New Doctor - Medical Protection Society

VOLUME 5 | ISSUE 2 | JULY 2012
UNITED KINGDOM
PROFESSIONAL SUPPORT AND EXPERT ADVICE FOR NEW DOCTORS
Giving the
green light
UNDERSTANDING
CONSENT AND CAPACITY
PAGE 6
www.mps.org.uk
Inside this issue:
Dealing with in-flight emergencies
Ever feel out of your depth?
Getting into academic medicine

MEDICAL PROTECTION SOCIETY
EDUCATION AND RISK MANAGEMENT
Looking for evidence
for your ePortfolio?
MPS is committed to the value
of education and training.
As well as helping you
provide the best care for
your patients, we want to
support your development.
On pages 6-8 of this edition of New Doctor magazine
you will find an article on consent and capacity.
Once you’ve read the article you can register for our
E-learning platform and complete two online learning
modules on the themes covered in the article.
Once you’ve completed the modules you can
download a certificate of completion as evidence
of your learning for your ePortfolio.
READ THE
ARTICLE ON
PAGES 6-8

Inside this issue of New Doctor…
4 Update
A round up of all the latest news and top events
for foundation doctors
5 Hot topic: Competency
MPS medicolegal adviser Dr Jayne Molodynski
explains why it is important to recognise the limits
of your competence
5 From ward to world
Dr Imran Qureshi, Doctors Advancing Patient Safety,
describes why more junior doctors should sign up
Medicolegal features
6 Essential learning:
Consent and capacity
Earn CPD points by reading this feature and learning
about consent and capacity, by Dr Gordon McDavid
10 Out of my depth
Many new doctors are pushed to the limits of
their competence; if you feel out of your depth
speak up before it’s too late, says Dr Jo Pointon
14 Dilemma: Dealing with an
in-flight emergency
The last thing you want to hear when on board a
long-haul flight: “Is there a doctor on board?” Dr
Clement Lau shares what happened to him
Specialty features
9 A day in the life of…
an F2 in public health
Dr Yasmin Akram will not be dining in her
favourite restaurant in a hurry after this placement
12 How to work in…
academic medicine
A career in academic medicine opens up a
chance to work at the frontier of medical science,
writes Dr Cathy Symonds
15 Book review
Dr June Tay reviews David Sokol’s book Doing
Clinical Ethics
EDITOR-IN-CHIEF Dr Gordon McDavid EDITOR Sara Williams CONTRIBUTORS Dr Jo Pointon,
DAPS, Dr Imran Qureshi, Dr June Tay, Dr Yasmin Akram, Dr Hannah King, Dr Clement Lau DESIGN
Jayne Perfect 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, Ben Simpson, Shelley McNicol New Doctor Medical Protection
Society, Granary Wharf House, Leeds, West Yorkshire LS11 5PY Tel: 0113 241 0530 Fax: 0113 241 0500
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4
6
10
12
Welcome
Dr Gordon McDavid – Editor-in-chief
MPS Medicolegal Adviser
Welcome to your latest edition of
New Doctor and my first edition as
Editor-in-Chief. I would like to begin
(whilst attempting not to sound too
much like an acceptance speech for
an Oscar) by thanking Dr Angelique
Mastihi for her extensive input into
New Doctor since becoming Editorin-Chief
in 2008. I’m sure you’ll agree
she has done an excellent job and I
hope to continue the good work.
I joined MPS as a medicolegal
adviser in 2011 having completed my
medical degree at the University of
Glasgow and having worked mostly
in respiratory and general medicine.
I have previous experience in the
medicolegal field and to keep me
out of mischief I’m currently working
towards a masters degree in medical
law and ethics and membership to the
faculty of forensic and legal medicine.
Enough about me… this edition
of New Doctor revolves around
competency, a really fundamental
issue for doctors at all stages of their
careers. It is vital for doctors to know
their limits and seek help appropriately.
Imagine finding yourself in the difficult
position of feeling out of your depth,
but being the only one available. Have
a look at Dr Pointon’s candid account
of a real-life scenario on page 10, or
Dr Lau’s description of being called to
assist with a medical emergency midflight.
You might also like to check
out the interesting feature article,
which can earn you CPD points or
the specialty features which provide
a fascinating insight into careers you
may not have considered.
I hope you enjoy this edition of
New Doctor.
3
CONTENTS
NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk

4
UPDATE
NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk
Update
GMC
launches
new tribunal
service for
UK doctors
A
new tribunal service to decide on the
fitness to practise of UK doctors was
launched on 11 June, in the biggest
Above: Niall Dickson, chief
executive of the GMC
Right: David Pearl, the
shake up of medical regulation in the United judge and independently
Kingdom since the formation of the General
Medical Council more than 150 years ago.
appointed chair of MPTS
The Medical Practitioners Tribunal Service MPTS will strengthen professional and public
(MPTS), based in Manchester and headed confidence that our hearings are impartial, fair
by a judge, will be part of the GMC, but will and transparent – the fact that the service is
operate separately from it and be accountable led by a judicial figure who has a direct line to
to parliament. The GMC will continue to parliament should provide that assurance.”
investigate and prosecute cases.
David Pearl, the judge and independently
MPTS panels have the power to, in the most appointed chair of MPTS, said: “One of my
serious cases, remove or suspend a doctor earliest priorities is to make improvements
from the medical register or place restrictions to the way that panelists are trained and
on their practice. They can also take early performance managed through regular
action by considering cases before a full appraisal and quality assurance, which will
fitness to practise hearing, where it may be bolster the quality of decision making.”
appropriate to place restrictions on a doctor’s Later this year the GMC plans to pilot a
practice immediately or suspend their practice proposed new system of consensual disposal,
while investigations proceed.
which would allow a doctor to avoid a public
The move paves the way for far reaching reforms hearing by accepting a suggested sanction.
of the fitness to practise procedures expected to The doctor would attend a meeting to explain
come into force over the next few years.
the circumstances and put forward mitigation
Niall Dickson, the chief executive of the at an early stage.
GMC, said: “Although panels already make Also this year, the GMC will be deploying
their decisions independently, it is important regional liaison officers to liaise with employers
that their autonomy is clear and that the and support responsible officers, with the aim
oversight of their work is quite separate from of identifying and tackling underperforming
our investigatory activity. We hope that the doctors early.
For more information visit: www.gmc-uk.org/news/13286.asp
Event When Where What Further information
MPS Communication Skills
Workshops
Throughout
year
Across UK
Careers Advice for Trainees 11 September Durham
Getting to Grips with Law and
Ethics: Medicolegal Skills for
Surgeons in Training
28 September London
BMJ Careers Fair 19/20 October London
Mix with other specialties and lower your risk at MPS’s
popular workshop
The UK Foundation Programme Office, Northern Deanery
and Medical Education England, are jointly hosting this event
MPS and ASIT present this joint one-day conference, which
confers essential skills for surgeons in training
Useful for any medical graduate, it covers CV writing,
interview skills, career planning and more
ABEL MITJA VARELA/ISTOCKPHOTO.COM
NEWS IN BRIEF
Junior doctors told
to shadow jobs to
improve safety
Junior doctors will have
to spend at least four
days shadowing their
first job in the NHS
before starting work,
the government has
announced. The new
system will be introduced
in England this August
when the new intake of
junior doctors is taken on.
NHS medical director
Professor Sir Bruce
Keogh said the move
would help improve
patient safety. Sir Bruce
said: “This shadowing
period could potentially
save lives and will equip
new junior doctors with
the local knowledge
and skills needed to
provide safe, high
quality patient care.”
Dr Tom Dolphin, of
the BMA, said: “I think
it will really help doctors
hit the ground running.
It is a stressful time
starting your first job so
this will be a good way
of easing that.”
The decision to
introduce shadowing
comes after pilots have
been carried out in
various places. In Bristol
mistakes new doctors
made in their first four
months were reduced
by 52% during the pilot.
Source: www.bbc.co.uk/
news/uk-england-18555083
www.mps.org.uk/workshops
www.foundationprogramme.nhs.uk/
pages/home/events
www.medicalprotection.org/uk/
conferences/Getting-to-grips-withlaw-and-ethics
http://careersfair.bmj.com/en/1/
national.html

Competency, in professional terms,
is defined as the ability to perform
the tasks and roles required
to the expected standard. It can be
applied to a doctor at any stage in their
career, not only to the newly qualified.
Competency encompasses the need
to keep up-to-date with changes in
clinical practice and the systems that
can impact on your role. Continued
professional development (CPD) is a
pre-requisite of many jobs, but none more
so than medicine, which is constantly
evolving. Doctors effectively never stop
learning; a heavy focus is placed on CPD
whatever specialty a doctor may work in.
Recognising your own limitations is the
key principle behind competency. The
I
set up Doctors Advancing
Patient Safety (DAPS) at
St Peter’s Hospital at the
beginning of 2009 to empower
junior doctors to make
improvements to the care of
their patients; to move away
from the traditional academic
audit and carry out useful
quality improvement projects
with real interventions. Since
then, junior doctor colleagues
have carried out many quality
improvement projects from
antibiotics, radiology, nutrition,
DNR status, medical ward
rounds and more.
Moving from St Peter’s to
St George’s, Sarah Hammond,
a consultant anaesthetist
joined me in running DAPS.
Together we have run quality
improvement projects, set
up a Student Safety Forum,
offered Special Study Modules,
developed a publication for
junior doctors around error
reporting, taken junior doctors
on a tour to a Services Hospital
in Lahore to carry out quality
Competency
MPS medicolegal adviser Dr Jayne Molodynski explains why
it is important to recognise the limits of your competence
GMC’s Good Medical Practice makes
it clear that your duty as a doctor is to
recognise and work within the limits
of your competence. When providing
care, you must work within your own
competencies, and ask for advice
when you feel out of your depth.
This case study illustrates how
competency issues can arise in
clinical practice:
Mrs J, a dancer in her 40s, visits
the emergency department with a
sudden thunderclap headache at the
back of the head. She is seen by F2
Dr Q. Dr Q organises a CT scan to
rule out a subarachnoid haemorrhage,
which comes back clear.
His next course of investigation is to
test the CSF for xanthochromia. Dr Q
begins setting up a tray and equipment
to perform a lumbar puncture. A couple
of nurses spot that Dr Q is setting
up the tray incorrectly, so alert the
registrar, Dr A, to what is going on.
Dr A takes Dr Q aside and asks him
about what he is planning to do. Dr Q
admits that he is unfamiliar with some of the
equipment and has only ever read about
the procedure. Dr A explains that Dr Q is
working beyond his competence, which
could have caused Mrs J harm. Dr A uses
the opportunity to give Dr Q an impromptu
lesson, explaining the procedure as he
successfully undertakes a lumbar puncture.
Read more features on competency
on pages 6 and 10.
From ward to world:
Joining Doctors Advancing Patient Safety (DAPS)
Dr Imran Qureshi, Director General, Doctors Advancing Patient Safety,
describes why more junior doctors should sign up
improvement work with junior
doctors there, jointly run a
patient safety conference with
the Royal Society of Medicine
and have produced a set of
videos featuring advice for new
F1 doctors. We have even
more plans for the future.
The best part about DAPS
is that anyone can get
involved, whether that be a
quality improvement project,
in our publication Reporting
for Duty, international safety
tour, etc. We have produced a
comprehensive set of materials
for carrying out a quality
improvement project so anyone,
anywhere can take part.
The quality improvement
project I have been most
impressed with saw two of
our DAPP doctors and two
doctors from Lahore develop
a solution to explain discharge
medication information to
illiterate patients.
The potential
benefit of the
intervention
was groundbreaking
and
will significantly
reduce morbidity and mortality
for patients in the third world.
We are extremely proud
of what we have achieved in
DAPS in such a short space of
time, whether that be engaging
healthcare students in patient
safety or developing a checklist
to improve ward rounds. We
are looking forward to the future
to see how we can positively
shape the landscape of
healthcare in the years to come.
To get involved or simply
see what we’re doing, visit our
website www.daps.org.uk.
5
UPDATE
NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk

6
MEDICOETHICAL FEATURE
NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk
Essential learning:
consent and capacity
Consent is an individualised process based on
respect – it is more than a signature on a form,
says medicolegal adviser Dr Gordon McDavid
Dr U is in his first week as an
F2 in ENT. A nurse asks him
to consent a patient going
to theatre, she cannot locate the
consent form in the patient’s notes.
She says that the consultant will get
very cross if the patient turns up
to theatre without the appropriate
documentation, especially as the
patient’s operation has already
been cancelled once, and it would
be terrible if it happened again. Dr
U appears unsure, so the nurse
adds that Dr U would only have to
take consent for a tonsillectomy,
which “isn’t rocket science”.
Dr U is in a dilemma that many
foundation doctors will be familiar
with. The nurse is asking Dr U to
work outside his competence, as
he has not taken consent from a
patient for a tonsillectomy before.
So how should Dr U handle this
situation? MPS advice is that
Dr U should seek advice from a
senior colleague before obtaining
consent so that the operation can
go ahead as planned.
Trust, confidence and good
communication are fundamental
to a successful doctor–patient
partnership and providing
healthcare involves decisions,
which should be made with your
patient. Failure to obtain consent
properly can lead to problems
including legal or disciplinary action
against you, or rarely criminal
prosecution for battery (contact
with an individual without consent.)
The foundation programme
curriculum stipulates that you should
be familiar with the GMC’s guidance
document Consent: Doctors and
Patients Making Decisions Together,
and be able to obtain consent in
line with this guidance. By the end
of your FY2, you should be able
to describe the principles of valid
consent and demonstrate this
understanding in your practice. You
should also be able to undertake a
capacity assessment.
What is consent?
Consent should be a discussion
with your patient that assists them
to reach a decision. You should
facilitate this process by providing
the information they need in an
appropriate format.
Whilst consent must be obtained
prior to providing healthcare,
often consent may be implied,
eg, when a doctor requests a
blood sample, the patient holds
out their arm thus implying their
consent to the procedure.
In an emergency situation where
a patient cannot provide consent,
(eg, the patient is unconscious) a
doctor may provide treatment to
safeguard the patient’s life or health,
acting in the patient’s best interests.
Discuss risks
It is important to warn patients
of the risks of treatment and
document that you have done so.
Clear documentation is necessary
to provide evidence of this.
In the 2004 case of Chester v
Afshar (2004), the surgeon failed to
document his discussions with the
patient regarding the possibility of
cauda equina syndrome following
discectomy for lower back pain
and it could not be proven that
Miss Chester had been warned
of all the risks. 1 Miss Chester
successfully argued that if she had
been warned, she would have
taken the time to think about it and
had surgery on another day, thus
avoiding the rare complication.
The GMC’s consent guidance
recommends that patients should
be given information in a balanced
and tailored way. 2 Patients should
be told of any possible significant
adverse outcome and of any less
serious side effects or complications
if they occur frequently.
Document, document,
document
While many patients wish to be
fully informed and involved in their
healthcare, some patients may not
want to know all the details about
treatments and their attendant
risks and benefits, making it difficult
to secure their valid consent.
Consent should be a discussion with
your patient that assists them to reach
a decision. You should facilitate this
process by providing the information
they need in an appropriate format
If a patient does not want to
discuss their condition or the
treatment in detail, you should
respect their wishes as far as
possible, but the GMC says: “You
must still give them the information
they need in order to give their
consent”. Safeguard yourself by
recording the fact that the patient
had declined this information.
Refusing consent
If patients are competent, they are
entitled to refuse consent, no matter
how illogical this may seem. If this
happens, it is a good idea to explain
to them the possible consequences
of their decision. Such discussion
is not with the intention of changing
their mind or coercing the patient,
but to clarify the situation. You
should listen to patients and respect
their views, even if you do not agree.
Check their understanding of
MBBIRDY/ISTOCKPHOTO.COM

LIFE IN VIEW/SCIENCE PHOTO LIBRARY
the decisions they have made and
document the discussion carefully,
taking into account factors such as their
religious beliefs or values expressed.
Patients can withdraw consent
during a procedure – but if stopping the
procedure at that point would genuinely
put the life of the patient at risk, the
practitioner may be entitled to continue
until this risk no longer applies.
What is capacity?
To provide consent a patient must be
competent (or have capacity) to do so.
So what if a patient is unable to give
their consent? They may be unable to
understand the information, or they may
be unable to retain the information to
weigh up the risks/benefits, meaning a
decision cannot be made.
In England and Wales, the Mental
Capacity Act (MCA) (2005) exists and is
based around five statutory principles:
1. A person must be assumed to have
capacity unless it is established otherwise.
2. A person is not to be treated as
unable to make a decision, unless all
practicable steps to help him do so
have been taken without success.
3. A person is not to be treated as
unable to make a decision merely
because an unwise decision is made.
4. An act done, or decision made, under
this Act or on behalf of a person
who lacks capacity must be done, or
made, in his best interests
5. Before the act is done, or the decision
is made, care must be taken to avoid
restricting the person’s rights and
freedom of action.
In Scotland, the Adults with Incapacity
Act (2000) applies; however, this is
currently under review. In Northern
Ireland there is no specific legislation
covering mental capacity, so decisions
should be based on common law (based
on previous cases) and best practice.
How do you assess capacity?
The method of formally assessing
capacity is described in the MCA and its
supporting Code of Practice document. 3
The assessment must be decision-specific
and there are two stages to the test:
1. Is there an impairment of or
disturbance in the functioning of the
patient’s mind or brain?
2. Has it made the person unable to
make this particular decision?
To have capacity to make a decision a
person should be able to:
■ ■ Understand the information
■ ■ Retain that information
■ ■ Use or weigh up that information
■ ■ Communicate their decision
The MCA states the following should be
considered:
■ ■The
past and present wishes of the
patient (especially any written statement
when the patient had capacity)
■ ■ Religious beliefs or values expressed
by the patient when competent
■ ■The
views of relevant others (eg,
carers, relatives)
FOR CONSENT TO BE VALID
■ ■ The patient should be informed
■ ■ The patient should be competent
■ ■ Consent must be given voluntarily
■ ■The
patient should be involved in the
consent process and encouraged to
give their consent to particular aspects
for which they do have capacity.
A person may temporarily lose capacity
in certain situations; such as if they
are in extreme pain, shock, under the
influence of drugs, secondary to delirium
or as a consequence of their condition.
Patients who have mental health
problems may have difficulty making
decisions about their treatment, but this
should not be assumed.
Assessing capacity can be very
difficult where patients suffer from
serious communication problems. All
practicable steps must be taken to
assist the patient in communicating
their decision (and thus retaining their
capacity) such as using interpreters,
large print documents or sign language.
In order to assess a patient’s
understanding, it is best to try to frame
questions in such a way that the patient
will need to give a full response eg, “Tell
me what you understand by…” rather
than “Do you understand?”
If you are in doubt regarding a patient’s
capacity it is worth seeking further advice
from your senior. It is vitally important to
ensure thorough documentation of a
formal assessment of capacity.
Deprivation of Liberty
Safeguards (DOLS)
On each occasion that treatment is
required for a patient who does not
have the capacity to consent, a decision
should be made in the best interests of
the patient.
The Mental Capacity Act Deprivation
of Liberty Safeguards (MCA DOLS)
for England and Wales provide legal
protection for those who lack capacity
and who may be deprived of their
liberty in hospitals or care homes. They
7
MEDICOETHICAL FEATURE
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8
MEDICOETHICAL FEATURE
NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk
apply to anyone aged 18 or over
who suffers from a mental disorder
or disability of the mind, and who
lacks the capacity to give informed
consent to the arrangements made
for their care and/or treatment. The
safeguards are designed to:
■ ■ Ensure people can be given
the care they need in the least
restrictive regimes
■ ■ Prevent arbitrary decisions that
deprive vulnerable people of their
liberty.
Elderly patients
It shouldn’t be assumed that people are
not able to make their own decisions,
simply because of their age or frailty. 4
As patients get older, there is a
temptation to believe that they have
decreased capacity to take decisions
about their treatment. However,
you should always work on the
assumption that capacity to give
consent for treatment exists, unless
it is proven otherwise.
End of life decisions
Before people lose the capacity to
consent to treatment, particularly as
a result of a progressive condition,
they may make an advance decision
(AD) or directive (or living will). If the
statement was made by a competent
adult, and there is no reason to
believe that they have changed their
mind, it should be respected.
The MCA provides some protection
for doctors dealing with advance
decisions. In particular, it provides
a safeguard for doctors acting on
advance decisions. You will not be
held liable if you:
■ ■Are
in doubt over whether there is
an AD and provide treatment
■ ■ Believe a valid and applicable AD
exists and withhold or withdraw
treatment.
Where there is doubt, the courts will
decide whether an AD exists and
whether it is valid and applicable to
treatment. Until the court decides,
nothing should prevent the provision
of life-sustaining treatment, or
anything believed to be necessary to
prevent a serious deterioration in the
patient’s condition. ADs (or directives)
are governed by common law rather
than by legislation in Scotland and
Northern Ireland.
REFERENCES
Children and young people
In England and Wales, anyone aged
18 and over is assumed to be a
competent adult and can give their
consent. In Scotland, the legal age
of capacity is 16. Young people aged
16-17 are usually treated as if they
are adults in that they are usually
assumed to be competent. However,
if they refuse a treatment, this can be
overridden either by someone with
parental responsibility or the courts.
In patients under the age of 16, it
is for the doctor to decide whether a
child has reached a suitable level of
maturity and understanding. Children
under 16 are often competent and in
the case of Gillick v West Norfolk and
Wisbech Area Health Authority (1985)
it was found that a parent’s right to
consent to treatment on behalf of a
child ends when the child has sufficient
intelligence and understanding to
consent to the treatment themselves,
ie, when the child is “Gillick competent”.
If children under 16 refuse a
treatment, this can be overridden by
someone with parental responsibility
or the courts. However, when there
is a difference of opinion between the
young person and their parents, this
is usually resolved within the family.
If there is no need for an immediate
decision, it is clearly preferable to delay
a decision until this can be resolved.
The treatment of young children
can be a contentious issue and it is
important to seek guidance from your
senior or MPS.
Parental responsibility
For young children who are not
competent to give their consent,
someone with parental responsibility
can give consent on their behalf. The
mother automatically has parental
responsibility unless she lacks capacity
herself. A father will have responsibility if:
■ ■ He is married to the mother of his
child (or was at the time of birth)
■ ■ He has made a parental responsibility
agreement with the mother
■ ■ He has obtained a court order
granting him parental responsibility
■ ■The
child was born after 15
April 2002 in Northern Ireland, 1
December 2003 in England or
Wales, or 4 May 2006 in Scotland
and the father is named on the
child’s birth certificate.
1. Chester v Afshar, UKHL 41 Pt 2 (2004)
2. GMC, Consent: Patients and Doctors Making Decisions Together (2008)
– www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp
3. MCA, Code of Practice (2005) – www.justice.gov.uk/protecting-the-vulnerable/mental-capacity-act
4. DH, Seeking Consent: Working with Older People (2001) – www.dh.gov.uk/en/index.htm
5. Ibid 2.
WHAT PATIENTS SHOULD BE TOLD
■ ■ All details of the diagnosis, and
prognosis, and the likely prognosis if
the condition is left untreated
■ ■ Any uncertainties about the diagnosis,
including options for further
investigation prior to treatment
■ ■ All options for treatment or
management of their condition,
including the option not to treat
■ ■ The purpose of a proposed
investigation or treatment; details of
the procedures or therapies involved
■ ■ Explanations of the likely benefits and
the probabilities of success for each
option; and discussion of any serious
or frequently occurring risks
■ ■ Advice about whether a proposed
treatment is experimental
■ ■ How and when the patient’s
condition, and any side effects, will be
monitored or reassessed
■ ■ A reminder that they can change their
minds about a decision at any time.
■ ■ A reminder that they have a right to
seek a second opinion.
USEFUL LINKS
MPS has produced factsheets and
booklets on the following topics. Visit:
www.medicalprotection.org/uk/
factsheets
LOOKING FOR EVIDENCE FOR
YOUR ePORTFOLIO?
MPS is committed to education and
training. As well as helping you provide
the best care for your patients, we want
to support your development. That is
why we have developed two online
learning modules on the topic covered
in this article, so that you can download
a certificate of completion as evidence
of your learning for your ePortfolio.
What to do next….
■ ■ Once you’ve read this article, simply
go to www.mps.org.uk/e-portfolio
where you can register for the
E-learning platform
■ ■ You’ll need your membership details
to register and log on
■ ■ Once logged on, you will be able
to access the consent modules
highlighted on the home page
■ ■ You can complete the modules at a
time that suits you
■ ■ Download your certificate of
completion and any supporting notes
■ ■ Other modules on a wide range
of subjects can also be accessed
through the E-learning platform

A day in the life of…
an F2 in public health
Dr Yasmin Akram will not be dining in her favourite
restaurant in a hurry after this placement
Public health, eh?” –
this is generally the
response I get from
medic friends when I tell
them which placement I’m
doing. “So you’re going to
sit and watch your bottom
grow for four months?” one
quipped. “Actually no,” I
tell him. “I’ll be sorting out
the health of the nation.”
My days usually start by
waking at 8am; today is no
exception. I dress sufficiently
smart enough to be taken
seriously. I jump onto the
commuter train at 8.36am (the
surgical ward round would
be done and dusted by now).
Stepping off in the city centre
I head towards the fancy
government offices, popping
into a neat little coffee shop
for a croissant on the way.
straight to work. I deal with
an outbreak of campylobacter
at a local restaurant – a
restaurant that I often
frequent. Needless to say I
won’t be dining there again
in a hurry. I’m firmly rooted
to my chair for the next
few hours, as legionnella
and hepatitis A cases and
a TB outbreak arrive in
overlapping succession.
On my lunch break, I
pop into the museum a few
minutes away, drawn in by
the picture of ‘the Afghan girl’.
The photographs are fantastic
– one in particular catches my
attention so vividly that I find
it hard to move on, and I’m
not the only one. It is a picture
of a boy no more than four
or five wearing a dog-eared
t-shirt, which once supported
The day starts with the weekly departmental
meeting; thankfully now I’ve been here a
few weeks, I understand what seemed like
gobbledegook language a few weeks ago
The day starts with
the weekly departmental
meeting; thankfully now I’ve
been here a few weeks, I
understand what seemed
like gobbledegook language
a few weeks ago. Albeit in
a semi-delayed manner, I
can now follow talk of LARS,
strategic needs assessments,
operational planning and
health equity. This offers the
opportunity to discuss my
ongoing cases with my team.
I watch the current chair
like a hawk so I don’t make
a fool of myself next week
when I will be chairing the
meeting in the presence of
the director of public health.
After the meeting it’s
a picture of Spiderman;
tears are streaming down
his face and in his tiny left
hand is a gun, which is
pointed to his own temple.
In my own small way public
health allows me to raise
awareness about health
issues locally, but Steve
McCurry has done a credit to
humanity by raising awareness
of even deeper issues across
the globe. I take one last look
and head back to the office,
picking up a freshly-baked
baguette on the way. I have
much to be thankful for.
When I return it is time
to chase up the ethics
committee approval of my
audit. The project is either
a labour of love or hatred, I
haven’t quite decided yet –
extensive and complicated,
yet interesting and with
publication potential. While
I’m trawling through pages
of ethical guidelines, one
of the CCDCs (consultants
in communicable diseases
and control) approaches
me. She is heading to a
television studio to give
health protection advice to
an Asian television channel
and asks if I would like to
come and watch. Hell yeah!
I think. “Yes, please” I say.
In the car she suggests that
instead of watching, maybe I’d
like to join in. What? Join in? I
don’t know what I’m doing but
it’s too good an opportunity
to miss. I agree, but mentally
kick myself for my wardrobe
indiscretions and choosing
an extra five minutes of sleep
instead of applying make-up.
Somehow I get through
it – politician-style – answering
the questions I want them
to ask, rather than the ones
they actually ask. I figure
it’s a good thing that noone
will be watching a live
show in the middle of the
day, well, at least until I find
out that my mother seems
to have used up her phone
minutes allowance calling
aunties, whose names I can’t
remember, to tell them when
the repeat will be showing.
Back to the office I go
and back to ‘real’ work. The
message light is blinking
annoyingly on my extension
and my list of due actions on
the health protection account
is growing. As with any clinical
situation, I prioritise – the
nursery outbreak needs
to be dealt with before
HIGHS
■■ Working 9-5
■ ■ Constant brain stimulation
■ ■ Flexibility to develop
own interests
■ ■ Managing my own time
LOWS
■ ■ Somewhat unstructured
timetable
■ ■ Outcomes of the work
often not obviously visible
■ ■ Reading pages of
policies and procedures
the standalone case with
no vulnerable contacts.
I look up at the clock; it
reads 5pm – half the office
is heading out of the door. I
leave at 5.25pm, by choice
rather than necessity. There is
something I want to finish, and
besides, I feel bad about my
slightly protracted lunch break
and frequent email checks.
After work, I meet a friend
for a spot of shopping,
although given the fact that my
job is unbanded it probably
isn’t a great idea to do this
too frequently. I could get
used to this lifestyle, I think to
myself. It’s a shame it’s over in
a couple of months – although
I do wonder if the novelty
will have worn off by then.
A good day’s work and
socialising done, I head
home. “So exactly where do
you see your patients?” my
father asks. “I don’t,” I smile.
“My work is about the bigger
picture, and I certainly do not
miss the shrill of my bleep.”
Dr Akram is a specialty registrar in public health in the Mersey Deanery.
She can be contacted at y.akram@doctors.net.uk.
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NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk
Out of my depth
Many new doctors are pushed to the limits of their competence – if you feel
out of your depth speak up before it’s too late, says Dr Jo Pointon
As I stood over my four-month-old
patient, syringe of morphine in
hand, concerned parent looking on,
I wondered how it had come to this. My
consultant’s parting words echoed in my
head, “Everything will be fine”. I threw a
reassuring smile at Mum, eyeing the door
behind her wishing my registrar would
burst through it. With an anxious voice,
the nurse, who was gently restraining the
child, announced: “Doctor, I think this
baby needs more sedation”. It hit me – I
was completely out of my depth.
Talk to a group of junior doctors and
most will have a story about how they
found themselves in over their heads.
They may have felt pressured, for a variety
of reasons, into taking on unfamiliar roles
or tasks. But what can a junior doctor do
if they feel they are being asked to work
beyond their competency level?
“Everything will be fine”
I found myself in this position as an F2 in
paediatric surgery. I was working within a
friendly, enthusiastic team and always
felt well supported. While I was on-call, a
four-month-old baby was transferred to
us with suspected intussusception. She
was immediately transferred to ultrasound,
where the consultant paediatric
radiologist would attempt radiological
reduction. My registrar would give IV
morphine for analgesia (not sedation),
which was in accordance with the
hospital’s guidelines for intussusception.
The intussusception proved difficult
to reduce. After a prolonged period,
the bowel could only be partially
decompressed. By this time, the baby
had received a large dose of IV morphine,
in excess of the recommended guidelines.
She was closely monitored and her
condition was stable. The decision was
made to allow some time for the swelling
in the bowel to subside and attempt
further reduction a few hours later.
That afternoon, both the on-call
consultant and registrar were tied up in
emergency theatre. The other registrars
were also in theatre or busy clinics.
The radiologist had rearranged a full
ultrasound list to accommodate our
patient and the pressure was on to ensure
Talk to a group of junior doctors and most will have a story
about how they found themselves in over their heads
that she was ready. It quickly became
apparent that I would be the only doctor
available to administer the IV morphine.
The hospital’s guidelines specified that
this should be the responsibility of the
paediatric surgical registrar.
I spoke to my consultant in theatre,
who recognised that I was being put in a
difficult situation. He explained, however,
that if the procedure could go ahead
and was successful, it would save our
young patient from invasive surgery and
the registrar would join me as soon as
possible. “Now remember”, he said, “she
has had a lot of morphine, so be cautious.
Don’t worry though, everything will be fine.”
Prepare for the worst, hope for
the best
I was not completely comfortable with
the task ahead of me. I did have some
experience, albeit F1 experience, of
using IV morphine in anaesthetics, but
not in this age group. In the limited time
available, I did what I could to prepare.
I printed the hospital’s guidelines for
intussusceptions; checked and double
checked the morphine dose in the
BNF; drew up an appropriate dose
of naloxone (just in case) and, finally,
TOMML/ISTOCKPHOTO.COM

I was not completely comfortable with the
task ahead of me. I did have some experience,
albeit F1 experience, of using IV morphine in
anaesthetics, but not in this age group
checked that we had all
the necessary resuscitation
equipment to hand.
It was not until the
procedure was underway
that I realised just how
underprepared I was.
Firstly, the child appeared
to be very uncomfortable,
crying louder and louder as
the air enema distended her
bowel. I had expected some
crying of course, given that
she was being held down in
an unfamiliar environment, but
was she in pain? I had, as
instructed, given morphine
cautiously, slowly approaching
the maximum dose. But
should I give more? How
much was safe, given that
only a few hours previously
she had received double the
dose for her body weight? As
an F2, did I really have the
appropriate experience to
judge this safely?
Secondly, the nurse’s
request for “sedation” made
it apparent that I had not
properly explained to her,
or to the mother, that the
morphine was for analgesia,
not for sedation. Again, I
felt under pressure to give
more morphine, but did not
feel it was safe, knowing
how much she had already
received. I had already given
her close to the maximum
dose and was unhappy
to give any more and risk
respiratory depression.
Finally, feeling weighed
down by my lead apron, I
realised that should the
worst happen and the
patient’s bowel perforate, a
recognised complication, I
did not have a large-bore
cannula to decompress
her abdomen. In addition,
should the bowel perforate
or the procedure fail, my
patient would need to go
to theatre immediately for
a laparotomy. It was surely
beyond my competency level
to be making such important
decisions for this child. How
had I let myself get into this
situation? Not only was I out
of my depth, I was drowning.
A lesson learnt
Thankfully, my registrar arrived
moments later. Unfortunately,
it became clear that the
reduction was not going to
work, but my registrar was
able to arrange for our patient
to go straight to theatre,
where our consultant would
be waiting. She was in the
anaesthetic room within five
minutes. The intussusception
was fully reduced at
laparotomy and the patient
made an excellent recovery.
Afterwards, what frustrated
me most was that I took on
this responsibility despite
feeling uncomfortable about
it. I think that as junior doctors
we are eager to work hard;
to be enthusiastic, diligent
and thorough in how we care
for our patients. Of course
we also want to impress. It
can at times be difficult to
admit that we are unable to
do something, especially if
we feel our seniors expect
more of us. Equally, however,
as good doctors we need
to be able to recognise our
own limitations, have the
confidence to discuss them
and, ultimately, not expose our
patients to unnecessary risks.
Dr Pointon was an F2 working in paediatric surgery in the East
Midlands. Thank you to Dr Hannah King, consultant paediatric
anaesthetist, for her contribution and advice.
ADVICE FOR JUNIOR DOCTORS
Although the guidelines used here specify a safe dose of
morphine, it is important to remember that all patients vary.
When in theatre, paediatric anaesthetists do exceed these
doses, titrating according to the patient’s physiological
response and their stress response to surgery.
However, anaesthetists also have the skills to manage
respiratory depression and the knowledge to gauge
when a patient will breathe spontaneously on extubation
and when postoperative ventilation will be required. The
margin between these two states in an infant is much
smaller than in an older child or adult.
In situations like this, where there are concerns
regarding deviation from the guidelines, it would be
advisable to contact one of the paediatric anaesthetists
or paediatric pain nurses for their support.
If you feel out of your depth:
■ ■ Put patient safety first – Despite the pressures you
might feel to perform a task, always consider the risks
involved for your patient
■ ■ Voice your concerns – Your seniors may not have
appreciated that you are unfamiliar with certain roles
■ ■ Ask the experts – Seek advice from those most
familiar with the task at hand, such as seniors in other
specialties or specialist nurse practitioners
■ ■ Further your training – Ask to be properly instructed
in how to perform the task required. This shows that
you are keen to improve your practice and take on
new responsibilities.
IAN BODDY/SCIENCE PHOTO LIBRARY
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SPECIALTY FEATURE
NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk
In the likes
of Holby City
and Scrubs you
are unlikely to see
someone from the world
of academic medicine rushing
to save the day. However, at the
real cutting edge of medicine you’ll
find medical academics. They may not
feature in many medical soap operas,
but underpinning all medical specialties
is a creative, scientific force pushing
scientific boundaries.
Medical academics are an incredibly
diverse group of individuals, and this is
reflected in the diversity of their work.
The unique perspective of the clinicianscientist
can prompt some of the best
research, inspired by clinical problems
and an understanding of the patients’
and clinicians’ viewpoint.
At the heart of academic medicine
is communication. If you can’t
communicate your findings, discuss
your proposed studies or work with a
varied group of colleagues, you’ll never
succeed in research. This is far from the
negative stereotype of the ‘mad boffin’
unable to talk to normal people. It is a
highly creative form of medicine and
allows an enormous sense of freedom
to direct your career. You can take a
problem that excites your curiosity,
design a study and (after much hard
work) try and solve it.
Academic medicine allows you to
become a true expert in your field and
allows a freedom to choose the direction
of your career in a way that is rare in
clinical medicine.
How to train in academic medicine
The Walport report was published in
2005 and it was aimed at addressing
the problem of recruitment into
academic medicine. It identified a lack
of a clear career structure as a barrier to
young doctors being able to establish
themselves in academic medicine. This
led to the development of an integrated
career structure that combined
academic and clinical training.
There are three main entry points into
academic medicine.
How to work in...
academic medicine
■ ■The
academic foundation programme
allows foundation doctors to
spend four months in an academic
A career in academic medicine
opens up a chance to work at the
frontier of medical science, writes
Dr Cathy Symonds
placement, allowing them to get a
grounding in research methodology.
■ ■Academic
Clinical Fellowships
(ACFs) are generally taken up by
core trainees in ST1-3, although you
can take up such posts at any point
in training. ACFs are available in all
medical specialties; 25% of the time
is spent in academic work. ACFs
must also achieve the same clinical
competencies as their purely clinical
colleagues but they are also expected
to meet academic competencies.
Ultimately, it is expected that ACFs will
formulate a study and use their time
to achieve pilot data that will allow
them to take time out of programme
to achieve a PhD. ACF programmes
are run through posts and run for a
maximum of three years. If an ACF
wishes to, or fails to progress, then
the post can revert to a standard
clinical post.
■ ■ For higher trainees who already have
a PhD or an MD, Academic Clinical
Lectureships (ACLs) are the next step
on the academic career ladder. Like
ACFs, lectureship posts are integrated
with clinical training, but 50% of the
time is spent as an academic. It is
expected that ACLs will build on their
doctoral research and develop a body
of work to apply for funding for a
clinician scientist award.
The clinical scientist is the ultimate aim of
the integrated academic pathway. This
combines NHS consultant work with
leading your own research group.
What do academics do?
Academics work in all fields of medicine,
from gastroenterologists working on
the basic science of immunology to
psychiatrists studying patients with
functional MRI to oncologists carrying
out qualitative work. What all this
work has in common is the process
of approaching problems scientifically.
It begins with an understanding and
a critical
approach to
existing literature.
Discussion with
colleagues is key in
formulating research questions
and designing studies to answer
them. In academic medicine you work
with a whole team of different people
and draw on their skills. As you progress
through your career, the contacts you
make can shape your work.
Communicating the findings of your
research is the most important role of
an academic. This can be in the form
of papers in journals; in seminars or
lectures to both undergraduates and
postgraduates; or in presentations at
conferences anywhere in the world.
Academics can be inspiring teachers
and be involved in both undergraduate
and postgraduate education.
At the heart of academic
medicine is communication.
If you can’t communicate
your findings, discuss
your proposed studies or
work with a varied group
of colleagues, you’ll never
succeed in research
What does it take?
Above all else academic medicine takes
a passion for your chosen subject.
Without passion, you will find it very
hard to keep motivated. Creative
flair to generate ideas and questions
is essential. Above all else, it takes
dedication and a drive to see an idea
through over a period of years.
Experience of research earned
through intercalated degrees or
whilst working is desirable, and it is
expected that someone applying for
an academic job at any level will have
taken every opportunity open to them
to gain experience of research, develop
research skills and publish in journals.

GUNTARS GREBEZS/ISTOCKPHOTO.COM
PASCAL EISENSCHMIDT/ISTOCKPHOTO.COM
Why I love
academic
medicine
By Dr Kyle Stewart
The word “academic” often makes
people think of old men in tweed jackets
pondering over the latest medical
papers. In reality academic medicine is
an exciting new avenue for doctors.
Academic posts for foundation
doctors have recently started to emerge
across the country, offering positions
in research (ranging from ward based
research to laboratory work), where you
can work with global specialists and
become an expert in a particular field.
An academic post should be
considered by those trainees who have
already established themselves ahead
of their peers in research, teaching or
writing. These posts often allow the
trainee a lot of unsupervised and nonclinical
time to pursue their own projects.
Often, the candidates who are accepted
are performing above average clinically,
as they eat into clinical attachments.
There are also posts in medical
education. I’m currently an academic
F2 in medical education at Torbay
Hospital in South Devon. I run
teaching and training sessions for
all members of the multi-disciplinary
team. This involves all types of teaching
including, my favourite, scenario-based
simulation training using manikins in
real-life environments. Recently we
ran a full trauma call in our emergency
department using the manikin. The
simulation ran right until the manikin
went through the CT scanner. The
training was filmed and we have now
identified learning needs both during the
initial assessment and the stabilisation
of the trauma patient.
Academic posts are a great way to
stand out from the crowd at interviews
and get some impressive work under your
belt. So get preparing and get applying!!
Dr Kyle Stewart is an academic F2
doctor in gastroenterology at Torbay
Hospital in Devon.
What are the best bits?
■ ■The
sense of achievement
when your research
delivers results.
■ ■ Recognition for all your
hard work when your
paper gets published.
■ ■A
greater freedom to take
your career where you want.
■ ■The
opportunity not only
to ask questions about
medical science, but
attempt to solve them.
What are the worst bits?
■ ■ Having two demanding
mistresses: the NHS and
academia.
■ ■ If you take time out of
programme, you can feel
‘behind’ your colleagues
who graduated with you.
■ ■ Research work is like
running a marathon and it
can sometimes feel like a
bit of a slog. The feeling of
a mountain of work to do
with a deadline looming
for your thesis submission,
a conference abstract
or a grant application is
definitely the worst bit.
HOW TO FIND OUT MORE
■ ■ The NIHR website outlines all the
details of the integrated medical
careers at: www.nihrtcc.nhs.uk
■ ■ The Academy of Medical Science
has promoted careers in academic
medicine and has an excellent
mentorship programme, visit:
www.acmedsci.ac.uk
■ ■ Each deanery and specialty has an
overall academic lead. Information on
who the leads are can be found on
individual deaneries’ websites.
■ ■ The BMA Medical Academic Sub-
Committee have produced a Medical
Academics Handbook providing
information on employment issues
and more: www.bma.org.uk
Dr Cathy Symonds is an ST3 in
psychiatry and an NIHR BRC Clinical
Fellow based in the Northwest of England.
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14
DILEMMA
NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk
Dilemma
Dealing with an in-flight
The last thing you want to hear when on board a long-haul flight:
“Is there a doctor on board?” Dr Clement Lau shares his story
I
was travelling on a longhaul
flight from Hong Kong
to Finland with more than
200 people on board. Two
hours into the ten-hour flight,
I was suddenly woken up by
a call for medical assistance.
The first thought that sprung
to my mind was “what
should I do?” I had very
limited clinical experience as
an F1 doctor.
I hesitated and thought
about the consequences
of providing help and what
would happen if I didn’t know
what to do. But what if I was
the only doctor on the plane?
The patient may be much
worse off if he or she did not
receive any medical attention.
I conjured up confidence and
stepped out to find out what
was occurring.
I approached the cabin
crew who were stood
surrounding the passenger.
There was already another
doctor there, a first year
doctor from Finland. A
ADVICE
Officially, a good Samaritan act is
where medical assistance is given,
free of charge, in a bona fide medical
emergency, upon which a doctor
chances in a personal as opposed to a
professional capacity. Waking up to the
resounding call on a plane: “Is there a
doctor on board?” you would immediately
think: “Should I intervene?” The GMC
would say yes – although you have no
legal duty to do so (in UK law), you have
an ethical and a professional duty to help.
MPS advice is to do the best you can
42-year-old woman was
experiencing sudden
onset chest pain and
breathlessness. She was
overweight with hypertension,
but had no significant past
medical history. I explained
my position to everyone
present. At this point I was
shown a piece of paper,
which explained the good
Samaritan law. It stated I
would not be responsible
for any medical assistance
that I provided. I felt slightly
relieved, but I wasn’t too sure
whether this applied to me as
a doctor practising in the UK.
The patient did not
speak English very well,
but was able to speak
Chinese. I took a history and
translated this into English
for the cabin crew and
other doctor. We promptly
gave oxygen, examined
the patient and decided on
a management plan. We
moved the patient to a
quieter area for observation.
I also had to explain to the
patient’s family about what
was happening to keep
them informed, and gave
appropriate reassurance.
We enquired about the
emergency drugs box and
also whether there was an
ECG machine available. It
was interesting that the
crew never asked us at any
point for any identification
when we asked to access
the medicines box, which
contained drugs such as
adrenaline and morphine.
There was an automatic
defibrillator that I used as a
monitor. We gave the patient
GTN spray to see if this
would relieve the chest pain.
After three or four puffs the
chest pain improved. We
therefore decided to give
her 300mg of aspirin and
continued to monitor her
condition. We decided that
we would each take it in turn
to spend time beside her for a
few hours in case any further
in the circumstances with the resources
available, working within the limits of
your competence. By responding to the
call you have taken on the role of a good
Samaritan. MPS will assist you with any
problems arising from a good Samaritan
act anywhere in the world – whatever
jurisdiction you’re flying in.
Before proceeding:
■ ■ Consider whether any factors might
be compromising your competence
(alcohol, medication and tiredness)
■ ■ Understand that you will normally be
treatment was required.
Clearly our dilemma was
whether this patient was
having an acute coronary
syndrome. The cabin crew
told me they would contact
medical ground staff, who
would advise us on the best
plan as to whether the plane
required diverting or landing.
After several attempts they
told us they could not get
any reception to contact
the ground staff as we were
flying over Siberia.
The patient was still
experiencing chest pain, but
this was starting to improve.
The cabin crew asked me
repeatedly whether we
should divert the plane or
land it at the next city. This
was a difficult decision
to have to make and the
situation I was dreading.
My thoughts were on
whether the patient could
make it to the destination
without requiring emergency
medical assessment
assisting experienced flight attendants –
so don’t try to immediately take charge.
During the emergency:
■ ■ Take a full history and carry out a
full examination in order to make an
informed assessment
■ ■ Suggest options for managing the
situation (balance benefits and risks of
treatment)
■ ■ Work within the confines of your
expertise and training, except in a
critical emergency
■ ■ Delegate and communicate appropriately.
ROB BOUWMAN/SHUTTERSTOCK

and treatment, but also
balancing the consequences
for the other passengers if
the plane had to be diverted.
What would be the legal
implications had I made a
mistake with my judgment?
I had to make a clinical
decision about the diagnosis
and decided against
diverting the plane, at least
until we had made contact
with ground support.
When Moscow was in
proximity, the crew informed
me that the pilot wanted to
know again about whether
the plane should be landed.
At this point, the patient’s
chest pain had eventually
settled and I felt more
confident about my decision
not to land the plane. Shortly
following this the cabin crew
gained contact with ground
staff who agreed with our
management plan.
We decided to document
everything we had done
in case there were any
questions about our
management plan. The
last two to three hours
of the journey seemed
to last forever before
we finally landed at our
destination. Much to my relief,
paramedics were waiting to
take the patient to hospital.
The cabin crew and patient
were very grateful for my help
and it turned out to be a great
learning experience for me.
Dr Lau is currently
an F2 working at
Stepping Hill Hospital
in Stockport.
Book
review
Doing Clinical Ethics:
A Hands-on Guide for
Clinicians and Others –
by Daniel Sokol, barrister
and senior lecturer
in medical ethics at
Imperial College London
(Springer 2012)
Reviewed by Dr June Tay, junior
doctor in anaesthetics, London
Doing Clinical Ethics is a concise and
comprehensive book, which is easy
to read. The author, Daniel Sokol,
beautifully captures the theoretical essence
of medical ethics and applies it to real
life. He divides his book into five chapters,
encompassing ethical theory and casebased
discussions, teaching, writing papers
and research in the ethical context.
Chapter 1 provides a step-by-step
guide to approaching a clinical scenario.
Sokol summarises the sections into moral
perception, moral reasoning and moral
action. Within moral reasoning, he outlines
the four principles: respect for autonomy,
beneficence, non-maleficence and justice.
He also introduces the “four quadrants
approach”, which can be applied to every
clinical case. These are medical indications,
patient preferences, quality of life and
contextual features. An example provided
was the case of a 22-year-old woman, BMI
51, with a history of self harm, who set
herself alight moments after discharge from
the emergency department, and as a result
had to be admitted to intensive care and a
specialist burns unit. Tattooed on her chest
was the following: DNAR (underlined) DO
NOT RESUSCITATE. He clearly analyses
the ethical issues employing the “four
quadrants approach”, which makes for
really interesting reading.
What I gained the most from the book is
encompassed in the next chapter, which
covers writing and publishing a paper.
Sokol draws most of the examples on
writing an ethics paper; however, these
are universally applicable to other topics
and articles. The elements addressed and
the examples given resonate well with the
challenges faced by clinicians – authorship,
rejections and abstract submissions.
Most of this insightful advice is not
obtainable from textbooks, but only
discovered through an individual’s experiences
and struggles. Nevertheless, these issues are
applicable to a junior doctor’s clinical career.
Not to be missed is the chapter on
delivering teaching. Sokol elaborates on the
various aspects of teaching junior doctors,
medical students and other clinicians, with
particular attention to teaching ethics.
However, it is advice that one could employ
to improve their teaching skills in general.
Perhaps this chapter would benefit from
further elaboration in a book on teaching skills.
The final chapter consists of appendices
using pertinent examples of ethical issues
that clinicians may encounter. Sokol provides
a few cases and discusses the ethical
principles involved. Among the two that I
found most pertinent to my role as a junior
doctor are “The Slipperiness of Futility” and
“The Dilemma of Authorship”. It is perhaps
the most engaging chapter in the book as
real-life examples are employed, which most
clinicians can identify closely with.
Overall, Doing Clinical Ethics is concise
and uses simple language devoid of jargon.
It particularly appeals to one who does
not have the patience to dwell on lengthy
prose. Perhaps some may feel that there
is a lack of philosophical discussion of
moral dilemmas, such as euthanasia and
physician-assisted suicide. Others may feel
that the aspects on teaching and writing
ethics are too general and not particularly
suited for a book entitled Doing Clinical
Ethics. Nevertheless, it is a good read for
anyone interested in medical ethics.
If you would like to review a book, website, film or app email sara.williams@mps.org.uk
15
BOOK REVIEW
NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk

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New Doctor (UK ed. Print) ISSN 2042-4175
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VOLUME 5 | ISSUE 2 | JULY 2012
UNITED KINGDOM