Physician Practice

The ACGME (qv) has described six competencies for medical practice in the US. One such competency describes Professionalism as "demonstration of behaviors that reflect a commitment to continuous professional development, ethical practice, an understanding and sensitivity to ethnic diversity and a responsible attitude towards patients, the professions and society"

As patient expectations increase, resources are constrained and pressure of work becomes burdensome it is essential that standards of medial practice are maintained. Individuals and organisations must adhere to high ideals and medical training must continue to teach the elements of integrity in daily medical practice.

A diligence in personal medical practice, a respect for others and constant review of practice and an understanding of the evidence supporting the decision making process will lead to maintenance of high standards. Providing patient centred care ensures appropriate setting of priorities. Recognition of poor performance in oneself and colleagues should identify the need for remedial intervention and opportunities for further development.

Audit, Quality, Risk Management

Audit has been introduced in the National Health Service at clinical level for all departments and all staff members over the last decade. It was preceded by medical audit, that is relating to doctors alone, over the previous 20 years or so, which was taken up by some departments more enthusiastically than others. Recently, the crisis in confidence in the paediatric cardiothoracic surgery results at one regional centre in the UK was supported by audit data on outcomes. Quality and risk-management are top-down tools that have been introduced to improve services to patients offered at hospital level and reduce incidence of complaints and litigation.

Clinical Audit should be part of every trainee's education, but attitudes to it vary greatly amongst both trainers and trainees. Despite great enthusiasm from some, there is cynicism about audit's ability to substantially modify clinical practice. Nevertheless, enthusiasts have always linked audit with education, whereas the more managerially inspired quality and risk management initiatives are far more tenuously hitched to learning. Procedure based specialties, especially surgery, are more amenable to outcome audits than medical specialties. Educational audit has received some attention. Educational audit tools have been developed by several organisations. Their impact on education varies greatly. Projects on clinical audit involving multi-disciplinary teams, the role of education in quality and risk management initiatives and the impact of educational audits (of varying types) and a comparison of the overall effectiveness of audits that are in many cases poorly supported by underdeveloped information technology in the UK but highly developed IT (though IT focused on resource management) in the US would be worth considering.

Consultant appraisal and revalidation

The recent introduction of annual appraisals for consultant staff remains controversial. Template documentation (see http://www.gmc-uk.org) sets out a model which Continuing Professional Development (CPD) features strongly. Standards for CPD are set by each Royal College; (e.g. RCPCH website)

Consultant revalidation will be introduced from 2004, although all the details of the model are not yet agreed. At its simplest it will depend on 5 previous satisfactory annual appraisals.

Revalidation for junior staff will depend on successful medical records of in-training assessment (RITAs) (Appraisal and Assessment)

Physician impairment

Medicine is a highly stressful profession and clinicians rarely make good patients. Physician stress may lead to impaired judgement, which may have profound effects on the ability to practice and make effective decisions. This may also affect the quality of teaching and increase the risk of abuse of the teacher-student relationship. Drug and alcohol abuse are not uncommon among this professional group and clinicians must remain aware of the potential in their colleagues and themselves to follow this route.

Clinical teachers have a privileged position and must not be allowed to abuse this role. All involved in the teaching and practice of medicine must seek to maintain the highest standards and be prepared to intervene if their perception is that students of patients are put at risk as a result of physician impairment.

Critical Care Pathways

The evidence-based medicine movement has gained ground in the UK over the last decade, particularly influenced by David Sackett and his supporters. Many doctors outside academic centres, however, found themselves sinking under the weight of the evidence. Attempts to solve this by producing evidence-based guidelines have led to a profusion of methodologies and (sometimes conflicting) written guidelines that may be stored in ward files but infrequently accessed. Critical care pathways have proved useful in post-operative scenarios, where failure to recover at the usual rate can prompt a series of investigations and interventions, but may be less useful in medical cases where the interplay of complex factors and multiple medical conditions can render guidelines unhelpful. Anxieties about "cookbook medicine ", which may disempower trainees and reduce their capacity to make clinical decisions, especially when the breadth of experience is being restricted by both shortened it training periods and shortened working hours when compared to previous decades, have generated considerable discussion and controversy.

Equipping lifelong learners

Postgraduate Clinical Tutors (PGCTs) do not all have co-ordinating responsibility for CPD because they primarily cover postgraduate medical education (link to Generic Job Description for PGCTs on COPMeD website). However, some do, and even those who do not, still have managerial roles in the Postgraduate Medical Centre (PGMC), where CPD takes place; may run CPD courses for Consultant, (especially "Training the Trainers" courses); may have a role in advising young consultants who are making the transition from PGME to CPD; and may have roles within their hospital, such as a Director of Medical Education, which imply greater responsibility for CPD.

Consultant CPD is based around gaining 50 credits per year, most of which would be directed towards helping the clinician to do their primary job. The recent introduction of annual consultant appraisal and quinquennial revalidation relates to successful uptake of CPD, though it is not yet fully clear how the revalidation process will be conducted for all.

Litigation and medical education

Litigation over medical education issues is uncommon at present. However, the last decade has seen an exponential rise in the number of clinical negligence claims in the UK. Therefore in medical education, doctors are increasingly aware of legal avenues that are available to solve problems. With the growth of appraisal and assessment, regulation of entry to training programmes and assessment of trainees, ultimately leading to the award of a CCST (Certificate of Completed Specialist Training), legal disputes can be the outcome of disagreements. At any one time most Deaneries in that the United Kingdom (14 in number) will have litigation underway with failed trainees.

Trainers at hospital level are not often faced with litigation issues, but when they are, may have issues of provision of evidence of poor performance strongly highlighted to them. Trainers can feel that they face a double jeopardy: if a poorly performing trainee is failed in the post, a challenge will often arise; if a poorly performing trainee is allowed to proceed to the next post, questions can be asked when that trainee fails or, worse still, is involved in a severe adverse incident. Some of these problems would be solved by valid, reproducible assessment methods, but these are still in development and in any case, some of the most difficult problems relate to attitudes and behaviours, which are difficult to measure. Comparison of litigation issues in medical education in the UK and US might be worthwhile.