Venue: Queen Mary University
Today was an early start so we could get to the career carousel activity which was organised for us. This involved us meeting 16 different doctors, each working within different specialities and having taken different routes in their career. This was very helpful as it allowed us to understand the reality of Medicine as a career which can sometimes be overlooked or glazed over. In reality, being a doctor is hard work, is an immense pressure and involves a lot more paperwork and administration than most people would imagine. Many of the doctors we spoke to, such as the A&E consultant emphasised the need to be able to switch off and leave the problems encountered at work, in order to maintain your mental state. I personally believe this is very important, as if you are a doctor who continually over works yourself, you will ultimately stop being of help to your patients due to the spiral of tiredness and fatigue that you have placed yourself in. It was worthwhile hearing this from the doctors themselves!
It was also very interesting to hear about their opinions on the future of the NHS. I was rather surprised to hear from a Registrar Oncologist that despite his disagreement with the existence of the private sector, he still works in this sector as well as the public sector. His reasoning for this despite him believing that it was unethical to charge for cancer was his worry that the private sector of providing healthcare was growing and his need to secure his career. I think this is a big concern and was actually something which was later mentioned by the GP that we were given the opportunity to speak with…
This particular GP had divided her working life between practicing in a Surgery and working within management. She expressed her worry of the idea that much of the goodwill that the NHS was founded on was disappearing. She told us that this was one of the reasons why she had decided to take up a managerial role as she believes that qualified doctors should run the NHS rather than politicians or any other type of people. Her reasoning was because she believed that doctors were the ones that understood the problems of the NHS and therefore they alone should be the ones trying to solve them whilst focussing on the best interests of the patients. I was really moved by this view and it really made me ponder upon the ways in which the goodwill and consensus of consideration could be maintained within the structure of our health service.
I also spoke to a Public Health doctor, I had never before considered the role of a doctor beyond their direct involvement with patients, research and teaching roles, so this was a completely unique perspective of the career.I learnt about the role of Public Health doctors in looking at the big picture of medicine. They are responsible for things like vaccination programmes, statistics and creating policies which will be of overall benefit to the general public.
Another doctor whose role allowed me to reflect on their importance towards patient safety was the Anaesthetic Consultant. I was already aware that Anaesthetists work with unconscious patients, those who are having an operation. The consultant mentioned that he is able to work in all departments which was something that had previously not crossed my mind – this type of career would perhaps be one of the most varied ones that one could have working as a doctor. One of the things he said was that he will stand at the head of the bed and overlook everything that was happening in the room. This reminded me of the time I spent in the hospital with my auntie after she had her Caesarian section. She was talking to me about her experience and one of the things she mentioned was how amazing she found the way the team all worked together, but in her opinion she thought the Anaesthetist was the most important. She described him as standing near her head and observing everyone else whilst monitoring her oxygen levels and her condition. She said that everyone else was busy carrying out their role in the operation, but it’s the anaesthetist that’s solely responsible for checking the person is kept in a good state. It was rather thought provoking to hear the idea of the role of an Anaesthetist being incredibly significant by both a doctor and a patient, and in the same manner!
This session involved recapping the 4 principles of Medical Ethics that by now, I was actually rather familiar with. One principle which was emphasised in this session above all others was the principle of Autonomy. I learnt that Autonomy should be thought of first. A patient’s autonomy should always be respected unless they do not have the capacity to make such a decision. It was very useful to learn that capacity is only true for a moment, for example, a schizophrenic won’t always be deemed as not having capacity, but only when they are having a psychotic episode. This allowed me to appreciate the true importance of Autonomy, as a doctor should always seek to give the patient the choice if possible. I knew that difficult ethical cases could be made available for open discussion amongst colleagues, but as well as this, it was rather interesting for me to learn about the fact that most hospitals have an Ethics Committee to which the difficult decisions are passed to. This may be situations involving issues such as confidentiality, consent and capacity. This session was delivered by Microbiology Consultant, who told us that it was rather common for difficult cases to be passed on to the Committee.
Gaining “informed consent’ is definitely something which has been given more prominence recently – the importance of this links to Autonomy and the idea that it is always ultimately the patient’s choice. I think this is something very important to always bear in mind, that no matter how much a doctor is certain that their idea of treatment will be perfect for the patient, and alternatively irregardless of how bizarre it may seem to them to accept their patients’ wishes to refuse treatment, this is what they must do. Autonomy rules!
It was really thought provoking to consider just how complex some of these ethical principles can become. We discussed the example of a wife who has contracted HIV, but doesn’t want her husband to know. It’s important to respect her autonomy and her confidentiality in this situation, but does that mean we should allow the husband to become infected? Ultimately, as a doctor your duty of care is solely to your patient, but there is also the consideration that you must have towards the wider population. I learnt and can now appreciate the very limited circumstances in which it can be justified to break confidentiality in: if the patient is going to harm themselves or others; a court order requires to see medical records; a situation where a child or incompetent adult needs to be treated; for the safety of public health. Amongst these reasons I was actually quite surprised that confidentiality could be broken for a court order as I would have accepted that privacy would still be maintained in this instance to respect the patient-doctor trust. But within these factors allowing confidentiality to be breached, one of the most important things that I took away was that if you do have to break confidentiality, you must always tell the patient that you are going to do so.
Consent is also another complicated field within medical ethics. I think it’s important to acknowledge the existence of “implied consent” such as when you share information about a patient amongst other members of the healthcare team in order to aid their care and acts such as taking pulse or temperature. However, other more serious acts such as operations, amputations, anything that’s irreversible, requires written consent. I was actually not aware of written consent being needed before today, so this was rather enlightening. I thought all types of consent were just taken orally, but it’s clear how if this was the case complications could later arise. The example of a patient who went into surgery having agreed to an amputation and upon coming out of the surgery realised he no longer had a limb and found that very difficult to accept it, is just one scenario where having obtained written consent was very appropriate. This particular patient that to then be referred to the Psychiatry department after he recovered from the operation to help him deal with the loss of one of his limbs.
There are also a list of things for a doctor to consider for a patient who lacks capacity:
- The doctor should act in the best interests of the patient.
- Check for previous family discussions.
- Think about whether the loss of capacity will be temporary.
- Contact a legal representative, if the patient has one.
The important things that I learnt is that legally relatives can only advise, but it is ultimately the doctors decision whether he/she chooses to listen to them. I learnt the consequences of this when considering the scenario in which a man has been involved in an accident and is left unconscious in urgent need of a blood transfusion. His cousin arrives at the hospital claiming that the man is indeed a devout Jehovah’s Witness and therefore cannot have the blood transfusion. It would be wrong for the doctor to blindly not provide the blood transfusion and let the patient die based on this assumption without conducting any further investigations into the matter.
There was a useful model which we used to help aid us in our discussions beyond the 4 principles of medical ethics…
- Seek information about the situation.
- Patient safety, make them safe.
- Use your initiative to try and solve the problem.
- Escalate by reporting to a senior colleague.
- Support the relevant person, may be the patient or family members who are affected by the decisions.
This session was presented by a consultant psychiatrist. It allowed me to appreciate some of the qualities which would be required for a doctor who chooses to specialise in Psychiatry with patience and persistence being rather prominent. We were able to watch a mock consultation between the Psychiatrist and a man who was suffering from Paranoia. It was really interesting to observe how the doctor chose to break it to the patient that the things he was seeing were actually in his imagination. I was rather surprised at how blunt and honest he was regarding this, he didn’t even attempt to agree with him at the beginning, but told him from the start. I noticed that the difference between Psychiatric consultations as opposed to normal consultations is that the person themselves often does not want to be there and it is actually up to the Psychiatrist to keep the line of conversation open and engage the patient.