.hospital.

• He also provided her with a letter, as her doctor, He also provided her with a letter, as her doctor,

confirming that she was fit to return to work. In that confirming that she was fit to return to work. In that letter he also stated that he was ‘Acting Consultant in letter he also stated that he was ‘Acting Consultant in Emergency Medicine’.Emergency Medicine’.

Case 1Case 1DiscussDiscuss

• Areas of breach of duties of a Areas of breach of duties of a doctordoctor

• What do you think the What do you think the consequences should be?consequences should be?

• Could this happen to you, how Could this happen to you, how would you deal with this situation?would you deal with this situation?

Case 1Case 1Panels viewPanels view

• Looked at by GMC panel fitness to practiceLooked at by GMC panel fitness to practice

• engaging in flirtatious text messaging and conversation with her,engaging in flirtatious text messaging and conversation with her,whilst being a medical practitioner responsible for her clinical care, was whilst being a medical practitioner responsible for her clinical care, was inappropriate and an abuse of his position as a registered medical inappropriate and an abuse of his position as a registered medical practitioner.practitioner.

The Panel noted its responsibility to protect the public interest, with particularThe Panel noted its responsibility to protect the public interest, with particularreference to maintaining public confidence in the profession and upholding reference to maintaining public confidence in the profession and upholding proper standards of conduct and behaviour. The public are entitled to expect proper standards of conduct and behaviour. The public are entitled to expect that doctors will be honest and trustworthy at all times.that doctors will be honest and trustworthy at all times.

• The GMC’s The GMC’s Good Medical Practice Good Medical Practice (2001 edition) states at paragraph 20 that:(2001 edition) states at paragraph 20 that:• ‘‘You must not allow your personal relationships to undermine the trust which You must not allow your personal relationships to undermine the trust which

patients place in you. In particular, you must not use your professional patients place in you. In particular, you must not use your professional position to establish or pursue a sexual or improper emotional relationship position to establish or pursue a sexual or improper emotional relationship with a patient or someone close to them.’with a patient or someone close to them.’

• and at paragraph 51 that:and at paragraph 51 that:

• ‘‘You must be honest and trustworthy when writing reports, completing or You must be honest and trustworthy when writing reports, completing or signing forms…You must not write or sign documents which are false…‘signing forms…You must not write or sign documents which are false…‘

Case 1Case 1VerdictVerdict

• Due to lack of Due to lack of insight and insight and remorse. Risk of remorse. Risk of establishing establishing inappropriate inappropriate relationships again relationships again

• Incompatible with Incompatible with remaining on the remaining on the registerregister

Case 2Case 2Not Available To WorkNot Available To Work

• GP who workedGP who worked• for OOH servicefor OOH service• to provide GP services to a nursing hometo provide GP services to a nursing home• privatelyprivately

• Twice absented herself from her OOH post whilst on a night Twice absented herself from her OOH post whilst on a night shiftshift• Calls had to be put through to other doctorsCalls had to be put through to other doctors

• Once found asleep at her deskOnce found asleep at her desk• Twice failed to respond to requests for a visit to nursing Twice failed to respond to requests for a visit to nursing

homehome• When a visit was made claimed she couldn’t stay and refused to When a visit was made claimed she couldn’t stay and refused to

see the patientsee the patient• Privately treated a mole with a laser the wasn’t suitable for Privately treated a mole with a laser the wasn’t suitable for

the job.the job.• Continued to do so despite being told by a plastic surgeon to Continued to do so despite being told by a plastic surgeon to

stopstop• Refused to acknowledge her mistakeRefused to acknowledge her mistake• Falsified documentation about laser treatment at the FTP Falsified documentation about laser treatment at the FTP

hearinghearing

Case 2Case 2Breaches Of Duties Of A Breaches Of Duties Of A

DoctorDoctor• Inadequately trained to use laserInadequately trained to use laser

• ““Recognise and work within the limits Recognise and work within the limits of your competence”of your competence”

• ““Make the care of your patient your Make the care of your patient your first concern”first concern”

• Falsified documentationFalsified documentation• ““Be honest and open and act with Be honest and open and act with

integrity”integrity”

Case 2Case 2VerdictVerdict

• Removed from medical registerRemoved from medical register• Failure to show insight into Failure to show insight into

shortcomingsshortcomings• Deep-seated attitudinal problemsDeep-seated attitudinal problems

Case 3Case 3Delay In TreatmentDelay In Treatment

• 32 year old driving instructor32 year old driving instructor• Unwell for 4/7 with flu-like symptomsUnwell for 4/7 with flu-like symptoms• Seen by OOH at 22:30Seen by OOH at 22:30

• Temp 36Temp 36• ClammyClammy• ?viral chest infection or pneumonia?viral chest infection or pneumonia• Didn’t record specific chest findingsDidn’t record specific chest findings

• Seen again by OOH at 02:00Seen again by OOH at 02:00• TachypnoeicTachypnoeic• CyanosedCyanosed• Signs consolidation left baseSigns consolidation left base• AdmittedAdmitted

• Died at 07:00 on ICU from LLL pneumoniaDied at 07:00 on ICU from LLL pneumonia

Case 3Case 3Breaches Of Duties Of A Breaches Of Duties Of A

DoctorDoctor• ‘an adequate assessment of the patient’s

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’.

Case 3Case 3OutcomeOutcome

• Case settled by MPSCase settled by MPS

Case 4Case 4Sick partnerSick partner

• While looking for the practice accounts in While looking for the practice accounts in your partner's room, you find under a your partner's room, you find under a bundle of papers a medical report about bundle of papers a medical report about your partner. your partner.

• It is dated last month and discusses his It is dated last month and discusses his recent medical problems which seem to recent medical problems which seem to centre around his infection with hepatitis C. centre around his infection with hepatitis C.

• This comes as a shock to you as you knew This comes as a shock to you as you knew nothing about this. What do you do now?nothing about this. What do you do now?

Case 4Case 4DiscussDiscuss

• Discuss issues regarding infectionDiscuss issues regarding infection• Do you talk to the partner directly or Do you talk to the partner directly or

involve a third party ?involve a third party ?

Case 4Case 4

• Read it thoroughly to ascertain Read it thoroughly to ascertain facts, has he been diagnosed and facts, has he been diagnosed and treated?treated?

• Risk to patients? Is he carrying out Risk to patients? Is he carrying out any exposure prone procedures.any exposure prone procedures.

• How did he acquire this infection?How did he acquire this infection?

Drug use, needlestick?Drug use, needlestick?• Support needed.Support needed.

Case 4Case 4Learning pointsLearning points

• The GMC guidance on serious communicable diseases The GMC guidance on serious communicable diseases says you must always take action to protect patients if says you must always take action to protect patients if you feel a colleague's health may put them at risk. you feel a colleague's health may put them at risk.

• Before breaching this confidence, discuss it with a Before breaching this confidence, discuss it with a partner, LMC member or your medical defence society partner, LMC member or your medical defence society

• How can doctors be reassured that their treatment is How can doctors be reassured that their treatment is confidential? confidential?

• Good Medical PracticeGood Medical Practice says that doctors whose health says that doctors whose health may put patients at risk should seek independent may put patients at risk should seek independent advice advice

• All doctors should be registered with a GP outside their All doctors should be registered with a GP outside their own practice own practice

References/ Further References/ Further ReadingReading

• RCGP Guide to Revalidation for GP’sRCGP Guide to Revalidation for GP’s

April 2009April 2009

• The Shipman InquiryThe Shipman Inquiry

55thth Report Safe guarding patients: Report Safe guarding patients: Lessons from the past proposals for Lessons from the past proposals for the futurethe future

Any questions?Any questions?

Take Home MessagesTake Home Messages

• Duties of a doctorDuties of a doctor• Importance to traineesImportance to trainees• Ideas for portfolio entriesIdeas for portfolio entries• Useful resourcesUseful resources• Aware of appraisalAware of appraisal• GP’s work independently GP’s work independently

so have to be especially so have to be especially mindful of fitness to mindful of fitness to practice issues.practice issues.