PLAB Lecture – Avoiding Common Medico-Legal Pitfalls ,Dr Udvitha Nandasoma, Head of Advisory Services, The MDU
Summary
This on-demand session is relevant for medical professionals and would cover avoiding common medico-legal pitfalls. The presenter is a former practicing hepatologist who works full-time for a Medical Defense Union and is well-versed in legal requirements. He will also provide exclusive insight into the UK standardized Pla examination curriculum in terms of ethical and legal requirements. Topics discussed include GMC guidance, confidentiality, professional boundaries, use of chaperones and social media, mental capacity, and consent.
Learning objectives
Learning Objectives:
- Understand the consequences of clinical incidents and different forms of accountability
- Recognize the importance of abiding by relevant legislation, guidelines, and regulations in medical practice.
- Explain the role and responsibilites of the GMC in maintaining the license to practice.
- Comprehend the implications of confidentiality, consent to treatment, and the use of chaperones when it comes to medico-legal issues.
- Outline key steps to take when addressing complaints and raising concerns in a medical context.
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Computer generated transcript
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
Thanks for, um thank you for the invitation to talk today. I can see from the chat that we've got people studying from all over the world. And I was asked to talk about avoiding common medico legal pitfalls. My name's Edin Soma by background, I'm a hepatologist and was practicing until earlier this year. But now I work full time for the MD U Medical Defense Union as head of advisory services. And what we deal with is answering Medico legal queries and helping doctors who run into Medico legal issues. I appreciate that a lot of this is very UK specific and actually very England specific within the UK. Um There are some common themes that come through it and I'll try and bring those out. But I was asked to sort of pitch this as a lecture for anyone preparing for the pla exam. Um So, so that's kind of how I've structured it. There is quite a bit to get through and I will try and go through it and then perhaps hopefully leave some time for questions at the end and I'll, you know, talk about whatever you like in that sort of setting. So to give some context to this. Um A lot of what I've focused on here comes from a thing called the pla blueprint for any, any of you who are actually doing the Plav exam. This is on the GMC website and talks about um essentially the syllabus for the examination. There's quite a lot of medico legal content in there. They're not necessarily key points, but they're kind of background to how you would be expected to interact with patients. Um and also some of the key areas of medico legal content you'll see here, they comment about behaving in accordance with ethical and legal requirements. I'm sure that's the same everywhere around the world. There is some specific content on confidentiality, consent to treatment, how to manage conflict, either between colleagues or indeed occasionally with patients, how to deal with complaints. And when the unintended things happen, adverse events, if a patient comes to harm, how to deal with, it's termed conscientious objection here, that can be thought about how your personal beliefs interface with medical practice where people may be having treatment or having decisions that making decisions that you're, you're not entirely in agreement or feel that conflict with your own principles. It also there's an increasing focus on treating patients and colleagues fairly without discrimination. And there's also a section about raising concerns and that comes from really events over several decades in the UK where there have been things where things have gone wrong in the health service or in medical practice where you can't, where, where the suggestion is that um the concern should have been raised earlier. This kind of mirrors our experience of when doctors face medico legal problems. Communication is often an element where the communication either between doctors or between a doctor and a patient has not been optimal. Obviously, a lot of them are at clinical management and it may be a clinical incident or a complication that triggers a complaint or a concern. But these other things go on proper use of chaperones for particularly intimate examinations is important. We get a lot of questions about confidentiality when a third party, often the police or another service wants to access records and doctors asking about when they can and when they can't do that, candor is about being straightforward and honest with patients when things go wrong, giving a proper explanation of what happened whilst also avoiding, of speculating and causing issues later on when that may not be quite right. Clinical records, either the content of them or them not being enough to showcase what the doctor did can be a problem. And we increasingly get questions about consent. Um certainly the direction of travel, I think in most of the world and certainly in the UK is to make the consent process focused on what a reasonable patient undergoing treatment would want to know, rather than what we perhaps might necessarily think they want to know, which is kind of the standard would have applied when um when I started out in practice. So again, returning to the pla curriculum, you'll see here that this is taken from the UK foundation program. The foundation training is what doctors in the UK would do when they first graduate. And it says here a few key things, this is phrased in really general terms, but it says practices in accordance with guidance from the GMC relevant legislation. So the law of the land, national and local guidelines and understands the risks of legal and disciplinary action if a doctor fails to achieve the necessary standards of practice and care. So that's a very sort of bland straightforward statement. But it actually says quite a few things think about that as showing that doctors have multiple lines of accountability. And again, this will be the same or similar around the world. There's a regulator in the UK, the General Medical Council, there's what the law of the land says you can or can't do, which is critical to how we act. Most doctors are in the UK are probably employed either through the NHS or another organization and the policies procedures, expectations of that employer will be important. We also have a, a coronial system. So is a AAA an officer called the coroner who there are several around the UK. And they investigate essentially unnatural deaths and look to see who died, why they died, where they died and establish basic things about the death and that can sometimes um fix on medical care. Also, this is also something that kind of fulfills that expectation of understanding the consequences of clinical incidents. These are the sorts of things that occasionally happen together very rarely I would say, but some things that can happen where something goes wrong in practice, a civil claim that's in common, so to speak. That would be when a doctor gets sued and that used to be, you know, 30 years ago, that was the main worry. Doctors would have very rarely, doctors face criminal investigations. This is sometimes where a patient has died from what's perceived to be really inappropriate or poorly delivered treatment. Now, that's very rare but does happen quite often. And I would say this is the thing we see most of often is a doctor accused of actually having sexually assaulted a patient during a consultation. Those are obviously much more difficult situations and extremely stressful for those concerned. And I'll talk a little bit about the importance of chaperones later on a disciplinary investigation is essentially an investigation by the doctor's employer where they don't think they are doing their job properly. Um And of course, patients in the UK can complain. And I say that not because other countries don't have complaints procedures, but in many other countries, um, the focus if something goes wrong may be for the patient to seek compensation from the doctor from the organization or the doctor concerned. Here, there will be a lot of complaints even where things haven't necessarily gone wrong, but where a patient has found a service frustrating or was unhappy about a consultation on all those things, um, demand a response. Both the General Medical Council and the complaints procedures set out in law expect that we respond professionally to those this GMC investigation. So, an investigation by the organization which registers doctors in the UK is probably the most intimidating thing that a doctor would have to go through. Er, that's not very rare. Roughly one in 40 doctors will face that over the course of a career and it can be extremely stressful and professionally threatening. I've explained that a coroner can look at deaths and we also have a range of other organizations that look and inspect on the quality of health care. And I'm sure again, this is not at all unique to the UK, but the media, the newspapers and the internet are obviously really curious about um medical events and, and so a lot of doctors can face breast scrutiny from time to time and that again can be very stressful. So that's part of the overview and I don't expect you to take that in. I just want you to understand that there is quite a complicated medico legal landscape and it's often not enough to say, look, is this legal or is it not legal? You have to think, well, look as a registered professional, what are the expectations on me? What would my employer expect and what could happen out of that? I hope those slides gave you some understanding of that. So I'm going to talk for this talk on a few key topics. I'm going to talk about the GMC. I'm going to talk about confidentiality, chaperones. We'll talk a little bit about professional boundaries and this is about things like, you know, is it ever appropriate for a doctor to treat themselves or their family in the UK? And I'll talk a little bit about the use of social media because obviously that's a big presence. Now, I will schedule a second talk where we'll talk through two other really big issues. One is mental capacity and consent, but those really need a bit more time. So I'll, I'll, I'll deliver that separately. So to talk about the GMC first, the GMC is the medical regulator. It deals with registration and licensing. So if you're working in the UK as a medical practitioner, you need to be registered with the GMC. They have a thing called a license to practice, which is what allows you to see and treat patients and prescribe and do other other things which come as a privilege of having a license to practice. And in order to maintain a license to practice, you have to go through a process called revalidation, which essentially means that you have to have an appraisal every year which covers the whole scope of your practice. You'll discuss the CPD, you've done the adverse events, you've been involved in response to complaints, what the scope of your work is, et cetera. And if you, uh if you accumulate sufficient of those, a recommendation can be made to the GMC that you maintain that license to practice. The appraisals happen every year, but revalidation is done on a five year cycle. Um The GMC also publishes a vast amount of guidance about medico legal and regulatory and ethical issues. Um I'll talk a little bit about that. Much of it is for reference. If you come across a situation, there are a few key things that I would suggest you read either from the purpose of doing an exam or indeed from preparing to practice in the UK. The other thing that GMC does is regulation and fitness to practice. So it's open to anybody to complain to the GMC about anybody who holds GMC registration and ask them to investigate a concern about their practice or their conduct, sometimes even their conduct outside medicine. Now, the vast majority of those complaints are actually not taken up by the GMC. They are triaged and filtered out. Um but some they can investigate and of course, the ultimate sanction from the GMT can be to remove someone's um ability to practice certainly in the UK. So I said I'd talk about GMC guidance. This is their core guidance. It's called Good Medical Practice published now 10 years ago and is actually going to be updated later this year. If there is one thing I would suggest you read either with a view to practicing in the UK or with a view to doing this exam, it would be that document. If you've got more time, I would also read these publications. They're all available online on the GMC website. They're all downloadable PDF S uh which deals with confidentiality, consent and the 0 to 18 guidance deals with those sorts of things in younger people, but also deals with issues such as safeguarding and child protection, which can also be challenges in practice and also question set in exams as well. Now I said I'd talk a little bit about the reach of the GMC and perhaps where the role of the GMC in their interest may be different from regulators in other jurisdictions. Um And I wouldn't hold this out as being a positive thing in the UK. But I would say, look, this is how this is the reality of practice. So imagine this situation that doctor is on a night out, visiting friends in London ends up being a little bit under the influence of alcohol and ends up in an altercation at Dow and at the Light Club, these are scenarios which do happen from time to time the police are called. The doctor accepts what's a tender in the UK. A fixed penalty notice. It's essentially you admitting that you, you committed. Um, here it would be a relatively minor offense but, but ends up being fined for being drunk and disorderly in a public place. Well, what could come of that? Well, this comes from that first document I suggested you look at called Good Medical Practice and this is that the GMC expect to be told if anywhere in the world, a doctor has accepted a caution from the police or criticized in an official inquiry. Ok. So again, I'm not going to delve into the detail of this. It's simply to illustrate that the role of regulation in the UK can sometimes go beyond the care of patients. It can look at issues arising from your personal or family life and the times where doctors have faced GMC investigations have been where there have been allegations of child mistreatment in the family where there been allegations of domestic violence, et cetera. So it can extend into that. It can also look at allegations of dishonesty even when that is outside, outside the sphere of medicine. Um there is a duty as said in the last line to report criminal charges, convictions or sanctions from other regulators. So if you happen to hold registration in two countries, if you run into issues in one of those, it's often the case that the other regulator will want to know about it. And even if the other regulator, you registered with isn't particularly interested. The GMC will generally communicate with those registration bodies proactively if you have an issue in the UK. So be mindful of that. So we've talked about the GMC, its basic functions as a licensing regulation and registration body and how the impact of its guidance can, can sort of impact beyond the medical sphere as well. I'm going to now move to some of the more core medico legal content. Um That that is, is what you're probably much more, more interested in. We're gonna start with confidentiality and I would say that confidentiality and by that, I mean, how you treat information about patients, how you treat requests for information about those patients, things like medical records, but other information as well, how that's treated could be a subject of multiple different talks, we could have a whole series on it. People do um dissertations on this sort of topic. So what I'm going to do is to give you a very quick overview and perhaps give you some idea of how you approach a scenario if you're asked to deal with confidential information. So these are the three principles I would hold in your mind is that if you're asked to disclose information about a patient. So say, for example, you're in A&E um a patient uh turns up with um uh having been in a, in a fight has some bruising on their face. Um a police officer comes in and asks you for details of their injuries. What should you do? Well, these are the things to consider. Do you have the consent of that patient to share their information? Is it something you're required to do? So, there may be a legal obligation to disclose information. Those tend to be very limited in the UK and very specific in terms of what information you're required to disclose. It's typically not everything you know about the patient or their health. Um, you might be required if a doctor occasionally is giving evidence in a court about something that they were a witness to and they may be required to give information in that setting. We also have a concept called the public interest in the UK and that's often what we get calls about at the MD U with the doc saying look, should I share information in this context? Unfortunately, the public interest is not kind of what it sounds like. It's not something the public might be interested in which could of course be all manner of things it's really about. Is there a public purpose in disclosing that information will sharing that information, for example, a threat to another person um serve a purpose such as protecting that person from harm. Now again, as I say, it's very difficult to cover this topic in depth. I've pointed you to the GMT Guidance on confidentiality. The NHS has really decent er sorry, really detailed code of practice on confidentiality with all sorts of scenarios as a reference guide. Again, I would look at that, but I think you probably won't have enough time to look at that. And for those of you who might want to practice in pediatrics will be doing further training in that sort of area, then often the issues about whether to share information about Children or their parents really relate to concerns about child protection or safeguarding. Um And there is separate guidance on on that as well, which kind of is about how the organizations such as the Social services department, et cetera, which should operate and what you need to be mindful of, of the request that they have and what it's appropriate to share or not to share. So these are just sort of shots of again, this guidance that is available online. So I've shown you kind of three key principles. How the patient consented. Is there a legal obligation? Is there a public interest in disclosing the material? There's lots of further reading about this. This is really to say, look, these are acts of parliament typically in England. Sometimes these stretch across the UK. That's the other thing I should say is that the UK has separate countries that have their own laws in much of this area. Some of it is very similar, some of it is different. So again, if you're practicing in Scotland or Wales, you need to be mindful of the legislation there or indeed Northern Ireland as well. Um So these are the things that can kind of touch on disclosure of information. The Data Protection Act uh deals with information, medical records of living people. OK. The access to health Records Act relates to a deceased patient. There's an access to health reports Act which deals with things like reports for occupational health purposes, et cetera. There are requirements to disclose information in the Terrorism act again, very limited in speculation in, in, in scope really about. If you come to know that somebody is making a threat of a terrorist act, it isn't a kind of duty disclose all their medical records. There are positive duties to share information about specific communicable diseases. Um and in some sorts of crimes, the Road Traffic Act requires that anyone who's asked to identify the driver of a motor vehicle involved in an accident. But again, that's very limited. It's about identifying the driver. It's absolutely not about their, their, their, their medical um medical condition. And as I say, some other jurisdictions like Scotland in the UK has a slightly different law about how they deal with evidence. Again, I don't really think that you would need to look into all of this for the purpose of preparing for practice or for a pla exam. It's just to recognize that this area can be quite complicated and it might be appropriate to seek advice from a senior colleague from an organization like ours, et cetera. If you, you, you're faced with a question and think, I don't know what the answer to that question is, but I remember that there might be some law that's relevant to it. Ok. A lot of these disclosures required by law, they usually require you to do something very specific name. A driver disclose information about a threat. They don't require you to disclose medical details about the patient. Typically, sometimes they'll say you must do something. Sometimes they will say it's permissible to disclose something in these circumstances and they'll often specify who it should be disclosed to. Again, this is not for you to kind of go to the detail of that. But remember whenever you're, you're disclosing information about a patient other than in the course of simple clinical care, be really mindful of those things. What's the minimum amount of information you need to share for that purpose? Is it permissible or required? And does it specify who it should be disclosed to? Um you know, it, it, it doesn't allow you to publicize a matter just because the law might require you to share it with a particular person. The other thing that um you might hear of is court orders and we're, we're, we're familiar with, with that from, you know, from, from, from most places around the world, a court will have the duty to require material to be disclosed if it helps inform whatever the court is considering. If you get something like that. The short answer will be you take advice from a colleague, contact a defense organization or if your employer has a legal department, consider contacting them. Because again, orders will be quite specific. They'll require a person or an organization. If that's not you, it may not apply to you. It will also specify the material to be disclosed. So if you're not sure, ask to see the document and share it with somebody who can interpret that for you. The other aspect of information sharing um is the right of patients to have access to record. There's only a very limited amount I'll say about this, which is that be prepared that anything you commit to a patient's record or put on an electronic system may well be seen by that patient. There are some circumstances where you can refuse to share information, but they are very, very limited. And the default position is that the patient will have a right of access to the information. You see when, when that happens, you might need to carefully review the records because sometimes medical records contain information about someone who isn't the patient a so called third party. So it could be a relative et cetera. And you have to think whether it's appropriate to disclose that and parents or someone with a a technical term called parental responsibility can also request the records of Children, but you need to be mindful of what's in the child's best interests as etcetera at the time. So again, that's a complex area where I'd say, seek advice if you're not comfortable with it or, or work in that, I'm gonna talk a little bit about one final area about confidentiality and disclosure, the, the so called public interest. And I said, I said at the start, this is probably poorly named, it should be perhaps the public purpose. So this is what the GMC says in its guidance. It's quite wordy. It talks about, you know, that people typically expect their medical information to be confidential. But occasionally you can face a circumstance where sharing information. Um if the benefits to an individual or society outweigh both the public and the patient's interest in keeping information confidential. So this can be in situations, say where there's a serious crime where you have a threat by somebody to cause harm to another person, particularly say harm to Children, et cetera. That might mean that even if a patient doesn't want you to share that information as it was shared during a clinical consultation, you might have an obligation to do that. Again, take advice. Those are the things that you that, that we're, we're, we're kind of approached about all the time. No, in terms of exam preparation, there are a couple of other things I would suggest you read disclosures about driving, um are quite common questions. So say you've got an elderly patient with dementia or a visual impairment or somebody with brittle diabetes who is constantly having hypos but continues to drive. And there's a real question about whether they should have a driving license. There is, you know, there may be again a public purpose in telling the licensing authority UK called the driver and vehicle licensing agency about that. Um But there is a, there's a fairly prescriptive process on how to do that. Again, the GMC has guidance about that on their website, which is actually one of the most more practical things they do. There is also I apologize for the typographic error on the side that there is also specific guidance on reporting knife and gunshot wounds. And this is really to deal with a situation where in certain parts of the UK, there were groups of young people involved in knife fights in it causing a public risk and significant harm. And so there's a positive obligation if someone presents to ne with a knife wound or a gunshot wound for that to be reported. However, what the obligation is, is to report the fact that somebody has been admitted with a stabbing or a gunshot wound. What will typically happen is the police will um attend and want more information and you still have to think on a case by case basis, whether it's appropriate to disclose more than that. So again, I'd look at those because they could be common scenarios. And again, we've got online learning on our website, you have to register on the website to get that, but we have online learning on these topics as well. Um If you want to pursue this in more detail, or if some of these things may be more relevant to you. If you happen to be working in A&E or, or um in general practice, dealing with di en tend to be really common issues. So, apologies that that was we had to go through that fairly quickly. But again, it's a complex topic. Look at those, those core sources of GMC guidance and remember those principles and in real life, take advice when you're not sure. So again, this is a, a scenario that I've put together from various different cases where we've had it, the MD and see what you think of it. So a doctor undertakes a medical examination on a patient. This is done for the purpose of that patient who is an amateur scuba diver does diving with a mask and oxygen, et cetera. Um includes a full general examination during a fundoscopy. The patient later complains they felt violated following the assessment. Now, um if we had more time, I'd open that up for discussion and say, why do you think that might have happened? I'll tell you given the pressure of time here that that happened because um they weren't suggesting that that the doctor had touched them inappropriately or anything like that. It's just that it was in a darkened room and the patient wasn't allowed to undress to redress following the full general examination, which had happened in their underwear before the doctor looked in the back of their eyes with the funders cope requiring them to be close to the patient. So again, be mindful that how people perceive examinations may be very different from how you perceive them. It was really only when I started doing this job that I thought kind of, you know, when as a gastroenterologist and hepatologist, I would do a, a rectal examination in a patient who had hematemesis. The patient may well think why on earth is you looking at, you know, putting a finger in my bottom relevant to me, vomiting blood, it's completely the different end. So be mindful of that mindful of communication and, and and people's expectations. So again, the expectation is that chaperones are present wherever possible for an intimate examination. Now, again, this is what the GMC says in its guidance, but be mindful that um sorry, your employers might have a different policy. They may sometimes just have chaperones routinely present in clinics for certain consultations, Boris chaperone or the observer to be helpful. It really can't just be a member of that person's family. It has to be somebody who is relatively independent uh from the patient as well as from you and be usually be somebody who has enough training now and doesn't need to be a nurse. It could be just a somebody who provides healthcare support in clinic, um you know, does things like you're in Dipsticks books, the patients in but is sufficiently trained to understand when an examination has done been done appropriately or not. But the other expectation the JMC has is that we record any discussions about chaperone. So essentially, if you're approaching a patient to do an intimate examination, my top tips will be to provide privacy for the patient to dress and undress. Ok. Remember it might be appropriate for other types of examination. Certainly in patients who've had histories of trauma or abuse in the past, then offering them for any type of routine examination may be appropriate. Think about how you communicate with patients be really clear about the purpose of the examination because often the rationale behind these won't be um clear for somebody who doesn't have medical knowledge and also explain exactly what the the the investigation will, will, will mean or the assessment will, will involve also keep a record in the very few cases we have where there is an allegation of an inappropriate examination. And this is one of the circumstances where the patient may make a complaint to the police rather than to to a medical authority. Often if we've got a clear record that shows that the exam was clinically appropriate and indicated that is hugely helpful in defending the doctor in that situation. As I said, they should be trained staff who are present within the curtain and able to see what's happening. This is something I'll be really clear about the gender of the doctor and the patient does not affect whether a chaperone should be offered. So, so 15 years ago, any allegation of an inappropriate examination would usually involve a female patient and a male doctor. Um Now we'd say a quarter of the allegations are made towards female doctors and we see every variation of gender between doctor and patient in that. So it's not a gender specific issue. Um If a chaperone is unavailable or refused, you can defer the examination if it's not an emergency situation to make other arrangements. Maybe a colleague who doesn't feel they, they, they, they must have a chaperone in this situation or give the patient time to further consider things. Um If you feel able to proceed, simply document that the patient has been offered a chaperone and hasn't declined, put down in the records, what you'd explain the examination will be and ideally recording the identity of a chaperone is really helpful. Again, I suspect this is something that is fairly unique to the UK. But we have had doctors facing allegations of inappropriate examinations multiple years after they've retired a few years ago, we had a doctor who was in their eighties and the allegation arose from a patient they saw 30 years ago. So these are rare but it is, you know, the records can be helpful even after that period of time. So moving on to the last couple of topics, I'm going to talk about professional boundaries. And I know that typically we think about that in terms of doctors having relationships with patients. And we know that, you know, around the world that is frowned upon, it's not thought appropriate to for that given the vulnerability of many patients in that context in the UK, where I think the UK is slightly different from much of the world, is in relation to prescribing and treating family members in many parts of the world. If you are a doctor in the family, it's not only fat appropriate, but it's thought, you know, bad if you don't offer your help to family members, et cetera. Now this is thought of quite differently in the UK and these are the types of questions we get about. Can I prescribe for myself? Can I prescribe for my family? Can I prescribe for somebody that I work with? And the answer in most circumstances is no. And the reason for that is is that the way we look at of being, being registered as a medical professional in the UK is largely that the privileges that go with that registration, the ability to prescribe and treat, really relate to your employment and not really translatable to your, your sort of life generally. And it's also very clear that that there's a big premium on having objective assessment of those close to you or indeed your own health. And so this is why you can see the guidance in front of you here that if you think there's something wrong with, you don't rely on your judgment. If you think it might affect your practice, especially, you must get a colleague to guide you as to whether that might affect your advice. And so that would be somebody with a role as your general practitioner or sometimes the occupational health doctor in your organization or hospital if you're working there. And again, it used to be fairly common practice, you know, 30 years ago, for doctors to register their Children at their own practice, that's really discouraged now. And it can lead to a lot of sort of controversy and problems, particularly when there are things like relationship breaks down. And you've got, um, you know, medical records, a mother and father register at the practice that can be very difficult. This also applies to kind of providing treatment to those care for you that unless it's an extreme emergency and there is no other alternative, avoid providing medical care for yourself or anyone with whom you have a close personal relationship. The fact that it isn't absolutely banned is not to kind of give us more scope. It's really to recognize some situations where you might be on a mountaineering holiday in the wilderness and you're the only one able to help. There may be a situation where you're working in an extreme environment, in an oil rig or somewhere like that where you will happen to know some of the people quite well. But you'll be the only medical source. So it's intended to be really extreme circumstances. Things that I would say don't qualify as being good reasons to treat yourself is that it means that you take less time off work that it's inconvenient, that it's hard to get an appointment. Those things aren't seen as justifications for treating yourself or, or your family. Um And again, this is the same sort of admonition, but in terms of prescribing, again, saying that objective medical care is important, so you must sort of avoid that. Now, I talk very briefly about the issue of improper relationships with patients or those close to them. You know, that is not at all unique to the UK. It's generally thought that doctors shouldn't have relationships with their patients, but be mindful that there are other elements to this. They have guidance on receiving gifts and essentially any sort of gift that might be even perceived to affect how you care for a patient or their family would probably not be appropriate. Um We occasionally also see doctors facing unwanted attention from patients and sometimes it's appropriate that um a clear boundary is set, often helpful if say somebody else at the hospital or at the practice, if it's in, in primary care, speaks with a patient sets appropriate boundaries and, and sort of, you know, is, is expressed about that and brings it out and is clear about it. Um I'm also going to talk a little bit about social media because I think that can also be a source of avoidable difficulty for doctors. So essentially prof professional boundaries, be mindful of needing to get an objective view about your own health and that of your family and avoid treating yourself wherever possible. So social media, um this is quite, quite dated. This is guidance that came in about the doctor's use of social media. The point, I think the central point is a really simple one, which is that we're expected to be as professional on social media as we are in our sort of day to day interactions. The risks of it is that it's a medium that invites to blur personal and professional boundaries. You know, it's amazing that somebody who knows what they're doing can really found out a lot about us from our social media profile, even though we haven't specifically put that sort of forward and it can invite direct contacts um from people you may have treated, which can sometimes be helpful. Sometimes not, it can be where negative feedback comes in about a doctor and avoiding getting into an online debate with a person about that is difficult. It's also important to show respect for colleagues and sometimes online debates as we know can get really heated. You've also got to be aware of the risk of giving medical advice online. We know that the internet is a great source of general advice and that there's a lot of great health related content on there, but it's dangerous to offer advice on treatment of an individual patient without knowing them. The other thing is, is how confidentiality can be compromised and this can happen um if you have accumulated information that can lead to the identification of a patient, so you may not name them, but they may be somebody who is brought into an A&E department following a notable incident in some where they can be basically, you know, their injuries are unusual. There might be a press report about the accident and the person ends up being named by somebody else, even though that wasn't your intention, you know, and remember about the risk of going viral, risk of it being, you know, being hard removed once posted. And remember that once you put something online, it may be there forever and it may be seen by people for whom you never really intended it. These are the key highlights from that GMC guidance that if you say I'm a doctor uh in social media, you should identify yourself by name. Now, the reason for that is, is not particularly you. The reason for that is really about the fact that that they want to draw a distinction between doctors and social media and people saying they're doctors when they aren't OK. Again, be mindful of confidentiality and be mindful of professional boundaries on, on social media. Next. So the thing that I would say is that the medicolegal landscape, some of it is simple and you'll get very familiar with it quite quickly. Other parts are really complicated. Just remember to pause and think, you know, that's why there are organizations like the MD U. We're not the only ones who do this, but this is why we have doctors who have full time jobs, essentially dealing with Medicare legal queries. It's because of the complexity of this landscape. In the next lecture, I'll talk about a, a few other concepts that are key. One is the duty of candor, the other is raising concerns. So about systems and colleagues occasionally and then we'll talk about big topics of mental capacity and consent. So if you want to think about some scenarios before next time, these are taken from the pla resources on the GMC website, uh the answers are there is as as well, but this is a question about consent and capacity. OK. And I won't go into this now, but this is sort of basis for next time. How would you approach this situation? OK. And the next one is about a 14 year old accessing contraceptive treatment. These are kind of fairly core scenarios in the realms of consent, consent and capacity in adults and in Children. Um and hopefully they'll, they'll form the basis of a, a discussion next time round. So I'm gonna stop there and I'll, I'll stop sharing my screen. Um, if anybody, uh, has any questions, I think we've got a few minutes. I'd be very happy to take them. Uh, it's, yes, it's regarding the, uh, legal issues for the consent. And like, let's just say if we have a patient in our treatment or in a facility and police policeman arrive and they ask that this patient, your treating is one of the suspects. Shouldn't we ask them first if they have a warrant for investigation or interview with this patient? Well, what is it that you're um that's quite a complex area because actually the powers of the police to obtain warrants in that situation before anyone is charged are relatively limited. What is it that they're asking you that that's the key question here because you, you're quite right that, you know, the police can say, well, we want to interview this person, the person can agree or refuse to be interviewed. Um but it's, you know, that, that, that they don't have a power in most instances to demand that you share information with them. Now, as I say that there are some acts so such as you know, if, if they're the driver in a, in a traffic accident, then the police have a right to ask for that details. And, but that's essentially name and address rather than clinical scenario. So you're right that in those instances, there would be, now, there can be some where if there is an ongoing risk and that can be with a knife and gunshot wounds. And you think that actually, um, sharing a bit more information that you've come to know as part of your consultation may help protect other people immediately at risk that might lead to more of a debate. But, but that's how I would look at it if, if you've got a kind of more, you know, thing of, can I share this specific information? I'd be very happy to talk about that more like it would be a threat to the patient's life itself. I mean, usually policemen are doing their job, uh they have their bosses to answer. We are doing our job, we have our bosses and mostly our bosses, our patient itself. But if it's the patients whose life is in a threatening or fatal situation that where they could get, be killed in a very, I know, I don't know in a conspiracy way. Sure. How would we approach and for the most safety for our patient, whether we would uh approach uh dean of the medicine or we would approach some other legal officers. Um I, I think you're dealing with, with a couple of other things here. Now, if you're dealing with a patient who is conscious and alert and they're the person at risk, but nobody else. Ok, then typically you would respect the patient's wishes in terms of what information would be shared with the police. Now, those situations can become really complicated because they may have a threat against them, but there may be a threat to other people in home to say Children in the home, et cetera. And there will be a fairly straightforward argument there for sharing limited information with the police. And really what they need to know is that there is a significant threat there in those situations, to protect, to protect another person. There's also another angle to that. And this is particularly where we see occasionally uh sort of organized crime or gang related shootings, et cetera. That in that situation, having that person on a ward, when there is a risk of somebody attending the ward and committing an act of violence can also raise a risk to um the staff on the ward and other patients. And in those circumstances, the organization will usually share some information with the police to allow the um the team to be protected, but it's not typically um necessary to share medical information in that context in terms of who you'd ask for advice. A lot of these scenarios are fairly routine and your senior clinical colleagues would be able to help. We advise on this sort of stuff all the time. The trust will have legal departments occasionally or access to legal advice on some of them more, more complex situation. So it it really depends on the facts of each case. But those are the elements that can sometimes be drawn into it. And as I say, I'm talking about, you know, how things would work in the, in the UK. I know in the principle of medical confidentiality can be much more absolute in other countries. Uh I had another question. It was uh regarding the chaperone or not just chaperone. It was uh uh regarding, can you hear me, sir? I can hear you. Please go ahead. Yes. Yes. It's, uh, like, uh, just today, one of my, uh, my parents, uh, told an incident because, uh, in India there is an incident right now which is, uh, regarding the sexual harassment of the wrestlers, the national athletes, wrestlers. And this raised like we were having a conversation and this raised the topic that we had a doctor. Uh, I don't know whether he's alive or not and he was a very professional doctor. Just a GP in Indian. Like no professional, just a GP. And he, uh, she said, like, uh, when he used to take, uh, like investigate, like, uh getting a stethoscope, auscultating and everything, like while, while my mother was getting treated, he used to say that he used to allow the male member to be right there itself. Uh, because usually it's just doctor and patient and they should be, there should be a confidentiality between them and they should know. But it's regarding, if there is a woman like the doctor itself, him himself is a me. But if it's a woman and uh there shouldn't be any allegations regarding uh any misconduct or misinformation or misinterpretation of any, any examination and, or any chaperone, the doctor us usually used to alive uh uh allow a male uh member to be present by this. For example, it's a woman then has her, he used to tell, no, tell her her, her husband to be present at very moment when the examination is taking place, should this be allowed? Because at sometimes you used to say no, there should be no one when the doctor and patient should be there. But sometimes for the sake of the safety of the doctor itself so that there won't be any misinformation or misinterpretation of any touch or any misconduct, the member, family member, um usually the male member should be allowed to be present there because if it's a kid, like it's a child, parents, any parent should be there. But if it's a woman for a male doctor, allow the male uh partner or the father or the husband to be right there and tell them everything, uh what examination is going to be and what is going to happen. So I think there's a few different things there. And again, I can only speak about, you know, practice in the UK. I think the issue of whether a family member is present is a separate one from an issue of a chaperone. Ok. So a chaperone has a very specific purpose to assess whether to support the patient. A but B to assess whether the examination was done was done in the way it typically should be for that type of intimate examination. So here there is a requirement to offer a chaperone. And again, I would emphasize it's irrelevant if the doctor is female and the patient is female, we have seen allegations made by female patients with female doctors or even male patients towards female doctors. So be mindful of that. Ok. Now, whether a family member or is present with an adult patient really depends on the wishes of that patient. Most often they may say, well, I want my partner to be here. Um You know, I want them to be here. I want them for support. I want them to listen to what said because I won't remember it all. Um There are sometimes where circumstances where you're concerned that there may be an abusive relationship or coercive control something like that where you may not want the partner there and may want to say, you know, to have a discussion with the patient on their own. Now, those are sensitive and difficult scenarios, but it it really depends. But I'd say conceptually I'd separate the separate out the issue of chaperone from whether somebody is present. Um and, and you know, think through each of the scenarios that you get sorry doctor there's a question in the plant. Oh, yes, I see. This is what if the patient has an STD? Can we tell their partner? Um It depends most of the and I should say the GMT does have separate guidance about communicable diseases, et cetera as well. Most of the, in terms of an STD, some of them are notifiable diseases. So you would make the notification for, to um essentially the public health service who would deal with issues such as contact tracing in other circumstances, whether you can disclose or not on that setting really depends on a risk assessment. So, you know, and the threshold is set as the public interest test. So essentially, if you think a failure to disclose, would put somebody at the risk of death or serious harm, then a disclosure might be justified. Now, in that setting, I think there are two elements. OK? So there's the clinical risk assessment about transmission and risk and you know, you may be able to do that or you may need to get special advice for that. Now, as I say in my past, live as a hepatologist, we get questions about the transmissibility of things like hepatitis C, et cetera. Um And then you've also got to think about, well, look, if the person gets a condition, is it treatable, et cetera? It's not simply the presence of a risk of transmission that allows you to share information about an STD. So again, I would say there is guidance on that. It really depends on the clinical risk assessment consequences and whether it's appropriate. And it's, again, it's something you can seek advice on and there is guidance there. So how to deal with an aggressive patient, refusing to give enough information during a history taking. Well, sorry, I know we've got a couple of minutes do tell me if you want me to, to sort of stop again. I think that it's obviously different from what we've been talking about today. But there's a couple of things. Most organizations if you start working in the UK will have some mandatory training about dealing with violence and aggression. It is largely focused on deescalating the situation and managing your own safety. Some services will be set up with panic alarms and room structures and things to stop you getting trapped in a room, et cetera. So be mindful of your own safety, first of all. So be mindful of that, an aggressive patient during information during history taking world, you can't force them to give you information. You need to keep a careful record of what information is limited. If there are other members of the team, if they've got a personal beef with you, might somebody else be able to get more information out of them. Um Otherwise, you know, can you let them calm down, can you explain to them why you need the information you need? I'm assuming you've gone through all those maneuvers to try and calm the situation down and get that. But otherwise, if it's not an issue of a risk to you immediately, it's simply just somebody being difficult, then I think you need to keep careful records of why the history was limited and what questions they've refused to, to answer because that will obviously be the context in which you've made decisions about their care. So I think we're pretty much up to time. I can't see any other questions unless you've spotted one um doctor. Would it be ok if people email you questions, if you share your email address or maybe lecture, if um yeah, I'll ping you, I'll ping you my email if they've got other other questions. That's uh that's no problem at all. Would it be ok? Could you write it in the chart, please? So people um let me see if I can do that. Oh, sorry, I'm not. Yeah. Oh, sorry. Yeah, sorry. I've got it on my other screen, on my other screen. There we go. There we go. That's great. Thank you very much. No problem. Thank you. And hopefully we're at time. Yeah, that's perfect. Thank you. That's exactly on time. So, looking forward to your next lecture and thank you for an amazing lecture today. It was an honor to have you. Thank you. Great. Thanks for the invitation and good luck, everybody.