Based on the the ALSO (American Academy of Family, 2006) and the very good medical book of Simon C., et al, Oxford Handbook of General Practice, Oxford Medical Publications, 2nd edition, 2005. www.oup.com

A. GOOD MEDICAL PRACTICE

About 80% of the patients are satisfied from their GP, however completely satisfied (e.g. according to information, communication and so on) are less than 50%. More than 50% of the information (that can reach 90%) can be lost a few minutes after they depart from the doctor’s office. Patients usually remember better what they believe is more important and find more easy to understand and its important, and if the information was given in the beginning of the session and ‘in small pieces’ instead of all at once.

It is important the doctor not to speak with medical jargon and to be simple and brief giving extra information from brochures and leaflets, diagrams and pictures. About patient’s compliance, only 1/3 of the patients follow doctor’s advice so that it is effective. Another 1/3 follow some advise but not adequate enough in order to be effective. The rest 1/3 don’t follow the doctor’s advice at all.

The prescribing rate many times is unnecessary high. A good medical practitioner needs high capability to detect the diseases (including psychological), empathy for the patient, verbal and non verbal communication skills (such as eye contact). Also a good doctor needs to ask open and not close questions (i.e. with answer yes or no) and to combine patient’s complaint with appropriate physical examination and appropriate (and not unnecessary) laboratory or imaging test results (e.g. X’ Rays or CT) in order to make one or more possible diagnosis and different diagnosis. According to the above, medical performance isn’t the same to every doctor.

The keys for good medical practice are: 1) A right diagnosis. 28% of the diagnoses are wrong. 2) An appropriate prescribing. 3-5% of the prescriptions have mistakes. 9% of the hospital admissions have to do with problems with prescriptions. 3) Communication. 40% of patients buy drugs that were different from those that were discussed and prescribed. 4) Organizing changes. The posts have to be assigned to the medical practitioners that will fulfill them with the best way and are competent for their role. 5) Teamwork and team leader who will guide the team members. 6) Personal factors such as knowledge, skills, competence and psychosomatic health. 7) Use of protocols, guidelines, algorithms, Evidence Based Medicine (and Cochrane) and accurate appropriate and not unnecessary lab or image tests. 8) A plan with objective targets and appropriate actions for its achievement. 8) Continue study, appraisal, revalidation and correction of the personal and team performance, so to be the best according to the plan. Effort for improving. 9) Good clinical care. 10) Relation with the patient. To communicate, to listen their view, to use information and terms that the patient understands, to respect privacy and dignity. 11) Good and adequate communication and corporation between colleagues. 12) Dignity and sincerity. To be open in everything and to avoid conflicts between personal and occupational roles. 13) Research. 14) Governance.

Good medical practice emphasizes that the doctor needs to have the patient’s care as first priority, to communicate with the patient kindly and with empathy, to respect the patient’s dignity and privacy, to listen the patient’s opinion and to respect it, to inform the patient with a comprehensive way, to respect the patient’s right to totally participate on the decisions about his/her health, to have updated and contemporary knowledge and skills, to recognize the limits of his/her skills, to be sincere and reliable, to respect and protect the confidential information, to ensure that his/her private opinion does not affect and prejudice patient’s care and to protect the patient of the risk of being treated by a colleague with inadequate skills and non capable for good medical practice.

The doctor needs also not to abuse his/her position as a medical practitioner. Furthermore the doctor needs to cooperate adequately with his/her colleagues for the best interest of the patient, not to make an unfair judgment for the patient or a colleague and finally always to be ready to justify his/her medical actions to his/her colleagues.

GMC in the UK performs annually appraisal and revalidation for all the doctors who practice in the UK, and from 2009 the standards will be more demanding. It is important for all doctors to be well informed and always their medical knowledge to be updated (and to prove it in order to be revalidated), to have an excellent bed side manner and to follow all the rules of good medical practice (GMP). A doctor can be erased from medical register in case of poor performance especially if followed by lack of insight.

According to GMP the following are essential:
• Well informed and updated medical knowledge.
• Successful working relationship - communication and teamwork.
• Supporting colleagues (and in general the hospital staff), listening their problems and helping them in case they are facing difficulties.
• Treating colleagues (and rest hospital staff) with respect: patronizing, ignoring, bullying, harassing, discriminating, being aggressive or disrespectful and threatening are all unacceptable behaviors.
• Taking up a post when they accept it.
• Reporting colleagues when their conduct, performance or health putting patient’s safety at risk.
• Good bed side manner and communication with patients. Any kind of manner such as ignoring, discriminating, being aggressive, disrespectful or not being polite are all unacceptable.
• Sharing information with colleagues and helping them improve.

B. MALPRACTICION

Usually medical mistakes are dialed with the attribution of the personal responsibility but with this way we don’t face the real reasons of the problem. However the first priority is to deal with the litigation instead of ransacking to the problem. This reminds us the aircraft accidents on the beginning of the last century where the responsibility was contributed to the dead pilot. However most problems are multifactor. Today it’s emphasized that the team work is very important for recognizing and correcting any mistake, in addition to the traditional prelacy of the team that discouraged the report of the opinion of the subordinate members of the team. There is also clear that the covering up of the problem doesn’t help.

The medical performance is related to the automatically and unconscious skills of the doctor (like the driving of a car), the dealing with problems based to memory rules (such as the algorithm ABC on CPR) and the skills to deal with new problems using analyzing skills or a PC program.

The medical mistakes happen because of a lapse of automatic process because of tiredness, stress, alcohol, drugs, noise etc. For example the doctor writes a wrong way of giving a medicine (e.g.IM instead of IV). Other times the doctor uses a wrong rule for a problem because he/she lacks experience or he has doubts or he is confused. Also he/she may make wrong conclusion for a problem based on the information e.g. on a 3rd trimester pregnant to contribute right quadrant pain to chololithiasis or pyelonephritis instead of including HELLP on the different diagnosis.

The doctor always has to listen his patient and built a mutual confidence, accept the patient’s and patient’s family aspect, culture and national background and their expectations and has to understand their stress and perhaps anger. The doctor has also to be able to deal with any problem that may rise, to discuss for alternative solutions, to have an accepted plan and to value the patient’s opinion about his/her health, worries and anticipations. Patients need to keep some control on the decisions that refer to their health and perhaps can refuse a specific therapy or surgery.

In case there is a disagreement between the doctor and the patient, then the doctor needs to refer the patient to another doctor soon. The doctor is always essential to inform the patient’s file if the patient understands the possible consequences of his/her denial to continue the proposed therapy and what are the limitations on the therapy plan according to the patient’s disagreement.

Team work increases patient’s satisfaction. The team must needs always a leader, the most experienced doctor. It’s also essential to encourage the team members to express (and not depress) their opinion and to discuss the plan for the patient’s care. It’s also essential to do often drill and practice to be ready for any problem.

Team work makes more effective the health care. The doctor must inform the personnel if we have to be absent for awhile. Personal conflicts, competition and prejudications – stereotypes about the role and skills of the team members (e.g. about nurses) and about dealing with the problem are obstacles to the adequate function of the team. Another problem is when the personnel number is inadequate.

When a disagreement arises then avoid accusing someone for a problem or mistake. Focus in the problem and its solution. Mutual insults make things worse. Find solutions with mutual benefit and insist to objective criteria. An accepted from all solution is easier. Team members need to avoid being intransigent. Team members have to focus in the problem and not in showing off their opinion. They have to be open to new information and possibilities.

You can ask an advice from another doctor in case the patient wishes to, or if the patient and/or his/her family aren’t satisfied. Also you need a colleague’s advice when the patient is critical ill and not improving or there isn’t a clear diagnosis or when you need more skills or knowledge from an experienced colleague. Then ask your patient if he/she wishes a specific doctor, if not you can recommend someone, but without prejudicing the patient about the other doctor’s skills or character, or about what the colleague will say. You need to encourage patient’s confidence to your colleague, but without praising or make judgments about him/her.

You do not need to call urgently your colleague unless it’s an emergency. You have to give your collage adequate information about the patient’s case. Chose if you need just an advice or to totally take over the patient. The doctor that is asked to give his advice has to cooperate with the patent’s doctor, to give his opinion written and clear, to discuss with the patients doctor about the further plan and to encourage the patient’s confidence to his/her doctor. The doctor that is asked to give his advice mustn’t steal the patient and must not refer the patient to another doctor without discussing with his/her doctor.

The usual reasons of malpractice and insufficient care is the failure of the less experience personnel to refer to a more experienced personnel or hospital, the failure of the most experienced doctors to deal with the case, the unclear or insufficient instructions for dealing with the patient, the insufficient team work and the failure of the senior doctors to recognize that the case isn’t their specialty or to ask an advise soon. The usual mistakes have to do with a wrong diagnosis or a non diagnosis of a condition (e.g. DM on a pregnant), the insufficient therapy of a medical problem or its complications and the insufficient observation of the patient’s condition.

In conclusion, the following things will help you to be more effective and avoid malpractice: Have a good communication with the patient, give to your patient time and explain your patient about his/her condition, the test results and the therapy plan with clear, not jargon, words. The patient has to consent for the therapy plan after adequate information. You need to have adequate knowledge and skills and to know your limits and sufficiency and if you have adequate experience and training. So perhaps you need to ask an advice or to refer the patient to a more experienced colleague. Also very important is to complete patient’s files adequately, because you may need them in litigation. Do not forget when you fill your files to refer to date and time and to sign in. Avoid not clear terms (e.g. asphyxia).

In case of mistake you have to recognize it on your patent. The most usual reason of litigation is that the patient thinks that his/her case will be covered up. You need also to show empathy and compassion and remember that always a litigation begins from a patent that is unsatisfied. Rarely patients press charges on a doctor that they like and believe he/she cares for them. Finally, it is essential to have a good communications with the rest team members.

REFERENCE

1.ALSO, American Academy of Family, 2006.
2.Oxford Handbook of General Practice, C. Simon, H. Everitt, T. Kendrick, 2nd edition, Oxford University Press, 2005.
3)GMC today, 20, July/August 2008.