Good medical practice

Good medical practice

A.D. Cumming

S.I.R. Noble

Since the time of Hippocrates, the role of the doctor has extended beyond the narrow remit of curing patients of their ailments. Good medical practice, or the art of medicine, hinges on recognising and respecting the breadth of physical, cultural, spiritual, experiential and psychosocial characteristics of each patient, and understanding their impact on the patient’s beliefs, attitudes and expectations. Doctors must deliver appropriate care which considers the technical complexities of modern treatment, and at the same time deals with the communication and interpersonal needs of the patient, at a time when he or she may feel most vulnerable. In addition to the diagnosis and treatment of illness, the scope of medicine has expanded to preventing disease through measures such as screening, vaccination and health promotion. Doctors are centrally involved in tackling lifestyle-related issues of the modern world, such as obesity, alcohol excess, cigarette smoking and sexual health.

Medical professionalism has been described in the UK by a Royal College of Physicians working party (2005) as ‘a set of values, behaviours and relationships that underpin the trust the public has in doctors’. They stated that doctors should be committed to integrity, compassion, altruism, continuous improvement, excellence, and working in partnership with members of the wider health-care team. They perceived that medical professionalism was relevant to leadership, education, career pathways, appraisal and research.

This chapter outlines how doctors must provide patients and their families with relevant but complex information, discuss management options, and reach appropriate clinical decisions, commensurate with the available resources. It also describes processes to develop, maintain and assure medical professionalism.

Medical practice

The doctor–patient relationship

The contents of this book are not all based on indisputable contemporary evidence; many reflect wisdom and understanding distilled over hundreds of years and passed from generation to generation of doctors. This perceived wisdom lies at the heart of the way that doctors and patients interact; it demands respect, and if the doctor also displays compassion, sets the scene for the development of trust.

Due to the complexities of many chronic diseases and treatments, and the multifaceted impact of illness on a patient, there is an increasing role for health care to be delivered by a multidisciplinary team (Box 1.1). This model of care recognises the different skills of each allied health professional and focuses patient care beyond surgical procedures or pharmacological manipulation. The doctor usually takes the lead in determining the overall direction of care but must also:

In many clinical disciplines, doctors from several specialties form a multidisciplinary team in order to formulate a treatment plan. In oncology, for example, this ensures that various modalities of treatment (surgical, oncological and palliative) are considered.

The doctor–patient relationship is in itself therapeutic; a successful consultation with a trusted and respected practitioner will have beneficial effects irrespective of any other therapy given. The doctor–patient relationship is multilayered, dynamic and bilateral (Fig. 1.1).

Regulatory bodies, such as the UK General Medical Council, seek to define the medical side of the doctor–patient relationship in terms of the ‘Duties of a Doctor’ (Box 1.2). It is common for medical schools to require undergraduate students to sign an ethical code of conduct based on statements like this.

image 1.2   The duties of a doctor registered with the UK General Medical Council

Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and make sure your practice meets the standards expected of you in four domains.

Difficulties in the doctor–patient relationship

Regardless of experience and skill, it is inevitable that, at some point in a doctor’s career, the doctor–patient relationship will break down. There can be many reasons for this; sometimes, these are beyond the control of the clinician, but often conflict arises when there is a genuine or perceived failure of the doctor to meet one or more of the duties outlined in Box 1.2. It is important to recognise a breakdown in the relationship quickly and, whenever possible, identify the reason. If patients are unhappy with an aspect of their care, they are entitled to a prompt, open, constructive and honest response that includes an explanation and, if appropriate, an apology. It is also important to reassure the patient that the issues raised will not adversely affect their future care.

Often, an acknowledgement that something is wrong and demonstration of a desire to put things right are sufficient to rectify any conflict. However, the longer one takes to address a problem, the more difficult it becomes to resolve. The patient may continue to be dissatisfied with the doctor and it may be most appropriate for another colleague to take over their care. It is important to reflect on such incidents, to identify whether one would approach a similar challenge differently next time.

Communication and other clinical skills

Communication lies at the heart of good medical practice. The most technically capable clinician will fail in the duty of care if he or she is unable to communicate effectively with patients or relatives, since this is essential for accurate history-taking, information-giving and decision-making. Likewise, the delivery of holistic care requires effective communication with other doctors and members of the multidisciplinary team. Clear and appropriately detailed clinical note-keeping is essential, as are timely and accurate written communications between professionals.

Failures in communication may lead to poor health outcomes, strained working relations, dissatisfaction among patients, their families and health professionals, anger and litigation. The majority of complaints received by health-care professionals could have been avoided by effective communication. Box 1.3 lists some common barriers to good communication.

Developing communication skills to facilitate accurate history-taking and information-giving takes many years and requires frequent personal reflection on previous consultations. A detailed account of history-taking, clinical examination and communication skills is beyond the scope of this chapter but is provided in Davidson’s sister book, Macleod’s Clinical Examination. However, some communication principles are discussed below and these can be applied to most consultations.

The main aim of a medical interview is to establish a factual account of the patient’s illness. The clinician must allow the patient to describe the problems without overbearing interrogation, but should try to facilitate the process with appropriate questions (Box 1.4). Techniques such as an unhurried approach, checking prior understanding, making it clear that the interviewer is listening, the use of silence when appropriate, recapping on what has been said, and reflection of key points back to the patient are all important. A major requirement is to express complex information and concepts in language with which the patient can readily engage. Non-verbal communication is equally important. The patient’s facial expressions and body language may betray hidden fears. The clinician can help the patient to talk more freely by smiling or nodding appropriately.

Beyond the factual account of symptoms, the clinician should also explore patients’ feelings, determine how they interpret their symptoms, unearth their concerns and fears, and explore their expectations before suggesting and agreeing a plan of management. Clinicians should demonstrate understanding, sensitivity and empathy (i.e. imagine themselves in the patient’s position). Most patients have more than one concern and will be reluctant to discuss potentially important issues if they feel that the clinician is not interested or is likely to dismiss their complaints as irrational or trivial.

Specific communication scenarios, such as breaking bad news or dealing with aggression, require additional targeted strategies (see Macleod’s Clinical Examination).

While many common clinical conditions can be identified on the basis of the history from the patient, the process of physical examination remains important in most clinical scenarios. Physical examination is an important characteristic of the doctor–patient relationship, at best benefiting from and reinforcing trust, but at worst a focus of complaint when the doctor–patient relationship has not been established or has broken down. Key findings on physical examination pointing to disease in specific body systems are described in the relevant chapters of this book.

Using investigations

Modern medical practice has become dominated by sophisticated and often expensive investigations. It is easy to forget that the judicious use of these tools, and the interpretation of the data that they provide, are crucially dependent on good basic clinical skills. Indeed, a test should only be ordered if it is clear that the result will influence the patient’s management and the perceived value of the resulting information exceeds the anticipated discomfort, risk and cost of the procedure. Clinicians should therefore analyse their patient’s condition carefully and draw up a provisional management plan before requesting any investigations.

The ‘normal’ (or reference) range

Although some tests provide qualitative results (present or absent, e.g. faecal occult blood testing, p. 857), most provide quantitative results (i.e. a value on a continuous numeric scale). In order to classify quantitative results as normal or abnormal, it is necessary to define a ‘normal range’. Many quantitative measurements in populations exhibit a bell-shaped, or Gaussian, frequency distribution (Fig. 1.2); this is called a ‘normal distribution’ and is characteristic of biological variables determined by a complex mixture of genetic and environmental factors (e.g. height) and of test results (e.g. plasma sodium concentration). A normal distribution can be described by the mean value (which places the centre of the bell-shaped curve on the x axis) and the standard deviation (SD, which describes the width of the bell-shaped curve). Within each SD away from the mean, there is a fixed percentage of the population. By convention, the ‘normal range’ is defined as those values which encompass 95% of the population, i.e. the values within 2 SDs above and below the mean. If this convention is used, however, 2.5% of the normal population will have values above, and 2.5% will have values below, the normal range; for this reason, it is more precise to describe ‘reference’ rather than ‘normal’ ranges.

‘Abnormal’ results, i.e. those lying beyond 2 SDs from the mean, may occur either because the person is one of the 2.5% of the normal population whose test result is outside the reference range, or because he or she has a disease characterised by a different result from the test. Test results in ‘abnormal’ populations also have a bell-shaped distribution with a different mean and SD (see Fig. 1.2). In some diseases, there is typically no overlap between results from the normal and abnormal population (e.g. elevated serum creatinine in renal failure, p. 467). In many diseases, however, there is overlap, sometimes extending into the reference range (e.g. elevated serum thyroxine in toxic multinodular goitre, p. 753). In these circumstances, the greater the difference between the test result and the limits of the reference range, the higher the chance that the person has a disease, but there is a risk that results within the reference range may be ‘false negatives’ and results outside the reference range may be ‘false positives’.

Each time a test is performed in a member of the normal population there is a 5% (1 in 20) chance that the result will be outside the reference range. If two tests are performed, the chance that one of them will be ‘abnormal’ is 10% (2 in 20), and so on; the chance of an ‘abnormal’ result increases as more tests are performed, so multiple indiscriminate testing should be avoided.

In practice, reference ranges are usually established by performing the test in a number of healthy volunteers who are assumed to be a random sample of the normal population. Not all populations are the same, however, and while it is common to have different reference ranges for men and women or children and adults, clinicians need to be aware that reference ranges defined either by test manufacturers or even within the local laboratory may have been established in small numbers of healthy young people who are not necessarily representative of their patient population.

For some tests, the clinical decision does not depend on whether or not the patient is a member of the normal population. This commonly applies to quantitative risk factors for future disease. For example, higher plasma total cholesterol levels are associated with a higher risk of future myocardial infarction (p. 583) within the normal population. Although a reference range for cholesterol can be calculated, cholesterol-lowering therapy is commonly recommended for people with values within the reference range; the ‘cutoff’ value at which therapy is recommended depends upon the presence of other risk factors for cardiovascular disease. The reference range for plasma cholesterol is therefore redundant and the phrase ‘normal plasma cholesterol level’ is unhelpful. Similar arguments apply for interpretation of values of blood pressure (p. 583), bone mineral density (p. 1065) and so on.

Some quantitative test results are not normally distributed, usually because a substantial proportion of the normal population will have an unrecordably low result (e.g. serum prostate-specific antigen, p. 518), and the distribution cannot be described by mean and SDs. Alternative statistical procedures can be used to calculate 95th centiles, but it is common in these circumstances to use information from normal and abnormal people to identify ‘cutoff’ values which are associated with a certain risk of disease, as described below.

Sensitivity and specificity

No test is completely reliable. All diagnostic tests can produce false positives (an abnormal result in the absence of disease) and false negatives (a normal result in a patient with disease). The diagnostic accuracy of a test can be expressed in terms of its sensitivity and its specificity (Box 1.5).

Sensitivity is defined as the percentage of the test population who are affected by the index condition and test positive for it. In contrast, specificity is defined as the percentage of the test population who are healthy and test negative. A very sensitive test will detect most disease but may generate abnormal findings in healthy people; a negative result will therefore reliably exclude disease but a positive test is likely to require further evaluation. On the other hand, a very specific test may miss significant pathology but is likely to establish the diagnosis, beyond doubt, when the result is positive.

In choosing how a test is used to guide decision-making, there is an inevitable trade-off between emphasising sensitivity versus specificity. For example, defining an exercise electrocardiogram (p. 534) as abnormal if there is at least 0.5 mm ST depression will ensure that very few cases of coronary artery disease are missed but will generate many false-positive tests (high sensitivity, low specificity). On the other hand, a cutoff point of at least 2.0 mm ST depression will detect most cases of important coronary disease with far fewer false-positives. This trade-off can be illustrated by the receiver operating characteristic curve of the test (Fig. 1.3).

Predictive value

The predictive value of a test is determined by its sensitivity and specificity, and can be expressed in several ways. The positive predictive value is the probability that a patient with a positive test has the index condition, while the negative predictive value is the probability that a patient with a negative test does not have the condition (see Box 1.5). The likelihood ratio expresses the odds that a given finding would occur in a patient with, as opposed to a patient without, the index condition (see Box 1.5); as the odds rise above 1, the probability that disease is present rises.

The interpretation and the utility of a test are critically dependent on the circumstances in which it is used. Bayes’ theorem dictates that the value of a diagnostic test is determined by the prevalence of the condition in the test population. The probability that a subject has a particular condition (the post-test probability) can be calculated if the pre-test probability and the sensitivity and specificity of the test are known (Box 1.6). A test is most valuable when there is an intermediate pre-test probability of disease. Clinicians seldom have access to such precise information but must appreciate the importance of integrating clinical and laboratory data.

Apr 9, 2017 | Posted by in GENERAL SURGERY | Comments Off on Good medical practice

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