Good medical practice

1 Good medical practice


Patients (and doctors) differ in their beliefs, attitudes and expectations. Good medical practice requires the ability to recognise and respect these individual differences. This chapter describes how to:


• Provide patients and their families with complex information.

• Discuss management options.

• Reach appropriate ethical decisions within resource constraints.


THE DOCTOR–PATIENT RELATIONSHIP


While some medical knowledge is based on clear evidence, much reflects wisdom and understanding passed down generations of doctors over hundreds of years. This wisdom is central to how doctors and patients interact; it demands respect, and if combined with compassion, fosters the development of trust.


The doctor–patient relationship is itself therapeutic; a successful consultation with a trusted practitioner will have benefits irrespective of other therapies. It is also dynamic, bilateral, and influenced by differing attitudes and beliefs. Patients with chronic diseases increasingly interact with a multidisciplinary team of health professionals. The doctor usually leads in determining the overall direction of care but must also:


• Guide the patient through the unfamiliar language and customs of clinical care.

• Interpret and convey complex information.

• Help patient and family to participate in decision-making.

Regulatory bodies seek to define the duties of a doctor (e.g. Box 1.1), and many medical schools require students to sign an ethical code based on such statements.



1.1 THE DUTIES OF A DOCTOR REGISTERED WITH THE UK GMC image



• Make the care of your patient your first concern

• Treat every patient politely and considerately

• Respect the patient’s dignity and privacy

• Listen to patients and respect their views

• Give patients information in a way they can understand

• Respect the rights of patients to be fully involved in decisions about their care

• Keep your professional knowledge and skills up to date

• Recognise the limits of your professional competence

• Be honest and trustworthy

• Respect and protect confidential information

• Make sure that your personal beliefs do not prejudice your patient’s care

• Act quickly to protect patients from risk if you have good reason to believe that you or a colleague may not be fit to practise

• Avoid abusing your position as a doctor

• Work with colleagues in the ways that best serve patients’ interests


CLINICAL AND COMMUNICATION SKILLS


Good communication is the single most important component of good practice. Failures in communication are common, and lead to poor health outcomes, strained working relations, dissatisfaction, anger and litigation among patients, their families and their carers. Some common barriers to good communication are listed in Box 1.2.



1.2 SOME BARRIERS TO GOOD COMMUNICATION IN HEALTH CARE image



The clinician



• Authoritarian or dismissive attitude

• Hurried approach

• Use of jargon

• Inability to speak first language of patient

• No experience of patient’s cultural background


The patient



• Anxiety

• Reluctance to discuss sensitive or seemingly trivial issues

• Misconceptions

• Conflicting sources of information

• Cognitive impairment

• Hearing/speech/visual impediment

At the beginning of a consultation, patients commonly feel ill and apprehensive. Their distress will be enhanced and communication impaired if the clinician appears indifferent, unsympathetic or short of time. First impressions are critical; the patient must be put at ease by a friendly and culturally appropriate greeting, with the clinician remembering to look at the patient, not the notes. The clinician must ensure that patients feel that they are the centre of interest, and should start by outlining the contents and agreeing the objectives of the consultation.


The main aim of a consultation is to establish a factual account of the patient’s illness. In addition the clinician must explore the patient’s feelings, their interpretation of their symptoms, and their concerns and fears, before agreeing a plan. These goals will not be met unless clinicians demonstrate understanding and empathy, not merely sympathy, which rarely helps. Many patients have multiple concerns and will not discuss these if they sense the clinician is uninterested, or likely to dismiss their complaints as irrational or trivial.


Careful questioning and listening will usually yield a provisional diagnosis, establish rapport, and determine which investigations are appropriate. The clinician must allow the patient to describe the problems with appropriate, not leading or overbearing questions. 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.


The doctor must always ensure that dignity is preserved and that the patient feels comfortable throughout the examination; this may entail the presence of a chaperone and always requires advance explanation of any examination.



INVESTIGATIONS


Modern medical practice is dominated by investigations. Judicious use of these is crucially dependent on good clinical skills. Indeed, a test should only be ordered if it is clear that the value of the result justifies the discomfort, risk and cost incurred. Clinicians should therefore draw up a provisional management plan before requesting any investigations.



THE ‘NORMAL’ RANGE


Although some tests provide qualitative results (present or absent), most provide a quantitative value. To classify quantitative resuts as normal or abnormal, it is necessary to define a ‘normal range’. Many biological measurements exhibit a bell-shaped, ‘normal distribution’, described statistically by the mean value and the standard deviation (SD, which describes the spread of results). The ‘normal range’ is conventionally defined as the range which includes 95% of the population, i.e. two SDs above and below the mean. Results more than two SDs from the mean occur either because the person is one of the 2.5% of the normal population whose result is outside the normal range, or because their disease is affecting the test result.


In medicine, it is also important to define results which correlate with biological disadvantage. In some diseases, there is no overlap between results from the normal and abnormal population (e.g. creatinine in renal failure). In many diseases, however, there is overlap with the normal range (e.g. thyroxine in toxic multinodular goitre). The greater the difference between the test result and the normal range, the higher the chance that the person has a disease, but results within the normal range may be ‘false negatives’ and results outside the normal range may be ‘false positives’. Similarly, when assessing quantitative risk factors, the clinical decision may not depend on whether or not the result is ‘normal’. For example, higher total cholesterol is associated with a higher risk of myocardial infarction within the normal population, and cholesterol-lowering therapy may benefit people with values within the normal range. Similar arguments may apply for blood pressure, blood glucose, bone mineral density, etc.


Each test in a member of the normal population carries a 5% (1 in 20) chance of a result outside the ‘normal range’. Indiscriminate repeat testing increases the chance of such ‘abnormal’ results and should be avoided.


Normal ranges defined either by test manufacturers or local laboratories are often established in small numbers of young healthy people who are not necessarily representative of the patient population.


If a substantial proportion of the normal population have an unrecordably low result (e.g. serum troponin), the distribution cannot be described by mean and SD. In these circumstances, results from normal and abnormal people are used to identify ‘cut-off’ values associated with a certain risk of disease.

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Apr 3, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Good medical practice

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