Thanks to everyone who contributed to the discussions about the Harshil, a fourth year medical student who witnessed something about which he wished to raise concerns. The question was whether, having witnessed James, an ST1, lie to a registrar and alter the medical notes, Harshil had a moral, legal or professional duty to raise concerns. We also linked up with a GMC tweetchat about raising concerns. You can see the highlights of the Twitter discussion in the storify.
This week’s question setter and expert was Dr Alison Sturrock, sub-dean at UCL medical school and lead for the GMC development unit at UCL which designs assessments for doctors referred to the GMC with possible performance problems. There was additional input from Dr Jayne Kavanagh, Ethics and Law Lead.
Information available at the start of the week:
Harshil is a fourth year medical student. He is doing a ward round with James, a CT1 doctor. They go to see Mr Collins who was admitted the day before with chest pain. Mr Collins has a normal ECG and negative troponin, however the consultant who did the post take ward round has asked for him to be reviewed by the cardiology team before discharge as he is high risk for ischaemic heart disease. Harshil is present when the bed manager tells James that he has to discharge three patients that day due to bed pressures.
James feels pressurised, and cannot identify anyone suitable to go home. He therefore discharges Mr Collins and tells him to arrange a cardiology referral through his GP. A short while later Harshil and James bump into the registrar who clerked Mr Collins; she has come to check up on him and is surprised to find he’s gone home. James tells her that the patient discharged himself against medical advice. Later Harshil sees James change the notes to say this.
Question prompting discussion on Twitter: Does Harshil have a moral, legal or professional duty to do anything? If so, what?
- Students’ have a professional duty to raise concerns if there is a risk of serious harm or patient care is compromised.
- Students may choose to raise concerns if they see a breach of professional standards (often a grey area as students are not always sure about what they have witnessed or the severity if it is an isolated incident).
- Students do not have to deal with these things in isolation, any more than a doctor would be expected to. Talking to other students, or to members of staff to get another opinion, might be valuable and help to clarify things in their own minds. Students should always talk to a member of staff if they have any uncertainty about the seriousness of a situation.
- Confidential sources of advice include: the UCL Raising Concerns website;the Medical Protection Society or another defence union; and the GMC decision making tool and anonymous helpline.
- Francis Report (executive summary)
- BMJ interview with Robert Francis on the findings of his report
- GMC statement following Francis Report
- GMC Medical Students: professional values and fitness to practise 2007
- GMC decision making tool and confidential helpline: 0161 923 6399
- UCL Raising Concerns website
- Year 4 Ethics and Law slides on ‘Raising Concerns’ on Moodle
Dr Alison Sturrock sub-dean at UCL medical school and lead for the GMC development unit at UCL which designs assessments for doctors referred to the GMC with possible performance problems, says:
In this case (based on a real case dealt with at UCL Medical School), Harshil contacted a member of the UCL Raising Concerns team. The team investigated further and submitted a report, and did not use Harshil’s name at at all at his request. There had already been complaints made against James, and he had already had a warning from his Educational Supervisor. After this incident he was reported to the GMC. Whilst waiting for the GMC to investigate this further, he continued to work in his hospital under close supervision. The Raising Concerns team was able to reassure Harshil that no harm came to this patient. He was seen in the rapid access chest pain clinic and treated by Cardiologists.
There are barriers for doctors and students to raising concerns which are understandable. They are due to doubts (what to report, how to report, what will be done) and worries (consequences for colleagues, effects on relationships, career implications, risk of complaint, previous ‘whistleblowers’ negative experiences). It is therefore increasingly important that we all work together, as institutions and individuals, to ensure that the environment encourages openness, and those that wish to raise concerns are supported.
In law there is no statutory duty for doctors to raise concerns, but the Francis Report recommends enforcing a statutory duty of candour (this means being open, honest and frank). It is widely accepted that doctors may not have a legal duty, but that they do have a moral and a professional duty to raise concerns. The newest GMC guidelines are clear about doctors’ responsibilities when patients’ basic care needs – their comfort and dignity – are not being met. Basic care is not the sole responsibility of nurses and managers – doctors have responsibility for whole patient care – they must take the lead on this. Students can be important advocates for patients, and must raise concerns if they witness care they feel to be substandard.
- Of course, it is important for students to understand that don’t have to deal with these things in isolation, any more than a doctor would be expected to. Talking to other students, or to members of staff to get another opinion, might be valuable and help to clarify things in their own minds. In cases in which it is not certain whether a concern should be raised, the BMA/ Medical Schools Charter suggest the following ‘test’: Would you like to be treated by this person? Would you subject your family to this situation?
- It is important to realise that by raising a concern you are not making an overall judgement eg about a colleague’s fitness to practice, you are simply letting an appropriate person know that something concerns you. The responsibility to investigate the concern and take action lies with others. Your professional duty as a student is to flag up potentially harmful behaviour and practices/systems. Just like child protection your concern may be a vital part of a jigsaw, that when pieced together could prevent serious harm. In this case Harshil was right to raise concerns about James’ behaviour, but it was then the responsibility of the medical school working with the NHS Trust to take appropriate action.
- If students have any concerns at all we encourage them to talk to a trusted member of staff. These may include an educational supervisor, a personal tutor, a Consultant on the firm, a member of the Raising Concerns working group, or another member of student support. Medical student concerns should normally be directed to UCL rather than the NHS trust to which they are attached but in some circumstances, if it is urgent to raise a concern about patient welfare, then the most appropriate person may be someone on the ward.
- Students are encouraged to look at the guidance provided on the UCL Raising Concerns website. This site includes advice of what to do, case histories, an incident report form that can be completed anonymously and also provides contact details for the members of the raising concerns working group. If a student contacts a member of this team, this person will ensure that the NHS Trust’s policy is applied.
- As future doctors we hope that our students will have the confidence to approach reporting issues of misconduct safe in the knowledge that they should not and will not be victimised for speaking out. Providing a safe environment for staff, colleagues and patients can only help create a better health service for the people of the UK. UCL Medical School fully supports our students in tackling this difficult issue.
Case 6 will go live on Monday 1st July. See you then!