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we're going to shift tax slightly, and it's a pleasure to introduce Ed Nanda Soma from the M D. U. He's a gastroenterologist in Sheffield and also a medical legal adviser at the M. D U. You may never have had anything to do with the M D U or the G M C or any significant work event so far. But if you do, and if that ever comes knocking at your door, having help and support, and what he's going to talk to us about today is how to do with the medical legal landscape and important things of how being aware of that can help minimize the risk of burnout. Thank you very much, Thank you. Mhm. Thank you, David, And thank you for inviting me to speak today, not least give me the opportunity to listen to those last two talks, which are really fascinating, that there's a couple of things in there that I'll say we're really chimed with our experience. The first was what Tom said about listening to yourself and acting early because we see stuff at the end of a situation which hasn't often been managed for for a long time, where someone's tried to cope and someone something has gone really wrong. Um, so that is a really sage piece of advice. The other thing from the last talk was a reminder to me of what One of my registrars, when I was a hepatology trainee in Kings said to me, is you lot spend all your time worrying about what sort of job you want. You want to think about what sort of life you want. Uh, obviously, I was too young and stupid to listen at the time, but I think those things are changing and it's really important. So I'm going to talk about the medical legal landscape. It is a contributor to burn out, but the interrelationship between these things is quite dynamic. You know, we see the greatest incidence of things. Like doctors reported to the G M C Facing investigations. It's often at the peak of their careers when they are most capable. When they've got most responsibility, they're doing most work, you know, and I'm sure that burnout impacts on these issues because sometimes their clinical issues, often they're issues that relate to relationships with colleagues. Um, you know, misjudgments in in their life outside medicine. Um, I'll talk about how to deal with complaints because we all get complaints and we all have to to deal with them. And we know that doctors find these difficult and they always feel a bit personal. I'll talk a little bit about writing reports, because it's a really boring subject in some ways. But writing a report from medical legal purposes one or two things you really need to do and take care about. And that can avoid setting all sorts of issues running where there's a suspicion that the doctor has not been forthright or or said what they should have said honestly in a report. The final thing I'll talk about really relating to this topic is, is supporting colleagues. So colleagues where you're really concerned that something going wrong, there are a couple of routes of support and a couple of things you can do, which are really important. And finally, for anybody who might be facing an interview, I've got a couple of tidbits of medical legal things that are happening at the moment that you you might want to know about for that sort of purpose. So we talk about the concept of medical legal jeopardy and and lots of different processes happening at once. Now, this sort of thing, you know, with with with multiple processes running this isn't even an exhaustive slide. You know, there are all these things that can happen. You know, 30 years ago, doctors were terrified of being sued, you know, having a civil claim. Now most would sort of shrug their shoulders and say, Look, that's for the M D u R N H s resolution to sort out It's these other processes that are really, really taxing, And I wouldn't say it's common to have all these at once. But I did have a junior doctor who faced a manslaughter investigation started when she was an S H o. The police discontinued it. Ultimately, the G M. C took it on, and it was all discontinued without progressing. But that was the week before she took up her consultant job. So it went on for that period of time. And obviously that sort of thing is hugely stressful and contributes to to burn out. Now, this is just a very quick and quick and dirty search I did on our system for the sorts of things apart from claims. So they're excluded from this analysis that the orthopedic surgeons contact us about. And I guess what I'd say is, Look, it's actually pretty similar to what most people contact us about. Patient complaints. GM see referrals, adverse incident reports and help with writing those a coroner's inquiry, uh, disciplinary processes or, you know, a question where you're There's a general medical legal question they want to raise with us. So I think orthopedics is not particularly different from other specialties. In that regard, I'll talk a bit about the G m. C. First. I'm not gonna sort of set out all GM see procedures I could spend spend the day talking about the G M. C in angry terms, but I won't do that. The thing that I think it's really important to realize is that a lot of doctors I speak to on the phone say, Well, why the G m. C interested in this? It's not a clinical matter, and the thing I would really impress upon you is is that whilst a lot of complaints, the majority of complaints that go to the G m. C. Have a clinical component most of those are relatively readily resolved. It's rare, unless there is a pattern of issues that are unremarkable and have gone on for a long time that those are the cases that that end up at a hearing. The sorts of things that that tend to cause difficulty is issues arising from someone's personal life. So it can be safe, for example, if they're in a stressful situation at home. If there are allegations of domestic violence, if there are criminal convictions outside the clinical space, all of these things can head to the G, M C and actually, um, cause more difficulty and be far harder to resolve. There is a duty to report certain criminal and regulatory proceedings and doctors finding themselves in, in sort of, you know, bizarre situations such as, you know, not paying a fair on public transport. Etcetera can find themselves, you know, facing some kind of investigation where the outcome may not be too severe, but it's still very stressful. And and it can be particularly difficult. Um, the final thing I'll talk about is health, because there's two elements to this. The first is that over quite a few decades, the G. M c. Have tried really hard to push us towards saying, Look, if we our patient's we need to be patient's like everybody else, you know we can't treat ourselves. We shouldn't self prescribe etcetera. And I think in the same way as the mood about these other things have changed since I started at the M. D u. Maybe 15 years ago. Um, you know, when I would talk to a group of GPS about self prescribing, there'd be generalized outrage that this was no longer thought to be acceptable. Now things have moved on quite a bit from that, but be really wary of that. And remember that the threshold for for acting in in that way and looking after your your family etcetera with prescriptions is really intended for that situation where you're you're you're on a desert island with nobody else able to prescribe. It's not intended for inconvenience or or the fact that you can't get a G P appointment. You know, um, that said, the G M c. Don't impose a general duty upon you to tell them about your health. What they say is you need to have an independent view from another clinician. You know it'll be occupational health, your GP or whatever is to what these issues and stresses or physical illness puts on your ability to work and follow that advice. That said, the G. M. C. Do look at health concerns brought to their attention. I would say that actually, they are quite good in that space. They do generally take a positive, a positive approach. The doctor at the center of it often won't find it particularly supportive, but it is often that framework that lets them reestablish their practice, you know, and if there is a concern that will relate to substance misuse or alcohol misuse. And the really commonest scheme for that is a doctor who say has, uh has a drink driving conviction that will almost always results in the G. M. C. Undertaking some kind of health assessment to to assess that situation. And that's really based on history, where those sorts of things have gone kind of miss, missed or misunderstood, and patients have come to harm in the past. I'm going to talk a little bit about complaints next, uh, and it touches on some of the themes we had in those last sort. Of course, we know that complaints can contribute to burnout. This isn't a study heavy talk, but this is is one of those things where, you know it's very clear that whenever you survey doctors, this is a real imposition. It's both in times and and and in terms of, of, of, of feeling that and it can have an impact on your practice. You know how many of you have had a complaint in relation to your clinical practice? Ask to work in hepatology. I certainly have three of us, no, And and the other thing that's really difficulties. As often as you progress further and you're clear, you you'll have, you know, never had sight of this. And then you'll seem to get a lot of complaints all in one go, because you are the person who is identified as being responsible, and that can be a real shock as well. Um, these are all threatening, and this is the second appearance of Maslow's hierarchy, and I know I did get this slide from one of my colleagues who is a psychiatrist. I'm not, um, but the really simple point is that these professional threats engage these really top two things, don't they? The self actualization needs an esteem. Even a minor complaint can get to that in those other circumstances where you know a doctor is facing a sanction, you know, the G. M. C or facing a police investigation on related matter, it can get on to all those things at the bottom of that pyramid in terms of the ability to have a career to to, you know, bring up their kids and do all those sorts of things. And we talked about resilience earlier on, and I would I would agree that it's one of those things that's got a really bad rep and probably for good reason. You know, the way it was presented today is exactly how it should be, which is if if there is anything we can do to help ourselves cope with the landscape in clinical practice and be more resilient, that's obviously going to help us. It's going to help our patient's, but it's not necessarily a policy response for a job situation that is is dreadful. Similarly, a lot of the personality traits that make you good doctors, you know, the slightly neurotic tendencies the tendency to be perfectionist to double check to be committed in that way can make these processes much harder. Okay, um, and ill health can be a contribute to the, You know, there are certainly doctors we've seen. You've had a blemish free career and have had significant problems. And it's and it's happened gradually, and it's taken a really long time before it's become really apparent that there's a health problem underlying it. Mm. Um, in terms of how to deal with a complaint, I'll say, Look, switch this round. Have you ever made a complaint about anything who's complained about anything to organization? So a few of us have. I'll take you through my traumatic experience of buying a Google Pixel six last year. It's the first non rubbish phone I bought for a very long time. Uh, I was really excited. I got it, and it was great. And then Google kept breaking it. As anybody else who has owned that phone probably knows all the software updates broke it. Um, And when I contacted them, all I wanted them to know is say was there is a problem. We will fix it, you know. But they kept saying, Oh, have you restarted it? Have you done this? We don't know anything about this and I thought, Well, it's It's all over the Internet do a Google search and I found myself getting very, very angry and annoyed about it. Um, and that was all it would take. You know, it all worked out as I sent the phone back and kept the free headphones. So that was that was good. But you know that. I guess in some ways we have to put ourselves in that in that frame when were responding to these concerns, Whether they're well founded or not, there is often some frustration at the end of it. Um, and what people want is what you want from a from a complaint. Um, but I would say, Look, it's normal that complaints always feel personal. It's sometimes easier when something's gone wrong, because you understand why that complaints there than the person that you've gone the extra mile for. I think my favorite one from our time last year was somebody who said, Look, it's really unacceptable because I had to wait 12 hours for the results of my liver biopsy. You know, we thought, Well, we thought we were doing okay, But but no, you know, and also they can be littered with emotive terms about your apparent attitude or professionalism, and these are really difficult because they are upsetting when someone says you're unprofessional. What I always do when I'm talking to somebody about that is look separate, that that's actually the part of this I'm least worried about. What are they actually describing that you did, You know, is there anything in there that causes worry? And if there isn't, then you know you have to set that aside as a as a kind of, you know, an emotive statement from someone who is upset. Um, all complaints have to be responded to any organization that is providing healthcare register with the C. Q. C has to have this sort of procedure, you know, and I've put these things in and that these are the things that kind of, I think contribute to feeling well, you know, nobody's going to care about my side of a complaint. It's just way. There's no point at approaching these things in a way to wind people up or to have an argument with a complainant, that's really helpful. But that doesn't mean that you have to accept what said is not true when it's not, You know, it's reasonable to assess this to to, um, acknowledged distress and suffering where there's something to apologize for. Apologize properly, you know, not the I'm sorry if you feel that. Say, Look, I'm sorry we did this, and that was clearly not the right thing to do. Because, looking back, we had these these criteria that that should have been into, On the other hand, where there's nothing to apologize for, you can say, Look, I'm sorry you've really had this rough time, but this is why we did the things that we did, you know, explaining what you did, referring to an external source of pretty be it guidance or or another review can be helpful because it takes some of that personal heat where the person relationship with you or your service is broken down to a point that they're not really listening to what you say. Referring to something outside that can be can be important. The other thing I would say is give a positive account and I guess that's the medical legal point here. That is a kind of concept that, for example, when you have somebody's committed to the notes Look, this patient had abdominal pain, but they discharged them and they came back with some abdominal pathology. There will often be an account. That sort of says, Well, they had abdominal pain, but they didn't really have abdominal pain. And it wasn't really pain, etcetera, and say Look, this makes no sense at all. You put that there in black and white, and this is going to lead to argument and what? And when you talk to doctors in that situation, what they always mean is, well, they have pain. But they also have these 10 10 signs I look for that were absent. These were the reassuring factors. These are the reassuring tests. So I'd say, Look, account for it in that way, you know, explain why, yes, you found some things that were concerning. But why you took the decision you did is often much more sensible. Um, what can be really helpful is writing out what happened in factual terms. That discipline kind of makes you think about what happened and makes you think Well, look, Did something happened here that wasn't right? Or am I comfortable that everything was done properly? As I said, look at authoritative guidance. See whether what you did was in that relevant scope. You know, talk to someone. It can be really helpful to talk to a trusted colleague. They don't need to know necessarily who the patient was. You know, you can talk to your medical defense organization. We talk to people all the time about complaints. We usually say, Look, send it in and we'll have a look at it. But quite often they just want to talk to someone about it. And if something has gone wrong, I would say that it is not usually that that prevents or gets in the way of a doctor's practice or career. It's It's usually other things that do so you know, uh, I guess what I would say is that these things can be made 100 times worse where notes are amended under the stress of feeling the pressure of something going wrong. Those are circumstances where you have something which wouldn't have gone beyond local level that escalates to, you know, the G, M. C or even a police investigation. In some cases I've seen I'm going to talk a bit about writing reports because I think this can also be stressful. Because if you're asked to write a report for a claim, a complaint to an S u R A coroner, you know, you know, it's another thing that you've not got time to do. You know, you're not allocated time to do that. Um, it is a skill and requires practice. And in general, the thing in your head is keep it factual and keep the timeline accurate. It's slightly different from how you present a case on a ward round. You know where you summarize the key factors. You know, this is a person came in with the fractured leg, had had this treatment on this day and is now here. You know, you're you're often talking about what your involvement was. You know that my first involvement in the care of that person was when I was called to the ward, you know, I went to the ward. I found them hypo, you know, shocked based on these things, etcetera. And that's often because these processes are trying to work out who did what in the sequence of events, you know also use plain language. That is important because often these things are read by other people who aren't medically trained. But I'll tell you, the other reason it's really important is it forces you to give a really clear explanation to really define what you mean. Uh, the other thing is is and and again this is, I guess how this touches on burn out. When I talk to a lot of doctors on our advice line, their concern is, Well, what might somebody else say? Well, I will say this, but a nurse might say that on the ward the other person involved might say the other, and I would say, Look, you know, you've got no control over that. The only thing you can control this you're giving an account that you're happy to stand by every word of whatever happens with it. And I would say, even after doing this job for 15 years, I can't always tell the cases that will escalate. There's a really complex interaction between what's happened, the attitudes of those around it, the family, etcetera, that is really uncertain. The other thing, I'm going to talk about briefly is supporting colleagues. Um, a lot of these and I would say that that I guess in my mind when I wrote this was doctors facing GM see investigations. They're often incredibly isolated in a process that can take really some time. There are some who their family won't know. They feel so ashamed about having their profession called into question. In this way, medicine is such a part of their identity, their family won't be told. And I think this is a learning point that we had over covid because in the past, if we'd all meet to talk about the case, we'll do that in in an office somewhere. And you wouldn't expect there to be other people there, etcetera. Um, but, you know, I remember doing teams meetings where the doctor would be in their car, you know, saying, Look, it's You know, some people do that because it's noisy in the house, but they'll say, Well, I didn't want I don't want my wife to know. I don't want my partner to know, and you know, if they can relieve that burden, it can make a huge difference because trying to cope with this without that support is really important. If you're really worried about them, have they gone beyond the kind of mentoring support that we talked about before? Which is hugely important, can prevent this happening. Then they need to see their GP or or occupational health again. If the doctors really reluctant to do that because it's too close to their employer, etcetera. You know there are other services available and I'll put a slide and the next slide we'll have details of that that they can talk to who are specialists in the health of doctors. Okay, Have they spoken to their defense organization? Because I'm always amazed when I get calls in the middle of the night from People are really worried about things that are never going to go anywhere, and they are really relieved just for someone to say, Look, this it's important we respond appropriately, but this is you know, you're not going to get erased for you know this complaint about somebody saying you're five minutes late to clinic, you know, that's that's not it. And equally there are other people who will have correspondence that is really alarming and either suppress it or not really realize the significance of it. So in both instances, if you talk to somebody who knows to sort of put that in context, it's important, and it can also help to talk to someone who's been through it before. I think in the past, doctors used to not talk about this sort of thing very much. I think that is changing. It's not uncommon about you know the lifetime risk of the G. M. C report is somewhere between one in 20 to 1 and 40. It's not uncommon, you know, This is what I meant in terms of independent support for practitioner health. This is NHS practitioner health. It used to be the Practitioner Health Program, and it was very much Clare Gerada, who used to be the past presidente of the Royal College of General Practitioners who pushed this. She also wrote a really excellent book or beneath the white coat that looks at health issues in doctors. And if if you've not read that, I really would recommend it. It's it's not overblown, it's scientific, and it gives you some really insights into this. Uh, the the advantage of this is that they There is nothing that these guys have not seen in terms of doctors with Hill health from, you know, people suffering burnout and stress to people who have serious mental health disorders. And there is a separation from from your organization, so people may find that reassuring. In the past, it all used to be very London based and that they they'd be happy if you gave them somebody's else's address in London to to register. And they quite openly say that. But now it is a national service that you can access, and they are very good. Um, we've also got a nascent peer support program. We've, you know in the past were very conscious that a lot of doctors who've been through this process really didn't want to talk about it. They didn't want us to publish their cases or to talk about them, even in an anonymized way. I think that's quite change changing in a lot of our and this was really set up in a response to a lot of our members coming to us, saying, Look, you know, we'd like to be able to help people who've been through this before. Um, you know, and and, you know other organizations may offer something similar. You may know somebody who's been through it that it's worthwhile talking to, um, Now I said, after all of that, I'd give you some light relief at the end with some new medical legal developments. So I shall. I shall do that very quickly. So how many of you have heard of good medical practice? So decent number of you? How many of you have read it? So one or two? So not bad. I mean, this is probably this is the kind of GMC's court guidance. I think the first iteration of it was 1995 and it kept going. Since there's a change in focus and emphasis, it's being updated. I mean, it's all good stuff in terms of their dealing with things that are relevant to the things we talked about today. I guess our concern about this and much of their recent guidance is Is that you know, you know what the reality of working in the NHS is? Um, but a lot of this is very aspirational. It's a bit like the consent guidance. You know, anybody who's had a covid vaccine was there was the consent process you went through, similar to what is set out in the G. M. C's guidance. Probably not, you know. And the difficulty is, is that unless this guidance reflects real practice, however well intentioned it is, we're always worried that the unintended consequences of that is that more and more doctors are kind of judged against it, which is probably not the intentional counterproductive but could happen. There's also this How many of you've heard of this patient's safety incident reporting framework? Um, so this is apparently coming in from 2023? I'd say. Look that up and look at the video on the website about that. This is the stated aims of it to have compassionate engagement, to have a systems based approach so we don't look at individual blame. Etcetera take a proportionate approach, etcetera. It's very difficult to know what will come of this. The video on the website very clearly says this is not the same thing by a different name. I think time will tell whether this is a more productive way of investigating incidents. The other thing is, I think that NHS England will take a role in overseeing um, organizations doing these sorts of investigations. Um, now, how many of you've heard of H sib? Uh, that's interesting. So this is, uh this is a body that's been around since around 2013 2014, which was intended to try and build Bring the culture of air accident investigation too. NHS investigations. Now, I suspect most of you have not heard of it because a lot of their work has been focused on maternity investigations, maternal death, intrapartum and still still both. If I have spoken to obstetricians about this, all of them will have said we've heard of them. And they may well have had an interview with a sip following a maternal death or a tunnel death. Now that's changing. This used to be kind of under the umbrella of NHS England. Now it's been created as a different body, which, with a very similar sounding name, Um, I think it's now the health care safety investigation body. Um, but it's it's being set up on its own. The maternity investigations are being going to be done by separate health authority, and they will be spreading out into other spheres of practice. You may come across them. And in fact, they have done some work in orthopedics, and this is really an investigation into implantation of wrong prostheses. Um, and I guess I put this up by way of reassurance. I think this is actually one positive development in the medical legal landscape in that these are the sorts of recommendations that come out things that are actually systems based and practical. Rather than saying, look, you know, you need to take more care looking at the packets. And we we had an internal talk from somebody from H said who who showed a picture of all the different prostheses, uh, in the cupboard, and I I couldn't believe how similar all the the labeling looks. So it's It's one of those systems things that that that that caught their interest, and you may be seeing sort of more of them. Um, so that's all I had to say. I'll take any questions on this or or anything else you've got as a burning topic. Thank you. Thank you very much. I think lunch isn't too far away. But I think we do have time for a question or two. Anything at all that we would like to ask Ed on this topic. Yeah. Stunned into silence. You've done everything. Thank you. Thank Thank you very, very much for that. And it's brilliant to have you with us. Thanks.