Medical students are in a unique and privileged position. You're provided with an opportunity to witness patient care first hand and to engage with members of the public at their most vulnerable.
This position isn't without its own responsibilities, however. Whether it's down to the systems in place in the hospital or practice you work in, or because of the actions of an individual, unfortunately you may witness situations where you feel that patient care has been lacking. If you found yourself in this position, what would you do?
Why would you raise a concern?
All doctors have a duty to raise concerns if they believe that patient safety or care is being compromised, and this applies to medical students too. The General Medical Council (GMC) and the Medical Schools Council (MSC) has recently produced a report called 'First, do no harm', about enhancing patient safety teaching in undergraduate medical education. It's well named, as the reason for raising a concern should always be to make sure the patient comes first.
If you came across a situation where a patient was at risk and opted not to speak out, you could be vulnerable to criticism and asked to justify your decision.
What's stopping you?
The thought of pointing out that something - or someone - is wrong can be intimidating, especially if you're the most junior member of the medical team. Lacking the skills and knowledge of your seniors, you're obviously in a very difficult position. It's easy to assume that someone else will raise concerns and that you can just keep your head down and carry on. But it's important to know what your responsibilities are as a qualified doctor, and also to recognise that you have responsibilities while you're still a medical student.
One aspect of developing learning in patient safety is considering the importance of challenging unsafe practice. However, the 'First, do no harm' report says that in an electronic voting report from the GMC's 2015 conference workshop, 33% of students disagreed, and a further 29% strongly disagreed, that their education and training took place in an open and fair safety culture where they felt able to draw attention to concerns about patient safety.
It's easy to assume that someone else will raise concerns
This would inevitably have an impact on students speaking up if they saw patients receiving poor care, and delegates at the GMC conference were also asked to suggest changes that could improve patient safety. Not surprisingly, one suggestion was better support for those speaking out, emphasising the fact that raising concerns does make students - and doctors - feel vulnerable.
Cause for concern
Concerns about a colleague's behaviour may come in many forms. It's not just their clinical ability or performance that can have an impact on patient safety, but also their conduct or personal behaviour. You may have noticed a change in their behaviour that raises concerns about their mental health, or you may be worried that a colleague is abusing alcohol. This doesn't only have an impact on patient care, but also raises the need for that colleague to receive appropriate support before something goes wrong, which could affect their entire career.
Whilst raising concerns for any reason makes us feel uncomfortable, providing it's done in good faith and for the right reasons, you are unlikely to be criticised. You could, however, be criticised and asked to justify yourself if you were aware of concerns but chose to ignore them.
MDU advice - how to raise a concern
- Don't be afraid to speak up.
- Consider whether any of your colleagues have also raised concerns and consider speaking up as a group.
- Speak to a senior member of staff as soon as possible.
- Explain what has happened, with examples if available.
- Keep notes of any incidents that concern you, ensuring you don't breach patient confidentiality.
- Be honest, open, objective and able to support your concerns.
- Don't make it personal if it concerns a colleague you don't get on with.
- Be prepared to make a statement to support your concerns or be interviewed if the colleague is investigated under the Trust's disciplinary procedures.
Setting the scene
Think about the above while considering the following scenario:
You've just qualified as an FY1, and are shadowing an FY2 in a surgical department. The FY2 is being supervised by a senior trainee, who has a reputation for being unapproachable.
One patient, who had recently undergone surgery, develops acute chest pain and the FY2 is very concerned. He is capable but anxious about the patient and asks you to contact the senior trainee.
When the senior trainee answers your bleep, you explain that the patient has deteriorated, describe his signs and symptoms, and clearly state the FY2 needs urgent assistance. The senior trainee is very dismissive and suggests the FY2 gives the patient 10mg of intravenous morphine to treat his pain and get the medical on call doctor to review the patient.
The FY2 knows the patient has very low blood pressure and respiratory difficulties, but gives the morphine as directed. He asks a nurse to monitor the patient while he rings the medical on call team. Whilst he is on the phone the patient suffers a cardiac arrest, and attempts to revive him sadly fail.
Both you and the FY2 are understandably upset. The surgical senior trainee arrives and documents in the records that he spoke directly with the junior doctor and advised him to treat the patient's pain with morphine. However, he adds that he advised starting at 2mg and titrating up to 10mg if the patient coped, and also to give aspirin and sublingual GTN before calling the medical registrar. You're immediately worried, as you know this wasn't the case.
Because this is a post-operative death it's referred to the coroner, and concerns are raised that this frail elderly patient was given a relatively high dose of morphine in one go. You later learn that the nurse, who was with the patient when he arrested, also made a complaint about the trainee to the ward manager, who was aware that this doctor was difficult to work with and unsupportive of juniors.
You speak to the ward manager privately and tell her about the trainee's inaccurate records. As a result, probity concerns are now raised, a formal complaint is made to the medical director and a disciplinary investigation into the doctor's actions begins.
This scenario gives an example of where concerns haven't been raised or acted upon in a timely manner. A patient may have been harmed, and the FY2 doctor is potentially in a very precarious position. Had concerns about the senior trainee been raised earlier, this might never have happened.
In a situation such as this, it's likely that both you and the FY2 doctor would be asked for your comments. You would have a duty to report your concerns truthfully, but as a member of the MDU you could seek our advice in relation to speaking up or providing your statement to the Trust.
Remember, patient safety must always be your number one priority.
Dr Kathryn Leask
Dr Kathryn Leask
BSc (Hons) MBChB (Hons) LLB MA MRCPCH FFFLM RCPathME DMedEth
Kathryn has been a medico-legal adviser with the MDU since 2007 and is a team leader, trainer and mentor in the medical advisory department. Before joining the MDU, she worked in paediatrics gaining her MRCPCH in 2002 and did her specialty training in clinical genetics. She has an MA in Health Care Ethics and Law, a Bachelor of Law and a Professional Doctorate in Medical Ethics. She is also a fellow of the Faculty of Forensic and Legal Medicine and has previously been an examiner and deputy chief examiner for the faculty. Kathryn is currently a member of the faculty’s training and education subcommittee and a member of the Royal College of Pathologists (medical examiner).
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