Medicine at a Glance

Chapter 1

How to be a medical student

In 1948 in Geneva the World Medical Association drew up a modern version of the oath.

At the time of being admitted a member of the medical profession:

I solemnly pledge myself to consecrate my life to the service of humanity;

I will give my teachers the respect and gratitude which is their due;

I will practise my profession with conscience and dignity;

The health of my patient will be my first consideration;

I will respect the secrets which are confided in me, even after the patient has died;

I will maintain by all the means in my power, the honour and the noble traditions of the medical profession;

My colleagues will be my brothers;

I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;

I will maintain the utmost respect for human life from the time of conception; even under threat I will not use my medical knowledge contrary to the laws of humanity.

I make these promises solemnly, freely and upon my honour.

Good doctors

Medicine can seem a large and daunting subject, not only for reasons of intellectual rigour, but also because so many facts need to be learnt. In learning (and practising) medicine, it is vital to realize that facts alone are not enough! Good physicians have the following characteristics:

A strong humanity, i.e. an interest in human beings.

An interest in disease, its causation and treatment.

An ability to communicate with patients, to obtain a correct and full understanding of their problems and, at the same time, to give accurate information sympathetically about the diagnosis, treatment and prognosis. Good physicians are non-judgemental, empathetic listeners.

An ability to examine patients and elicit abnormal physical signs.

An ability to marshal the facts into a coherent story and present them clearly to relevant parties, i.e. ‘case’ presentation of the history, examination and structured summary, a probable and differential diagnosis, with plans for further investigations, and treatment.

An up-to-date knowledge base so that appropriate management (diagnosis + treatment) plans can be made.

An ability to realize when knowledge/skills are deficient and an ability to learn in response to new knowledge, ideas, etc., from the best source available.

An ability to acknowledge errors and learn from them. It is important to be open with patients and colleagues as soon as errors/misjudgements are recognized.

Appropriate technical skills in diagnostic and therapeutic procedures.

An understanding of economic, social and cultural, political and health-care systems so that the best possible help can be delivered to patients in the most timely fashion. If a deficiency in one or other of these systems damages patients, physicians should seek improvements.

Excellent managerial and interpersonal skills, with personal, financial and intellectual probity.

Health care spend related to outcome—different countries can spend the same amounts with very different outcomes, as shown in this graph, where health care expenditure is plotted against health care system performance

(From The World Health Report 2000: health systems: improving performance)

Hippocratic oath and the modern perspective

High ethical and moral standards are an imperative for good practice – the Hippocratic oath and its modern successors aim to codify behaviour. They are guidelines to best behaviour, although medicine is more complex than implied by such phrases. However, regardless of phrasing, the implication that physicians should have the highest ethical, moral and technical standards stands. Society respects physicians, and consequently physicians face social as well as other penalties if performance is poor.

Health-care systems

Health-care systems are imperfect compromises among society’s aspirations, wealth, humanity and individual needs (see figure above and Table 1.1). It is vital to understand how any system works, so that it can be used in a patient’s best interests. If individual or organizational failure occurs, this should be highlighted to the appropriate responsible individuals, agencies or, rarely, the media.

Table 1.1 The three fundamental objectives of health systems.

How to learn

Becoming a doctor means acquiring a set of skills, knowledge and values. How this is best done depends on the individual and the medical school. However, concentrating on one area/skill to the exclusion of others is counterproductive. Facts alone do not make a physician, and nor do learning or technical skills alone. It is the right combination of the above list that ‘maketh the physician’. Students need to determine the right balance for themselves, bearing in mind their individual aptitudes, and their medical school’s doctrine. A reasonable approach is the ‘patient-centred’ one, approached in a ‘problem-based’ fashion, supplemented by dedicated learning sessions (e.g. seminars, lectures, etc.); students should:

See patients, so learning communication skills.

Ascertain symptoms and signs, so learning clerking and examination skills.

Formulate a diagnosis or differential diagnosis, so learning diagnostic skills. The first part of this book aims to aid in diagnosis, i.e. the turning of symptoms and signs into diseases with names.

Present findings to attending physicians, so learning presentation skills.

Formulate investigation and treatment plans, so refining diagnostic and therapeutic skills. The second part of this book aims to help here.

Observe patients’ progress, so determining whether the original diagnosis and therapy were correct. This feedback is an essential component in improving diagnostic and therapeutic skills.

Deficiencies in knowledge and technique are identified at each stage and corrected using information/skills training obtained from books and libraries, electronic resources, physicians, other health-care professionals, patient groups, skills workshops, learning sessions, etc.

Some medical schools have a structured approach to this process, with substantial guidance at each stage; others are less formalized – which appeals more depends largely on you. Which is better is unclear.

How to behave on the wards

It is particularly important when performing ward work to:

Introduce yourself to the ward staff as well as the patient, so that they know who you are and why you are there.

Respect patients’ privacy, and their right to refuse to see you.

Ask for consent before seeing a patient.

If you undress a patient to examine him or her, help him or her to dress again once you have finished.

Be courteous to nurses and other members of staff (e.g. physiotherapists, ward cleaners, cooks, etc.) at all times.

Be punctual in attending teaching sessions – you will find that your teachers, who are often busy clinicians, are often late; this is not deliberately done to infuriate you, rather it reflects how hectic their lives are. It is reasonable to wait c. 10 min, before ‘bleeping’ to remind them of the session.

Write in the notes: different medical schools have different policies on this. Often, however, senior medical students are expected to write in the notes. This is a legal document, so write legibly, never use pejorative phraseology, and sign your name, along with your status as student, legibly at the end. Never amend the record at a later time, unless you clearly identify who you are and when the alterations occurred.

Enjoy yourself!

Chapter 2

Patient confidentiality

The duty to respect patient confidentiality stems mainly from two ethical principles. The first is ‘respect for autonomy’, or the right for an individual to have control over his own life, or in this context to have control over who has access to personal information about him. The second is based on the idea that there is a duty to act to bring about the best consequences, which in the context of medical confidentiality means maintaining public trust in the medical profession. Breaching patient confidentiality could result in a loss of trust, resulting in patients feeling less inclined to be open about their condition and symptoms and ultimately leading to a lower standard of health care.

From a legal perspective, patient confidentiality is generally seen from a public interest perspective rather than from a private interest perspective. Although the Human Rights Act 1998 indicates that there is also a private right to confidentiality, in practice this makes little difference because of the considerable weight given to the public interest in maintaining patient confidentiality. The legal duty to respect patient confidentiality however is not absolute, and making decisions about whether or not to breach patient confidentiality involves balancing the consequences of breaching confidentiality with the consequences of not breaching confidentiality: i.e. balancing the public interests.

Confidentiality has not been breached if the patient has given valid consent for the release of the information. If the patient has not given consent and could be identified, either by being named or as a result of information being divulged, then there has been a breach of confidentiality.

Consent to disclosure of confidential information (see Chapter 3)

There are some circumstances where consent to sharing a patient’s medical information can be implied. For example, it is generally accepted that information about care of a patient will be discussed within the medical team. Express consent would not normally be required. However, information discussed within a medical team should be on a need to know basis.

In most other circumstances, express consent should be obtained unless there is a legal obligation to disclose the information, or unless the medical professional believes that the public interest in disclosing the information requires it (see below).

If an adult patient is incompetent to give consent, doctors should act in the patient’s ‘best interests’. In the case of a minor, if he is over 16 years he would generally be assumed to be competent to give or refuse consent for disclosure of information. Minors below 16 are assumed not to be competent to give or refuse consent unless they are assessed as being ‘Gillick competent’ (see Chapter 3). It would normally be the case that doctors should inform parents of medical treatments for those under 16 years. However, if the child refuses consent to inform parents and is ‘Gillick competent’ and it is in his best interests not to inform parents, then the doctor may withhold information from the parents.

Handling patient’s medical records and data

Patient’s medical records should normally only be released with the consent of the patient or in response to a court order. The police do not have an automatic right to look at medical records, which should only be released in response to a court order or if the medical professional considers it to be an acceptable breach of confidentiality (see below). A coroner, however, does have the right to access a dead patient’s records in order to go about their duties.

When using patients as case studies in publications such as clinical papers or textbooks, consent should be sought from the patient where possible. If this is not possible, extra care should be taken to ensure that the patient cannot be identified.

Breaches of patient confidentiality

Unacceptable breaches of patient confidentiality

The most common situation in which medical professionals wrongfully breach confidentiality is as a result of carelessness. For example discussing famous patients at dinner parties or leaving patient notes on buses. The General Medical Council would regard such breaches of confidentiality as serious professional misconduct.

Situations where there is a legal obligation to breach patient confidentiality

Some examples of situations where there is a legal obligation for the medical professional to breach patient confidentiality are in the context of:

Notifiable diseases.

Termination of pregnancy.

Births.

Deaths.

Details of anyone alleged to be guilty of an offence under the Road Traffic Act 1988 (on request by police only).

Court orders.

However, these breaches should only be made to the relevant authorities.

Situations where the medical professional may but is not obliged to breach patient confidentiality

These situations involve weighing up the public interest in disclosure versus non-disclosure. The General Medical Council offers detailed guidance in this area and this guidance carries a lot of weight with the courts (see www.gmc-uk.org). Three key points from the guidance are as follows: