ethics/portfolio Flashcards
Different forms of teaching you have done
Informal teaching - bedside teaching - for medical students
Lectures
Workshops - CBLs
Presentations - fertility work to nurses
Simulation for clinical skills
Collected feedback
I enjoy teaching - it helps me learn, helps me to develop my teaching and mentoring skills
I am hoping next year to get my post graduate certification in medical eduction to further develop my skills
What are good Qualities of a teacher?
Sets appropriate, specific and chellenging goals
Has a clear plan to achieve their goal and has a clear delivery of the topic
Involves the students and contiually assesses their learning and provides feedback
To be positive and encouraging
Promote enthusiasm in students
able to adapt to students and alter their methods accordingly
Respects students
Gathers feedback and reflects on negative feedback
a teacher plays a pivotal role in shaping competent, compassionate, and confident professionals. The right blend of these qualities ensures that learners not only acquire knowledge but also develop the skills and attitudes necessary to provide exceptional patient care.
which teaching methods do you know ?
one to one interactive teaching
- you can tailor the session to the needs of the student.
- cons - the student can not learn from their peers
Small group teaching
- good as there can be interaction between different member of the groups
- can’t always meet the needs of every student - some may sit back and relax and some do all the work
Formal - lectures
- good because you can reach a big audience quickly
- cons - communication is mostly one way limited options for interactions
Within each of the above
Interaction discussion
Practical simulation
Role play
Observation followed by related practice
PBL
lecture followed by assessment
What is PBL - pros and cons
Process best describes by the Mastricht ‘seven jump’ process
PBL tutor is a facilitator - they do not participate actively in the discussion. Role is to guide them.
Advantages - self directed, students discover information for themselves - tends to lead to better retention
Encourages students to develop Problem solving skills, communication na dteamwokr
it allows students to make mistakes and learn from them
PBL promotes initiative, focus on specific goals and research
Disadvantages
- requires more resources than traditional teaching
- many students are not used to this way of learning
- requires good teamwork and therefore may not function well if all students are not contributing
- students may research in too much detail
You have been asked to organise a weekly educational meeting for your colleagues - how would you approach this?
I have actually recently been asked to organise a 2x monthly journal club for the cardiology team
So I would approach this in a similar way
- what would they like to learn
- who would they like to hear from
- what is the objective
- finding out which is the best day for everyone to attend
- organising different people to give the teaching
- ensuring there is a room available for the teaching
Important to communicate and work with others
Important to involve senior colleague
ensure the meeting is chaired appropriately
make sure I know how to use the computer/projector
collect feedback
Tell us about teaching feedback
the feedback I have received has always been positive and encouraging
medical students also appreciate the effort I have put in and how I make the teaching sessions interactive. May of them say they feel much more confident on the topic afterwards
‘Dr Charlotte played the largest role in our training and development. Charlotte gave her time and considerable effort to helping us find training and practice’
I was doing teaching for 2nd years induction to clinical placements
- initial feedback - could have slowed down - given more detail on clinical examinations
- I re-did this teaching for the other half of the year and changed it and had much better feedback
what is clinical Audit?
Clinical audits is a review of current health practices against agreed standards designed to ensure that as clinicians we provide the best level of care to our patients and that we constantly seek to improved our practice when it is not matching those standards.
What is the audit cycle ?
Identify and issue or problem
Identify a standard (from NICE or relevant Royal Colleges or local trust standards)
Collect data on current practice
collect data on current practice - a pre agreed period of clinical practice for a specific group of individuals
Assess conformity of clinical practice with the standard
compare results to standard to determine how well it has been met
Implement change
Closing the loop - re-audit
Tell us about an Audit you did?
DOACs
NICE guidelines - baseline bloods including FBC, clotting screen renal and liver nuncio
monitoring of bloods at least 3 mon
Insufficient monitoring could lead to inappropriate dosing and adverse events.
99 patients
started on ODAC between 2018 and 2022
baseline bloods noted
started DOAC noted
Checked if follow up bloods completed at 3 months - hospital and GP record
If doses were changed
patients with impaired renal function were analysed separately
Results
83% of patients were started on the correct initial dose when factoring in indication and CrCl
76% of patients with impaired renal function were on correct initial dose when factoring indication and CrCL
80% of patients had bloods after 3 months
11% had DOAC levels
45% had dose changing
Previously DOAC Audit was in 2016 - 30 patients - 90% of patients had follow up bloods and 30% had DOAC levels (this audit suggested they should be performed as routine bloods
Why is this important - from 2015 16% of patients on anticoagulation were on DOAC - in 2019 62% of patients on DOAC were on anticoagulation (average increase of 18% per year)
Recommendations
- ensure CrCl used to calculate dosing of DOAC
- close monitoring of patients with renal impairment
- All patient should be referred to anticoagulation clinic after starting on DOAC
- potential role for monitoring of DOAC levels in patients with higher risk of complications
QIP
No set guidelines for monitoring DOAC levels
(DOAC levels are anti-Xa levels that are converted to DOAC levels)
41% of patients had complications - 35% bleeding, 5% thrombosis
Data analysis looked at factors that identify patients at a high risk of developing complications
no strong correlation between risk factors and complications
likely multifactorial
-ve correlation between DOAC levels and CrCl
- those who experienced bleeding events - DOAC level > 198
ongoing further data collection
Because DOACs have predictable pharmacokinetic and pharmacodynamic responses at a fixed dose, they do not require monitoring. However in specific clinical situations and for particular patient populations, testing may be helpful for patient management.
We looked specifically at the patients who had DOAC levels and analysed this data
Currently involved with another Audit on lipid lowering therapy. Clear guidelines set on lipid lowering therapy.
Tell us about your Audit experience
I led this audit
My consultant had the idea
I planned it
Did the data collection - had a team of 4 people - who helped with the data collection
Delegated tasks
Statistical analysis - I had help with someone more experience
Presented it at local Audit meeting and presented some of the results on Cr Cl and DOAC levels with risk of adverse events
Why are Audits important?
one of the key pillars in clinical governance - audit ensures that quality of care is maintained at an agreed standard.
Allows identification of problems and ensure that salutations are implemented
Audits encourage services to make better use of resources
Problems associated with audit process?
Problems generally
- audits are often local processed - may not be transferable to other trusts or units
- based on retrospective dats, data may be missing
- can be difficult to identify a solution to the problem
- done by clinicians who have other duties so may not focus fully on the audit
problems with junior doctors carrying out audits
- may rotate frequently so audits don’t get finished / re-audit can not be performed.
- tend to choose topics which are easier and shorter - may not have great importance
Audit Vs research?
Audit - a process which compares clinical practice against set standards, are you following established guidelines, are you aligned with best practice.
Research - does not check if you are complying with standards. It aims to create new knowledge that can be used to develop new standards of care. determines if treatments work and to what extent they do.
Research is based on a hypothesis
essentially - research helps to establish best practice and audit checks that best practice is being applied.
Research experience ??
DOAC - looking at DOAC levels
Masters Degree - comparing frozen embryo trasfer to transfer in ormone mediated cycle - retrospective cohort study, systematic review and meta analysis
Scoping review of spontaneous regression of thyroid neoplasia
Ventral mesh rectopexy for rectocele
Predictive factors for outcomes of trial phase sacral nerve stimulation
Publication
Pelvic floor dysfunction after obstetric anal sphicter injury - effects of physiotherapy
Attended journal clubs
Done a practical statistics for medical research course
Why is research important?
- enable you to understand the evidence on which decisions are based
EBM involves an ability to crucially appraise current medical evidence - having an insite into what constitutes good and bad research as well as the structure of medical evidence and statistical concepts
Since medical practice is constantly evolving - it is essential to keep up t date with current published research.
Develop critical thinking - Participating in research helps junior doctors learn how to critically appraise medical literature, interpret data, and assess the quality of evidence. These skills are essential for practicing evidence-based medicine and delivering the best possible care.
Important for improving patient care
Should all trainees do research?
I believe that while not all trainees need to pursue formal research, engaging with research principles is beneficial for every doctor. Research is the foundation of evidence-based medicine, and understanding how to critically appraise studies and apply their findings to clinical practice is essential for delivering high-quality patient care.
this could be done through attending journal clubs, attending conferences and relevant courses, getting involved in smaller advocacy research, doing literature searches.
What do you understand by research governance?
a framework setting out principles of good practice in the management and conduct of health and social care in research in the uk.
what is governance?
a set of rules that govern the way a particular activity should be undertaken.
Principles that apply to all health and social care research in the UK?
Safety - they safety and well being of the individual prevail over the interests of science and society
Competence - all the people involved in managing and conducting reattach and are qualified by education, training and experience
Scientific and ethical conduct - all research projects are scientifically sound and guided by ethical principles in all their aspects.
Patient, service user and public involvement - they should be involved with the design, management, conduct and dissemination of research, unless otherwise justified.
Integrity, quality and transparency
Protocol
Legality
Benefits and risks
Approval
Accessible findings
Insurance and Indemnity
Evidence bases medicine?
essentially the combination of the best available research evidence with your own clinical experience and judgement. This is then applied to a specific case taking into account patient values.
What are the steps involved in evidenced based medicine?
A question arises refgarding the care of a patient
A situation where the existing giuidliens are out of date or need to derive your own approach
where national guidelines were not suitable
Situations where there are new controversial treatments which are not yet routine practice
Different levels of evidence?
1a. systematic review and meta analysis of RCT
1b. RCT
2a. controlled study without randomisation
2b. well designed quasi-experimental study, such as a cohort study
3. descriptive studies, comparative studies, correlation studies, case control studies
4. expert reports/opinions or clinical experience
What is clinical governance ?
a quality assurance process - designed to ensure standards of care are maintained and improved and that the NHS is accountable to the public.
to ensure that patients receive the best possible care. It involves fostering a culture of accountability, transparency, and learning across all levels of a healthcare organization.
what are the 7 pillars of clinical governance?
clinical effectiveness and research (everything you do should be designed to provide the best outcomes)
Audit
Risk management - to minimise risks to patients and staff
Education and training - ongoing professional development, self direct lifelong learning.
Patient and public involvement
Using Information and IT
Staffing and staff management
Relating to a junior doctor - CARE
C - clinical effectiveness
A - Audit
R - Risk management
E - Education and training
What is your own experience in clinical governance?
Clinical effectiveness - research experience, facilitated the use of guidelines within the department (oxygen prescribing and assessment)
Audit - involved in audits
Risk management - double check prescribing, seek help from senious, suppor junior colleagues so they dont make mistakes
Identified problem with aspects of patient care and raised the issue with seniors
made mistakes that you have then repoited and discussed with colleagues
Education and training
I have a PDP
read about cases I have seen when I get home
difference between a standard, a guideline and a protocol ?
Standard - defined level of quality that must be achieved
Guidline - a statement which is designed to assist clinicians in making decisions.
A protocol - a step by step approach to dealing with an issue
Patient wants to self discharge what do you do ?
find out information
events leading up to admission
read notes
speak with nurse in charge
speak with patient
reason with them
explain risks
find out why they want to leave
assess capacity
if they do want to self discharge - maximise patient safety - as beneficence is a key ethical principle
Provide Adequate safety netting advice
Ensure she understands the risk of self discharging against medical advice
I would give her time to consider before return to talk again
what is Capacity?
Mental capacity is the ability to make decisions by yourself.
The Mental Capacity Act 2005 states that every adult has the right to make his or her own decisions and that capacity should be assumed until proven otherwise. All individuals should be encouraged and empowered to make their own decisions. Individuals have the right to make decisions that may seem unwise to others.
How is Capacity assessed?
Assessing capacity is a two stage test. If there is no impairment of mind (stage 1) then the patient can be assumed to have capacity. If there is an impairment of mind then to demonstrate capacity the patient must:
Understand the information relevant to the decision
Retain the information
Weigh up the information in the decision making process
Communicate the decision
Do you still have a duty of care if a patient chooses to send discharge?
The first ethical principle in medicine is beneficence, which means I must act in the patient’s best interests. The patient wants to leave and so I must act to ensure that she is safe. I would make sure that she understands what to look out for with regards to any signs of worsening infection and impress upon her that she should seek medical help if she is deteriorating. I can provide her with medication on discharge and make sure that she has follow-up arranged.
patient driving after seizure
How would you approach this issue?
Initially you need to establish whether the patient is still driving. The patient should be given the benefit of the doubt – those keys may belong to the person that brought him here! Build up rapport and understand the patient before investigating whether he still drives.
start by asking about other things
how has he been since the seizure
then establish if they are still driving
Ask him outright
I would explained that he must inform the DVLA and stop driving.
Potentially a danger to himself and others
He would not be covered by insurance if he continues to drive
Remain non judgemental and empathise with patient - acknowledging the impact it will have on his life
patient continues to drive despite told he can’t - what would you do ?
understand the reasons beind the patient’s decisions
He may rely on it for work/family reasons
try to achieve a resolution before breaching confidentiality
IF he still refuses then I would explain that I have a duty to inform the DVLA and breach confidentiality as I feel he poses a significant risk to the public
why is confidentiality so important?
integral to the doctor patient relationship
without it there would be no trust and patients may not divulge information essential for their care
Confidentiality is part of patient autonomy and patients have a right to choose who their information is shared with.
When can confidentiality be breached?
- of the patient consents
- disclosure is in the patients best interest and it is neither appropriate nor practical to seek consent
- disclosure is in the publics interest
Sepsis - what might prompt you to ask for urgent senior review?
A raised lactate of more than 4 mmol/L would make me urgently discuss this case with the on call ITU team and my senior team. Additionally, other factors that would make me quickly escalate this case include a low systolic blood pressure of less than 90 mmHg, despite fluid resuscitation; reduced level of consciousness; a respiratory rate of more than 25; an unresponsive or rising lactate despite treatment. These should all prompt discussion with the ITU team. Any evidence of end organ damage would also make me quickly escalate this patient to my seniors.
sepsis - history questions
ask about onset
symptoms the might point toward the cause of sepsis
Recent contact with others who are unwell
Recent Travel
Ever had similar admission
Side effects of Methotrexate?
Myelosupression - can lead to neutropenic sepsis
Pneumonitis
Pulmonary fibrosis
liver fibrosis - make sure to monitor FBC and LFTs
Make sure to take a thorough drug history
Methotrexate monitoring
Prescribing methotrexate
Methotrexate is a drug with a high potential for patient harm. It is therefore important that you are familiar with guidelines relating to its use
Methotrexate is taken weekly, rather than daily
FBC, U&E and LFTs need to be regularly monitored. The Committee on Safety of Medicines recommend ‘FBC and renal and LFTs before starting treatment and repeated weekly until therapy stabilised, thereafter patients should be monitored every 2-3 months’
Folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after methotrexate dose
The starting dose of methotrexate is 7.5 mg weekly (source: BNF)
Only one strength of methotrexate tablet should be prescribed (usually 2.5 mg)
what may lead to the development of myelosuprression in someone who takes methotrexate?
secondary to drug interactions and anything that might affect the excretion of methotrexate resulting in elevated drug levels.
The most common drug interaction which can lead to methotrexate toxicity is with NSAIDs which are commonly used in rheumatoid arthritis to manage flares of pain, inflammation and swelling. NSAIDs and methotrexate in combination can result in nephrotoxicity which reduces the excretion of methotrexate, leading to toxicity.
Other meds - recent penicillin use or PPI
Has the patient been taking folic acid regularly - Folic acid is given in combination with methotrexate to reduce the toxic effects of methotrexate. Methotrexate inhibits the enzyme which converts folic acid into its active form, which is necessary for the synthesis of both DNA and RNA. If the patient has recently stopped taking folic acid, this may be a reason for the onset of myelosuppression for someone who has previously been stable.
patient agitated - trying to leave what do you do
start by trying to calm them
talk to them to a quiet room
taking someone with me to help calm the situation
if remains agitated could ask a family member to come in to try and help
Seek information - try to find out why they are upset and want to leave. Listen calmly to patient
Calmly and clearly explain to the patient that he
