Tuesday, 31 January 2012

More thoughts on doctors' morals

Moral Compass
Moral Compass by psd

I wanted to write a quick post to follow-up last week's discussion on the GMC consultation on Good Medical Practice. Several doctors commented that they were concerned that the line which said that they should act "at all times" in a manner that would not reduce trust in themselves or other doctors left them open to possible persecution over lifestyle choices.
For example Ditzy wrote:
"Most of us are up in arms over the ambiguity of what activities, in their private lives, the GMC felt was appropriate for them to regulate. A one off drunken dancing on the tables at the village pub? An affair with a married person? Multiple sexual partners? Frequenting the bookmakers? Falling out of nightclubs every Friday night? There simply is no guidance and any of these actions could, potentially, be said to bring the doctor and the profession into disrepute although none of them are illegal. "

I decided to go back and find out what the reaction was to the introduction of this clause in to the 2006 version of Good Medical Practice. The results of the official consultation are available here. This includes feedback from doctors and the wider public on the 2005 draft document (which unfortunately I can not locate). They note that:
"While honesty and trustworthiness within the doctor-patient relationship are perceived as important by the public, most people no longer appear to expect doctors to demonstrate moral excellence in all aspects of their lives, and it is widely recognised that they are ‘only human’. Some doctors also felt that expectations of probity, as set out in the draft document, are no longer appropriate."

So the GMC recognised in 2006 that the public did not expect 'moral excellence' of doctors. 

But when the guidance was published it was reported in the Guardian, by Sarah Bosely, as being a "tougher ethical code". Why was this? Jane O'Brien, Head of Standards and Ethics for the GMC, is reported as saying that the GMC had been criticised for not giving clear enough guidance to doctors in the past, for example, about how long after a professional relationship ends would it be appropriate to start a sexual relationship with a patient. But Good Medical Practice was not intended to be a rule-book.
"The guidance encourages doctors to think through their behaviour, and is not a set of rigid rules by which they can be judged - which may leave the GMC open to criticism. "We don't think there is a way of making guidance that would provide that absolute boundary," Ms O'Brien said."

An article by the writer Dea Birkett in the Health Services journal, commenting on the 2005 draft policy was very clear that she did not want to know what doctors got up to when they were not at work. Her suspicion was that the guidance had been updated to make it more 'politically correct'.

But what has the reality been? Are doctors being sanctioned for legal sexual activity that might be frowned upon by the public? I haven't reviewed all the Fitness to Practice procedures which are published on the GMC website but there are some accounts in the press. A trainee anaesthetist was suspended for 9 months after accessing (legal) hardcore porn on a hospital computer. Another doctor who had an 'inappropriate' relationship with a patient for several years, and who was cautioned for kerb-crawling, was not suspended.

In the past year, 43 doctors were referred to a GMC hearing  for 'indecent behaviour' but the outcomes are not described. Having reviewed some fitness to practice proceedings it seems likely that these are serious events such as the sexual assault of patients. It seems that it would be very unlikely that having an affair would be deemed 'indecent behaviour'.

In summary, when the current version of Good Medical Practice was introduced there were concerns from the doctors and public that it would involve holding doctors to an exceptional moral standard. However, there is no evidence that doctors are being reprimanded for the types of behaviour which Ditzy has raised in her comment.

Does this reassure anyone? 

Thursday, 26 January 2012

"at all times..."

The Passage of Time 
The Passage of Time by TonyVC

EDIT 6/5/2013
'at all time' has been removed from Good Medical Practice 2013
Used to be:
57 You must make sure that your conduct at all times justifies
your patients’ trust in you and the public’s trust
in the profession

65. You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession.
The GMC, the body which regulates doctors in the UK,  is consulting on the next version of Good Medical Practice. The consultation ends on Friday, 10th February, 2012 and you can learn more here. Since 2005 Good Medical Practice has been the core guidance for doctors on how they should act professionally. In a previous post written almost exactly 2 years ago I discussed the fact that  the guidance states "You must make sure that your conduct at all times justifies your patients' trust in you and the public's trust in the profession." but does not make clear what kind of conduct might be expected to reduce confidence in a doctor or doctors as a whole. It is perhaps deliberately vague.

The last version of Good Medical Practice was issued in 2006. Times have changed since 2006 and in this consultation the GMC have started using social media to spread the word about the consultation and get some informal feedback. They have started a Facebook page and a twitter account, @gooddoctoruk

There has been a lot of discussion of the consultation on Twitter, primarily around how much doctor's lives outside their hours working as a doctor should be regulated. Do we have to be professional "at all times"?

To get the debate going Shree Datta, co-chair of the British Medical Association's Junior Doctor's Committee wrote a piece on her thoughts around the current guidance on conduct outside of work. She thinks that in the current guidance there  is "little reassuring detail" about what might be considered appropriate or inappropriate. She says: "The simple fact is that people make mistakes and it is unrealistic to expect doctors alone to remain flawless at all times in every aspect of life. Yet the current guidance suggests that that is what is expected of doctors and arguably does not ringfence our privacy or allow for our personal autonomy."

The GMC then asked the question "Do you think the GMC should regulate doctors lives outside medicine?" This was the response from 1167 people. 94% said No.
The GMC have responded to this saying:
"Most commonly fitness to practise cases citing this paragraph arise where doctors are convicted of criminal offences, accept cautions or equivalent sanctions across the UK. But occasionally we also take action on doctors’ registration as a result of doctors’ behaviour in the public sphere, which while not illegal, may undermine patients’ or public trust in the profession.
The rationale for this has always been that patients need to trust their doctors absolutely. Many patients will be vulnerable when they seek medical care and need to be able to trust doctors implicitly.
For the doctor/patient relationship to be successful, patients must trust doctors to be honest and to act with integrity in their patients’ interests. Patients do not want their doctors to have criminal convictions, particularly for violent or sexual offences, and they may not want to be treated by a doctor whose conduct they find morally repugnant or unacceptable. For example, many people would not want to confide in, or agree to be examined by, a doctor found guilty of crimes relating to child abuse or child pornography, even though there was no evidence that the doctor was clinically incompetent."
The comments that the GMC have shared from people who said No in the poll suggest that they thought that there were being asked about the regulation of activities which would usually be considered legal. But by their response it seems that the GMC think that this question also relates to taking action if a doctor is convicted of illegal activity.
Now we have gotten to the stage of the official consultation. Here is the question that doctors  and others are asked to respond to:
"In September 2011, 1,167 people responded to our online poll asking how far the GMC should go in regulating doctors’ behaviour outside medicine. The vast majority (94%) thought the GMC should not take action against doctors for their conduct outside medical practice. We think that if a doctors’ conduct undermines trust in the profession. It should, in some cases, lead to action on their right to practise medicine. (This approach is also taken by other health regulators in the UK). We therefore think it is important to make this clear in Good Medical Practice (see paragraphs 67–8 of the consultation draft).
Do you agree that the guidance achieves a fair balance in terms of the GMC’s role and remit?
Yes      No      Not sure"
This is section 67-68
67 You must be honest and trustworthy in your professional practice.
68 You must make sure that your conduct at all times justifies your patients’ trust in you and the public’s trust in the profession.
This wording is actually very similar to the current version which can be seen here. 
On Twitter some have suggested that since the GMC "did not get the answer they wanted" in the pre-consultation they have simply asked the question again. The GMC have responded through twitter that the pre-consultation activity was just that; a full consultation was still needed. But it is interesting that the strength of feeling about the question above has made it into the official consultation documents.
So are we experiencing a shift in how doctors think they should be regulated? Do we think that as long as we conduct ourselves appropriately during the working day then it does not matter what we do out of hours?  Should the GMC take any action against those who receive a criminal conviction? What does it mean to be professional in the 21st century? 
It's certain that this topic is going to be discussed for a long time.

By the way, if you look at my old post you'll see that whether patients trust doctors seems to be based on their interactions with them as a professional. We don't know what impact other factors have.

EDIT: Initially this post stated that the poll was of 1167 doctors. This was wrong. The poll was open to anyone and it is not known how many respondents were doctors.

exploring sliderocket

I came across sliderocket today and thought it looked very interesting. I found it browsing chrome extensions and it can be used as a Google app. There is also education licensing. There are interesting features like extensive analytics, feedback and polling allowed in presentations. But ... not in the free version. So this shows some of the more limited features.

What do you think? Any experience with this?