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MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICEFoundation doctors:Receive a free Oxford HandbookRenew your membership with MPS andyou can choose a free Oxford Handbookwww.mps.org.uk/foundationyears15 AVAILABLE TITLESAnaesthesiaF1 Doctors50% subscription rate discount – renew your MPSmembership before 31 May 2013 and you will receive a50% discount on your subscription – so you pay just £20instead of £40 for your F2 yearPlus receive a free Oxford Handbook of your choicefrom the 15 available titles.Renew online today – www.mps.org.uk/F2F2 DoctorsReceive a free Oxford Handbook of your choice from the15 available titles, when you renew your membership foryour fi rst year of specialty training.Renew online today – www.mps.org.uk/STRenew your membership todayT 0845 718 7187E juniordoctor@mps.org.ukW www.mps.org.uk/foundationyearsCardiologyClinical and LaboratoryInvestigationsClinical DiagnosisClinical SurgeryEmergency MedicineExpedition MedicineGastroenterologyand HepatologyGeneral PracticeGeriatric MedicineObstetrics and GynaecologyPaediatricsPsychiatryRespiratory MedicineTrauma and OrthopaedicsMPS1194: 01/13

3Inside this issue of New Doctor…Page 4 UpdateA revalidation update for all foundation doctorsabout what to do nextPage 4 EventsA snap shot of all the top events for foundationdoctors over the next few monthsPage 5 Hot topic: Consent foraudio/visual recordingsMPS Medicolegal Adviser Dr Pallavi Bradshawexplores what consent you need totake photographs and make recordingsPage 5 Top five medical appsDr Josephine Neale has done the app workso you don’t have toPage 6–7 Dilemma: DNAR ordersDr Jonny Morris describes a tricky case ofa patient with a do not attempt resuscitation(DNAR) orderPage 8–9 Ask MPSHere Dr Sarah Clarke shares the hurdles shefaced when tackling the mental capacity issuesin relation to her patient Mr KPage 10-12 Essential learning:Law and ethicsEarn CPD points by reading Dr Paul Nisselle’sfeature on the key legal and ethical topics in thefoundation curriculumPage 13 From ward to world:Saving lives in EthiopiaDr Tom Bashford won a Patient Safety Award forhis work promoting safer surgery in Ethiopia.He shares his storyPage 14–15 A week in the life of anF2 working in a refugee campWorking in a Burmese refugee camp can reallyopen your eyes to what matters in medicine, saysDr June Tay. She shares her personal experiencesEDITOR-IN-CHIEF Dr Gordon McDavid EDITOR Sara Williams CONTRIBUTORS Dr Jo Pointon, DrJune Tay, Dr Tom Bashford, Dr Paul Nisselle, Dr Sarah Clarke, Dr Jonny Morris, Dr Josephine Neale DESIGNJayne Perfect, Anna Wanczyk PRODUCTION MANAGER Philip Walker MARKETING Peter Macdonald,Kim Beaumont EDITORIAL BOARD Dr Stephanie Bown, Gareth Gillespie, Dr Paul Mackin, Dr Chris Godeseth,Dr Jayne Molodynski, Shelley McNicol, Dr Jo Galvin, Dr Pallavi Bradshaw New Doctor Medical ProtectionSociety, Victoria House, 2 Victoria Place, Leeds LS11 5AE Tel: 0113 241 0530 Fax: 0113 241 0500GET THE MOST FROMYOUR MEMBERSHIPVisit our website for publications,news, events and other information:www.mps.org.ukFollow us on Twitter at:www.twitter.com/MPSdoctorsOpinions expressed herein are those of the authors. Pictures shouldnot be relied upon as accurate representations of clinical situations.© The Medical Protection Society Limited 2013. All rights are reserved.GLOBE (logo) (series of 6)® is a registered UK trade mark in thename of The Medical Protection Society Limited.Cover: © IMAGES/VSO/PHOTGRAPHER BEN LANGDONWe welcome contributions toNew Doctor. Please contact us on0113 241 0377 oremail sara.williams@mps.org.ukWelcomeDr Gordon McDavid – Editor-in-chiefMPS Medicolegal AdviserWelcome to your new edition ofNew Doctor and the first of 2013.The cover story of this issue chartsthe story of Tom who left the confinesof a large London teaching hospitalto travel to Ethiopia for a year to driveup patient safety standards in AddisAbaba. Read about how he won apatient safety prize for his efforts onpage 13.Every doctor will face difficultsituations from time to time whereit is necessary for the treating teamto draw on their collective experienceto achieve a desirable outcome.Have a look at the dilemmas featuredon pages 6 and 8.On page 8 Dr Sarah Clarke givesa candid tale of her difficulties inmanaging a patient at the interfacebetween two specialties.While on page 6, the controversialissue of end-of-life decisions istackled head on by Dr Jonny Morris.Another thought-provoking articleis Dr Paul Nisselle’s piece on the keyethical principles governing medicalpractice. This piece describesthe interlocking relationship betweenethics and the law, knowledgeessential for any practising doctor.This topic is so important we’vesupplemented the article with twoonline modules, why not havea look and download a certificateof completion for inclusion in yourePortfolio. I hope you enjoy the issue.CONTENTS NEW DOCTOR | VOLUME 6 | ISSUE 1 | 2013 | UNITED KINGDOM www.mps.org.uk

4UpdateA snap shot of news for foundation doctorsUPDATE NEW DOCTOR | VOLUME 6 | ISSUE 1 | 2013 | UNITED KINGDOM www.mps.org.uk©IAN HOOTON/SCIENCE PHOTO LIBRARYRevalidation round-upThe GMC has begun revalidating alldoctors – here’s what you need to knowEvery doctor who is registered witha licence to practise needs to revalidatewith the GMC; this includes doctors infoundation year two and specialty training.To revalidate new doctors will require theirresponsible officer to make a recommendationto the GMC that they are up-to-date, fit topractise and should be revalidated.You will already be in regular discussionabout your progress with your supervisors.These discussions should include reflectingon strengths and weaknesses and significantachievements or difficulties, which will usuallyencompass information on significant events,and complaints.The organisation that will be supportingyour revalidation is called your ‘designatedbody’; these vary depending on where youare a trainee (see text box).Doctors will need to collect supportinginformation to show how they are meeting theGMC’s professional standards in day-to-dayEvent When Where What Further informationMPS Communication SkillsWorkshopsNational Conference forAspiring SurgeonsASiT Foundation Skills inSurgery CourseFoundation ProgrammeSharing EventThroughoutyearAcross UK2 March Birmingham5 April Cardiff12 June Londonpractice. This information will be generatedwhile training, but the GMC expectsyou to collect additional information where yourtraining programme does not expect youto collect evidence.When you revalidate will depend on howlong your training lasts:■■If your training lasts less than five years,your first revalidation will be at the pointof eligibility for CCT■■If your training lasts longer than five years,you will be revalidated five years after yougained full registration, and again at the pointof eligibility for CCT.When your training is complete, yourdesignated body will change to theorganisation where you practise. The GMCshould be informed when this change occurs– you can do this using GMC Online.From this point you will need to have regularappraisals and collect supporting evidenceto show you are meeting standards.The GMC has included useful information on their website,including an FAQ section, visit www.gmc-uk.org/doctors/revalidation.asp or email revalidation@gmc-uk.orgMix with other specialties and reduce your risk at MPS’spopular workshopMedical students and foundation doctors are invited tosubmit abstracts for oral and poster presentations at thisresearch conferenceThis popular one-day course will equip senior medicalstudents and junior doctors with the fundamental techniquesrequired for surgical successThis event is a great opportunity for foundation doctors topresent and shareRegional variationsEnglandDesignated body:postgraduate deaneryResponsible officer:postgraduate deanNB. This will change whenpostgraduate deaneriesare replaced by localeducation and trainingboards in April 2013.ScotlandDesignated body: NHSEducation for ScotlandResponsible officer:medical director for NHSEducation for ScotlandWalesDesignated body:Wales DeaneryResponsible officer:postgraduate deanNorthern IrelandDesignated body:Northern Ireland Medicaland Dental TrainingAgency (NIMDTA)Responsible officer:postgraduate deanwww.mps.org.uk/workshopswww.rcsed.ac.uk/aspiringsurgeonsbristolwww.asit.org/events/conferences/2013/pre-courses/FSSwww.nact.org.uk

5Consent for audio/visual recordingsConsent for taking photographs and making recordings isvital, explains MPS medicolegal adviser Dr Pallavi BradshawHOT TOPICThe smart phone revolution hasfundamentally changed the waywe interact in society and hascreated a reliance on technology thatpervades even clinical practice. Withthe invention of medical apps, goneare the days of white coats ladenwith various clinical handbooks. It isunsurprising that mobile phones areoften used to take photographs ofinteresting cases and recordings madeof interesting patients. Whilst most ofthese photographs are taken to showto colleagues to aid diagnosis or tobe used as potential case reports,the doctors taking the photographsmay be inadvertently breaching GMC,employment and legal obligations, ifthe right consent has not been taken.Documented consent is requiredfor all images taken (save for internalinvestigations and pathology slides)and trusts will usually have specificconsent forms that should be usedor medical photography departmentswho can guide you through the process.The GMC has producedsupplementary guidance Makingand using visual and audio recordingsof patients (2011), it sets out theprofessional obligations of takingimages or recordings of patients. Issuesaround confidentiality and consent areparamount and must not be overlookedeven in the theatre setting withanaesthetised patients.Any image whether it is anonymisedor otherwise, forms part of the medicalrecord, so this data must be storedand processed as per the DataProtection Act (1998). It is thereforenot acceptable to be carrying imagesof patients on one’s mobile phoneor electronically sending them on.There is clearly a risk of the data beinglost or stolen and the fact remainsthat most hospital doctors will notbe registered as a Data Controlleras would be required. Should theimages become lost you would havea duty to notify your employer and thepatient, which would lead to difficultquestions being asked and likelydisciplinary action. There may be timeswhen a photo would aid diagnosis inemergency situations if the clinicianis off site, but generally these imagesshould be relayed via secure emailsand immediately deleted after storingin the records. You should discusssuch deletion with your employer’sIT department.If there is a clinical need or adesire to take images for diagnosisor education purposes it is notappropriate to use personal camerasand mobile phones. Agreementby a patient to take an image doesnot obviate your obligations toyour employer, or your duties ofconfidentiality. There are ultimately nocircumstances, save for emergencies,when taking patient images on a mobilephone, whether consented or not,is justified, so should not be done.NB. Doctors working in a GP settingor in private practice should seekfurther advice if they are concerned.Top five medical apps for foundation doctorsDr Josephine Neale, an F2 from Warwickshire, has done the app workso you do not have to. Here are her top five apps for new doctorsDiAppBetesDevelopedfrom nationalguidelinesby a teamin UniversityHospital Southampton, this isa gem for those who have everfound themselves adjustinginsulin dosing regimes withoutmuch success.Although it is not a replacementfor senior advice, this appprovides support andclear information for insulinprescribing, hypoglycaemia,specialist referral criteria andwhen to stop or start diabeticmedication in an inpatientsetting.Cost – free.NICE BNFNo morerummagingaround the wardto find a BNF –now it can be at your fingertipswithout the need for an internetconnection after the initialdownload. There is an easysearch function and you canbookmark your most frequentlyused pages. The BNF forchildren is also available andworth downloading.Cost – requires an NHS Athensaccount to login.CliniCalcIf you havetroublerememberingyour A-agradient from your Anion gap,or your Child-Pugh from yourCHADS2, this is the app foryou. Categorised by specialty,this app has everythingfrom simple GCS remindersto predicted spirometricvalues, with some statisticalcalculations in there as well.Cost – free.PasTestYou probablywill have seenor used PasTestduring your timeat medical school. Now yourtime is precious and on-the-gorevision is a necessity – this iseven available without internetconnection. Like the full site,the features include QuestionBrowser, Timed Tests and MockExams. Cost – free demoversions, further question bankrequires a subscription fee.Patient.co.ukMuch of afoundationdoctor’s job iscommunicatinginformation topatients. After a high-speedpost-take ward round, thisapp can help you translateyour medical jargon into plainEnglish for your baffled patients.Conditions from Achalasiato Yellow Fever are summarisedconcisely and many haveaccompanying diagrams.Cost – free to view conditionleaflets.NEW DOCTOR | VOLUME 6 | ISSUE 1 | 2013 | UNITED KINGDOM www.mps.org.uk

12MEDICOETHICAL NEW DOCTOR | VOLUME 6 | ISSUE 1 | 2013 | UNITED KINGDOM www.mps.org.ukInformativeDOCTORPaternalisticmanaged to fracture his pelvis. ECT wasnew at that time, and medical opinionwas divided on whether a relaxantanaesthetic should be used. 5In the subsequent legal action,the court was invited to decide betweenthe two competing medical schoolsof thought – relaxant or no relaxant.The court said it was not competent todecide on a medical issue. The judgein that case said that: “A doctor is notguilty of negligence if he has acted inaccordance with a practice accepted asproper by a responsible body of medicalmen skilled in that particular art.”This has been tweaked a bit overthe years, but the ‘Bolam test’ or‘Bolam standard’, also called the ‘PeerProfessional Acceptance’ or ‘Reasonabledoctor’ test, remains the yardstick.Hippocrates wrote that doctorsshould: “Continue with diligence to keepabreast of advances in medicine.”In 1711 Alexander Pope cautioned usto: “Be not the first by whom the neware tried, nor yet the last to laythe old aside.” Neither ethics nor thelaw requires us to be the best doctor inthe world, but we do need to attain andmaintain that level of skill in what we dothat would attract peer support.Shared decision making“Doctor’sorders”Passive PATIENT ActiveREFERENCES1. Schloendorff v Society of New York Hospital (1914)2. NHSLA, Risk Management Handbook (2012)3. Gillick v West Norfolk and Wisbech Area Health Authority (1985)4. Donoghue v Stevenson (1932)5. Bolam v Friern Hospital Management Committee (1957)SharedDecisionMaking“Patient’schoice”JusticeThere are three elements to Justice:■■■Distributive justice – fair distributionof limited healthcare resources■■ ■Rights-based justice – respect forpeople’s rights, such as prohibitionof discrimination■■■Legal justice – respect for the law.On an individual patient level,there are some obvious elements to‘Justice’– for example, not discriminatingagainst patients on the basis of theircolour, race, religion, etc; but can werefuse to perform cardiac surgery ona patient because they smoke? Is thatdiscrimination – punishing the patientfor not stopping – or a fair medicaljudgment based on their increased riskof complications at and after surgery?More broadly, we do our best tomaintain a focus on the patient infront of us, but we are aware of theneed to balance that patient’s rightsand needs against the need for anequitable allocation of healthcare fundsand resources. Who decides whatis ‘equitable’? The ethical principle ofJustice imposes a moral obligation todecide fairly between competing claims.Dr Nisselle is a senior consultantat MPS Educational Services.He can be contacted atpaul.nisselle@mps.org.ukLOOKING FOR EVIDENCE FORYOUR ePORTFOLIO?MPS is committed to education andtraining. As well as helping you providethe best care for your patients, we wantto support your development. That iswhy we have developed two onlinelearning modules on the topics coveredin this article, so that you can downloada certificate of completion as evidenceof your learning for your ePortfolio.What to do next….■■Once you’ve read this article, simplygo to www.mps.org.uk/e-portfoliowhere you can register for theE-learning platform■■You’ll need your membership detailsto register and log on■■Once logged on, you will be able toaccess the modules highlighted onthe home page■■You can complete the modules at atime that suits you■■Download your certificate ofcompletion and any supporting notes■■Other modules on a wide rangeof subjects can also be accessedthrough the E-learning platformTo learn more visit MPS’s website■■Access the MPS library offactsheets, this includes detailedinformation on the law aroundconsent and confidentiality –www.medicalprotection.org/uk/factsheets■■Visit the handbooks and bookletssection, to read more aboutconsent and the ethical mazethat is modern medicine – www.medicalprotection.org/uk/adviceand-publications/booklets-andhandbooks.

13From ward to worldFROM WARD TO WORLDSaving lives in Ethiopia© IMAGES/VSO/PHOTGRAPHER BEN LANGDONEthiopia has one anaesthetist for every 5.3 million people. Dr TomBashford won the Patient Safety Award from the Association ofAnaesthetists for his work promoting safer surgery in EthiopiaThere are feweranaesthetists in thewhole of Ethiopia, acountry of 85 million, thanin the London hospital whereI work. I feel there is a moralobligation on countrieswith so many trained healthprofessionals to supportvolunteer work overseas.I recently returned from anout-of-programme careerbreak (OOPC) during mycore anaesthetic training,where I worked in a largepublic hospital in AddisAbaba, the capital city ofEthiopia.Volunteering as a juniordoctor in the developingworld is challenging. Thereare difficult boundariesto negotiate to ensure youremain within the limitsof your competence whilstbeing useful. I startedmy placement by reviewingthe existing anaestheticpractice in the hospital againstinternational standards. I thenused this as a tool to plana number of interventionsthat seemed likely to be bothsustainable and carry a highlikelihood of improving patientoutcomes.As a result of my work, fiveprojects were implemented:anaesthetic pre-assessment,the WHO SSC, continuouspulse oximetry monitoringin recovery areas, improvedobservation protocolsin recovery areas, and thedevelopment of a highdependencyunit (HDU).While this sounds ambitious,there are a huge numberof charities aiming to worktoward improving healthinternationally and one of theprivileges of being a longtermvolunteer is the chanceto act as a conduit for thesein a single institution.One large problem Iidentified was that patientswere dying or sufferingbrain damage on the wardsbecause their oxygenlevels were dropping andover-stretched staff weren’tspotting this until it was toolate. I increasingly found thatdespite having been donatedthe necessary equipment (eg,pulse oximeters), many staffneeded training in how touse the equipment effectively.We were able to confidentlydeliver this training.I received support andfunding from VSO, the ClintonHealth Access Initiative(CHAI) Ethiopia, The YaleGlobal Health LeadershipInstitute, University CollegeLondon Hospitals (UCLH)Charitable Foundation, RotaryInternational and the LifeboxFoundation. In additionwe were given permissionto use the Immediate LifeSupport Guidelines of theResuscitation Council UKto prepare teaching aids andprotocols. All the work wasdeveloped in conjunctionwith local staff leaders withthe aim of making a lastingand sustainable differenceto the working of thedepartment.Volunteering as a junioris daunting, but we shouldnot underestimate thevalue of our training andskills. Long-term volunteeringrepresents a chance tomake a lasting differencewhile developing areasof your own practice that arehard to expand within theconfines of the NHS trainingladder. I would encouragenew doctors to take up thechallenge.For more information please visit www.vso.org.uk or www.aagbi.org/international/volunteer-opportunities-overseas. Dr Bashford can becontacted on tom.bashford@doctors.org.uk. Watch a video about hisproject here – www.medicalprotection.org/uk/videos/road-to-safersurgery.NEW DOCTOR | VOLUME 6 | ISSUE 1 | 2013 | UNITED KINGDOM www.mps.org.uk

MEDICAL PROTECTION SOCIETYPROFESSIONAL SUPPORT AND EXPERT ADVICEHow to contact usVOLUME 6 | ISSUE 1 | JANUARY 2013THE MEDICAL PROTECTION SOCIETY33 Cavendish SquareLondon, W1G 0PSUnited Kingdomwww.mps.org.ukwww.dentalprotection.orgGeneral enquiries (UK)T 0845 605 4000F 0113 241 0500E info@mps.org.ukMPS EDUCATION AND RISK MANAGEMENTMPS Education and Risk Management is a dedicated divisionproviding risk management education, training and consultancy.T 0113 241 0696F 0113 241 0710E education@mps.org.ukPlease direct all comments, questions or suggestionsabout MPS service, policy and operations to:Chief ExecutiveMedical Protection Society33 Cavendish SquareLondon W1G 0PSUnited Kingdomchief.executive@mps.org.ukIn the interests of confidentiality please do not include informationin any email that would allow a patient to be identified.What our members sayabout our service:96% of members said they wouldbe likely or very likely to recommendMPS to their colleagues.92% scored good, very good orexcellent for the service they receivedfrom our medicolegal advisers.94% scored good, very good orexcellent for the service they receivedfrom our membership team.UNITED KINGDOMwww.mps.org.uk/new-doctorThe Medical Protection Society is the leading provider of comprehensive professionalindemnity and expert advice to doctors, dentists and health professionals around the world.MPS is not an insurance company. All the benefits of membership of MPSare discretionary as set out in the Memorandum and Articles of Association.The Medical Protection Society Limited. A company limited by guarantee.Registered in England No. 36142 at 33 Cavendish Square, London, W1G 0PSNew Doctor (UK ed. Print) ISSN 2042-4175New Doctor (UK ed. Online) ISSN 2042-4183