General Medical Council Guidance Research Articles

WP1.10 - Are we Appropriately Consenting Patients for the Risks of Post Operative Urinary Retention following Groin Hernia Surgery?

Abstract Aims Consent is a fundamental process within surgery. General Medical Council (GMC) guidance advises that any recognised risks of harm resulting from a procedure should be discussed. Post-operative urinary retention (POUR) is a frequently encountered risk following groin hernia surgery, yet it can be missed when consenting. We aimed to review how frequently POUR occurs following groin hernia surgery in our hospital, along with how frequently it was consented for. Methods Retrospective data was collected on all patients undergoing planned groin hernia surgery in a single centre over a 6-month period between March and August 2023 . Data was collected on demographics, post-operative complications including POUR, and any other complications requiring hospital re-admission within 30 days. Consent forms were reviewed to identify whether POUR was documented as a risk. Results 128 groin hernia surgeries were carried out over the 6-month period. 13 patients (10.2%) experienced POUR, which was the most common complication in this group of patients. 7 of these patients did not have POUR documented as a risk factor on their consent. With only 46% overall having POUR documented as a risk factor on their consent. Conclusion Despite POUR being a common complication following groin hernia surgery, patients are often not being informed of this as part of the consent process. As over half of those patients who did experience POUR were not warned about this potential complication. Considering its frequency and potential impact on patients, improvements in consenting for POUR should be made.

Discrepancy between medical conditions self-reported by bus drivers and medical records.

Medical incapacity at the wheel is a rare but high-profile factor in accident causation. The UK Driver and Vehicle Licensing Agency (DVLA) does not require a review of medical records on the application for a bus licence, but applicants sign a self-declaration of medical history. There is debate over what, if any, verification of medical information is required for doctors who complete the medical assessment. To assess how self-declaration compares against General Practitioner (GP) patient records for a series of bus drivers undergoing driver licensing assessment in a 12-month period. Review of GP reports received for bus driver medicals undertaken in a 12-month period between 1 July 2022 and 30 June 2023. Of the 145 medicals undertaken, 12 (8.3%) GP reports contained undeclared medical conditions that required further evaluation and may have impacted on fitness to drive. Studies into the contribution of medical incapacity at the wheel to vehicle accidents are sparse, as, thankfully, are the events themselves. Nevertheless, given the updated General Medical Council guidance to doctors on confidentiality and public protection responsibilities, and evidence to suggest that doctors' knowledge of the DVLA guidelines is poor, it might be pertinent for the DVLA to reconsider its approach to driver self-reporting in some circumstances, given the discrepancy highlighted here.

Adherence to General Medical Council guidance regarding disclosure of alternative treatments during the consent process.

General Medical Council (GMC) guidelines dictate that reasonable alternatives to treatment should be disclosed during the consent process. We aimed to determine whether GMC guidelines on disclosure of alternatives during consent are being followed in a real-world example which is disclosure of non-operative management as an alternative to appendicectomy in uncomplicated paediatric appendicitis. We undertook a retrospective single-centre observational study and national consultant specialist paediatric surgeon survey. Two groups of 50 consecutively treated children (<16 years) with acute uncomplicated appendicitis were included in the observational study during two periods. UK-based consultant surgeons who treat appendicitis were included in the national survey. The main outcomes were disclosure and use of non-operative management (NOM) as an alternative to appendicectomy. Overall, in the observational study, NOM was disclosed in 30 (30%) children and 77% (23/30) opted for this treatment method when it was disclosed. There were 83 survey respondents representing all 25 eligible specialist paediatric surgery centres. Ten (12%) consultants reported routinely offering NOM, 39 (47%) offer it in select circumstances, and 34 (41%) never offer NOM. Only 25 (30%) respondents always disclose NOM as an alternative to appendicectomy, whereas 22 (27%) never do. Consultants who never disclose NOM are more likely to prefer appendicectomy over NOM compared with those who always disclose it (p<0.001). In this illustrative clinical scenario, observed and reported practice regarding disclosure of alternative treatments during the consent process do not meet GMC guidance. This risks depriving children and caregivers of a choice that they are entitled to.

Audit on the Adequacy of Consenting Practices for Neck of Femur Fracture Surgeries.

Doctors are bound to obtain informed written consent prior to any form of surgical procedure on a patient. The General Medical Council (GMC) and the Royal College of Surgeons of England (RCS) provide guidance on what constitutes valid consent. Failure to obtain valid and adequate consent can have legal ramifications. All relevant material risks associated with the surgery must be discussed with the patient during the consenting process. This was a retrospective cross-sectional study of the consenting practices for neck of femur fracture surgeries, covering a period of three months, from the 15thof April to the 15thof July 2023. We evaluated the consent forms of 100 patients, of which 63 were consent form-1 and were included in the study. The British Orthopaedics Association (BOA)-endorsed consent forms, together with the RCS and GMC guidance on consent, which were used as the standard for the audit. The majority of the consents were obtained by senior house officers (SHO) and core surgical trainees who did not have prior formal orthopaedic training (52.4%). The risks that were most frequently documented were infection, blood clots (deep vein thrombosis and pulmonary embolism), and bleeding, with documentation rates of over 90%. Prosthetic joint dislocation following hemiarthroplasty or total hip replacement was not mentioned in 22.2% of the forms. Neurovascular injury was not documented in 20.6% of the consent forms. Less than 75% documentation rates were observed for postoperative pain (74.6%), anesthetic complications (73%), failure (malunion/non-union/loosening of prosthesis) (68.3%), leg length discrepancy (60.3%), bone damage/fracture (50.8%), death (49.2%), wound-related complications/scars (42.9%), and hip stiffness (14.3%). None of the patients had been advised about the probable need for catheterization following surgery. We also noted that 22.2% (n=14) of the consent forms did not contain the diagnosis or the indication for surgery, 12.7% (n=8) did not mention the intended benefits, and 28.6% (n=18) of the consent forms had no mention of the responsible consultant.We also noted that in 25.4% (n=16) of the cases, the possible requirement of a blood transfusion had not been mentioned. The audit revealed several deficiencies in the consenting of patients for neck and femur fracture surgeries. There were poor documentation rates for risks associated with surgery, especially the less common and rare ones. We also identified several deficiencies in the remaining aspects of the consent forms that were not in keeping with the GMC and RCS guidance on consent. The lack of orthopaedic training and knowledge among the senior house officers and core trainees may be a contributing factor.

Challenge of achieving truly individualised informed consent in therapeutic endoscopy

ObjectiveGuidance covering informed consent in endoscopy has been refined in the UK following the obstetric case of Nadine Montgomery, and in light of updated General Medical Council guidance. All risks...

A61A comprehensive training programme for Medical Support Workers at a large teaching hospital

The Medical Support Worker (MSW) programme enables International Medical Graduates (IMG) and refugee doctors to support clinical teams, whilst General Medical Council registration is gained [1]. North Bristol NHS Trust, a large teaching hospital in South-West England, has designed and implemented a novel training programme for a second cohort of 30 MSWs. A comprehensive learning needs assessment informed the content of the programme. Learning needs were identified from two probing questionnaires and reflective pieces, completed by 22, 27 and 29 MSWs respectively; alongside Health Education England and General Medical Council guidance [2, 3]. Four principal areas were identified- (1) Communication, (2) Portfolio Development, (3) Career Development, (4) Preparation for work in the NHS. A subsequent teaching programme consisted of simulation, human factors, communication and ethics training, alongside community theatre delivered communication skills, interview preparation practice, portfolio training sessions and a specifically tailored lecture series. The programme was evaluated using two delayed surveys, formed largely of Likert scale questions, completed by 25 and 17 MSWs. Communication, social skills or cultural change were highlighted as the biggest challenges by 64% MSWs. Only 48% of MSWs felt confident working in the NHS. Confidence in managing emergencies, sensitive discussions, presenting cases, and updating relatives was low (0-35%). 75% requested teaching in assessing acutely unwell patients and decision-making. 60% wanted to improve teamworking skills. : Confidence working within the NHS rose from 48% to 92%. 100% of MSWs reported that the teaching programme helped them prepare for work as doctors in the NHS. There was a greater understanding of the structure and function of the NHS, the role of allied healthcare professionals, plus the portfolio and professional development requirements of doctors (92%). 100% of MSWs felt their communication skills had improved. 87.5% reported increased confidence with informal conversation and 100% reported increased confidence in voicing opinions and raising concerns. Additionally, 100% of MSWs reported increased confidence recognizing and assessing acutely unwell patients. Confidence in managing emergencies, sensitive discussions, presenting cases, and updating relatives improved (60-88%). This well-received, novel programme addresses some of the unique learning needs of MSWs and helps them prepare for work as doctors in the NHS. Collaborations with other trusts are taking place to establish whether the programme could be adapted for IMGs more broadly. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Esthetic Clinic Management Software—Can we improve patient safety?

To evaluate the features of esthetic-specific Clinic Management Softwares (CMS) and scrutinize these against the General Medical Council (GMC) and Joint Commission (JC) guidance, an indicative CMS framework with GMC and JC compliant features is developed, to improve patient outcomes, service quality, and work toward a centralized database for complications to enable research analysis. A systematic search was performed to evaluate the CMS on the market tailored to esthetic clinics. An analysis was made of the GMC guidance for record keeping and the JC standards for Patient Safety Systems. The CMS features were each scrutinized against the GMC and JC guidance including complication capturing. Eighteen esthetic-specific CMS were identified and analyzed. None of the included CMSs were 100% compliant with both GMC and JC guidance. In 2022, the mean monthly cost of the basic packages for each of the CMS was £106.4, with a standard deviation of £83.3. The main users of the CMSs were doctors and nurses. CMS are a potentially powerful tool to form a centralized database that will allow for increased transparency on the number of procedures performed as well as complications.

Undergraduate teaching of surgical skills in the UK: systematic review.

Students must be proficient in surgical skills according to General Medical Council and Royal College of Surgeons of England guidelines. If these skills are not appropriately taught, there is a risk of an incoming junior workforce with inadequate surgical skills. This paper aimed to review the literature relating to undergraduate teaching of surgical skills in the UK and summarize future suggested training methods. The databases MEDLINE, Embase and SCOPUS were searched, and the existing literature relating to methodology of undergraduate teaching of surgical skills in the UK over the past 10 years was summarized. The Medical Education Research Quality Instrument was used to assess research quality. A total of 19 papers were included. Cross-sectional evaluations and survey-based studies highlight a clear deficit in surgical skills teaching in the UK. Medical students are currently unable to fulfil their own learning needs and meet requirements set out by the General Medical Council. This lack of surgical teaching appears to negatively affect student desire to pursue a surgical career. The three main themes for improvement are extracurricular surgical skills days, near-peer teaching and simulation. Each method appeared to improve learning, although no studies utilized medium- to long-term follow-up to demonstrate efficacy and there lacks a clear consensus as to the 'standard' of undergraduate surgical skill education. There was also potential for selection bias and response shift bias in many of the studies assessing pre- and postintervention confidence and opinions. There is a concerning lack of surgical skills teaching that has resulted in medical students and junior doctors not having the necessary surgical skills as per General Medical Council guidance and students feel that their own learning needs are not met. This failure to address the learning deficit may be responsible for the fall in surgical competition ratios. While surgical skills teaching must be improved urgently, more robust evidence is required to evaluate the optimal ways of approaching this issue.

DE02 Honing in on clinician needs: a grassroots development of an educational resource for dermatologists

Abstract Keeping up with the influx of scientific research papers can feel overwhelming, especially alongside busy clinical responsibilities. A PubMed search of the term ‘dermatology’ produced 29 565 results for 2021 alone, and, consequently, clinicians face spending hours a week scanning journals just to stay up to date. This is coupled with increasing clinical demand due to rising waiting lists and skin cancer pressures. Innovative solutions to the problem include regular newsletters, which have been proven to be an effective tool in medical education in other specialities (Kolli A, Nguyen A, Portney D et al. The Lens: can a weekly newsletter improve medical student knowledge of the ophthalmology literature? J Surg Educ 2021; 78:1905–14). To address this challenge in dermatology, we created a newsletter to make dermatology research more accessible. Two consultant dermatologists created a system whereby clinically relevant articles are chosen following a review of ∼30 journals. These are condensed into short clinical summaries, containing relevant findings, limitations and applicability, emulating a journal club style. This was initially distributed within our local hospital, but the team and readership have since expanded. From January 2022, in addition to the written newsletter, a freely available podcast for each newsletter was created giving an opportunity to learn on the move (e.g. while commuting). At 12 months, the newsletter has 206 subscribers, and the podcast has achieved 810 total plays (with download locations ranging from the USA to India). More recently, we have reached new audiences via Instagram, with 1700 views and 123 likes of the content thus far. A survey was distributed to current subscribers to determine the usefulness of the newsletter as an educational resource. Eighteen responses were received, and 100% agreed that they felt more informed on recent publications in dermatology from reading the newsletter (83% strongly agreed; 17% agreed). In addition to this, 100% felt that the articles chosen were relevant to their clinical practice (78% strongly agreed; 22% agreed). Feedback included comments such as ‘it is a great way to keep informed on recent publications that may be of interest’ and ‘super useful bite-sized information’. The General Medical Council guidance on Good Medical Practice requires doctors to ‘keep professional knowledge and skills up to date’. We feel the interest in our grassroots journal club publication and the survey results (with all our respondents feeling more informed on dermatological research, particularly with articles relevant to their clinical practice) highlight an unmet need for accessible educational resources to enable busy dermatologists to become aware rapidly and efficiently of the latest clinical developments.

Abstract No. 527 Audit of the consent process in interventional radiology and patient perspectives

The current guidance on pre-procedural consent from the General Medical Council (GMC) recommends a two-stage process (1). In many interventional radiology (IR) departments in the UK, patients are consented on the same day of their procedure, often immediately prior to their procedure, in breach of GMC guidance. The aim of this two-cycle audit was to evaluate patients’ perspectives on consenting processes in an IR department.

Emotional Intelligence and Good Medical Practice: Is There a Relationship?

Emotional intelligence (EI) is defined as the ability to perceive and manage the emotions of oneself and others. Despite being one of the most highly used psychological terms in popular nomenclature, its understanding in the context of clinicians remains poor. There is a dearth of literature on this topic, and this submission examines the relationship between a clinicians’ EI and the key domains of “Good Medical Practice” guidelines from the General Medical Council, United Kingdom. It aims to review and critically analyse the existing literature on EI and Good Medical Practice while attempting to establish a relationship between the two.This submission thus examines the relationship between emotional intelligence and a clinician’s on-the-job performance. The findings demonstrate how emotional intelligence can aid the clinician in all aspects of their working life in the context of practising in line with General Medical Council (GMC) guidance. The authors also recommend exploring the possibility of inclusion of EI within a modern medical curriculum, as it may lead to improved practice in clinicians.

Vascular Surgery Curriculum 2021: the trainee perspective

The 2021 iteration of the Vascular Surgery Curriculum represents the first major change to vascular training since being awarded separate specialty status by the General Medical Council (GMC) in 2013.1 Developed following the ‘Shape of Training’ review and in light of updated GMC guidance on postgraduate curricula, the new curriculum aims to specify the professional standards and clinical capabilities required to provide trainees with the competencies to be a day 1 consultant vascular surgeon in modern clinical practice.2,3 The process of transition started in August 2021, with all trainees migrating to the new curriculum by August 2023. From a trainee perspective, the new curriculum offers a number of positive changes which should improve the process of working towards certification.

108 Neck of Femur Fractures: Streamlined Approach to Improve Consenting Practices

Abstract Aim Neck of femur fractures (NOFs) are synonymous with frailty, and successful outcomes are achieved with operative fixation. The United Kingdom’s General Medical Council guidance governing consent highlights the importance of thorough pre-operative discussion of risk with the patient. We aimed to audit consenting practices in NOF patients within our unit against the British Orthopaedic Association’s (BOA) criteria, with the addition of delirium as a risk factor. Method In cycle one all operatively managed NOFs over a two-month period in October-November 2019 were retrospectively reviewed. Consent forms 1 (CF1) and 4 (CF4) were assessed against BOA-endorsed criteria. Our intervention included a standardised sticker detailing 14 important risks was introduced and a departmental seminar on delirium. A second cycle was undertaken from August-October 2020 to close the audit loop Results No consent form documented all BOA-approved risk factors in cycle one (N = 35). Of cycle two’s 35 patients, 70.8% CF1 were completed using the novel sticker. All of these had 100% BOA-approved risk documentation. Consent forms without the sticker in cycle two documented 9/14 risks (mean value). No CF4 had any risks documented in either cycle. Delirium was documented in 51% in total and in 75% patients with CF1. Delirium documentation improved from 2.9% in cycle one to 51.4% in cycle two. Conclusions Clear lapses in operative consenting processes were identified, especially regarding delirium and CF4 documentation. The introduction of a novel consent sticker drastically improved compliance with BOA guidance for CF1. Recognition and departmental education regarding delirium significantly reduced incidence between cycles.

Changes in 2020 to General Medical Council guidance on consent.

Changes in 2020 to General Medical Council guidance on consent.

Work-life balance in medical students: self-care in a culture of self-sacrifice

BackgroundWork-life balance is a key contributor to doctors’ wellbeing and consequently is a central factor in their career decisions. General Medical Council guidance outlines the importance of work-life balance as part of compassionate self-care. Learning self-care should begin as an undergraduate, when academic and clinical workload can contribute to stress, anxiety and burnout.MethodsSequential mixed methods study of medical students in Years 3–5 at the University of Birmingham, UK. Students (n = 145) defined work-life balance in free-text answers and self-assessed their current work-life balance via questionnaires. Following this, a sub-sample of students (n = 44) participated in exploratory individual mini-interviews.ResultsWork-life balance emerged as a broad and multifactorial concept. Questionnaire respondents most frequently referenced enjoyment, meeting work requirements and time management in their definitions. Interview participants highlighted additional influencing factors such as peer groups, study skills, family and professional culture. Students expect a significant shift towards work after graduating and expressed concerns about the stresses of delivering patient care. 42% (n = 60) of students felt they had received support with their work-life balance during their training, mostly from family and friends. Most students had not received support or advice on their work-life balance from University or hospital staff.ConclusionSelf-care and work-life balance are essential for medical students and doctors to cope with lifelong learning and deliver effective care. Medical school staff should be pro-active in supporting students to develop these skills, particularly during critical transition periods. Early interventions targeting study skills and time management may be beneficial. Further research should include students in Years 1–2 and compare different institutions.

Telemedicine during COVID-19: a survey of Health Care Professionals' perceptions.

The National Health Service (NHS) has rapidly adopted telemedicine solutions as an alternative to face-to-face consultations during the COVID-19 pandemic. The majority of HCPs (Healthcare Professionals) were unfamiliar with Telemedicine prior to the current pandemic. Remote consultation is expected to continue for the foreseeable future, thus we designed this survey. A survey designed to evaluate the use of telephone consultation by HCPs, assessing its implementation, challenges and drawbacks. A web link survey conducted through SurveyMonkey was sent to HCPs across six UK Trusts the period of May 2020. The survey received 114 responses (84%) being doctors. 95% of respondents had not received training prior to engaging in telemedicine consultations. 64% were unaware of the updated General Medical Council guidance concerning remote consultations. The most common barrier in remote consultation was the inability to access patient records raised by 37% of respondents. However, 73% of respondents felt that patients understood their medical condition and the instructions given to them over the phone, and 70% agreed that videoconference consultations would add to patients care. Telemedicine can be used for selected groups of patients in the post COVID-19 era, and the HCPs carrying that should have the sufficient experience and knowledge expected to operate these clinics.

Updated GMC guidance on decision-making and consent: implications for urologists

We summarise the updated General Medical Council guidance on consent and decision-making. We explore the emphasis on enabling supported decision-making and the implications this has in day to day urological practice. In particular, we address some of the issues encountered in one-stop clinics, on pooled elective lists and with pre-written consent forms. The new guidance will emphasise the importance of sharing information relevant to your patient in light of the Montgomery ruling. Every decision is unique. We must appreciate the importance of the process of decision-making and understand our role as the clinician. Here we suggest some practical considerations to address the updated General Medical Council guidance. Level of evidence: Not applicable.

Responsiveness and the Role of Rights in Medical Law: Lessons from Montgomery†.

Over time, medical law has moved away from paternalism in favour of an approach grounded in patients' rights. Using Montgomery v Lanarkshire Health Board (2015) as a case study, we offer a deeper analysis of this emerging approach. We argue that patients' rights should be evaluated in terms of their contribution to making medical law more socially responsive, by developing it to give effect to social needs and aspirations pertaining to health care. Although rights can play an important role in achieving social responsiveness, they also carry the risk of entrenching approaches unrepresentative of patients' actual needs and empirical realities. This is evident in Montgomery, where the law, despite being derived from General Medical Council (GMC) guidance, has effects that differ significantly from the GMC's goals. Drawing on socio-legal literature, we outline a new approach for guiding the use of rights in medical law focused on the functional consequences of rights in facilitating patients' aspirations, and the capacity of rights to respond to social and institutional contexts in which medical interaction occurs. We conclude by showing how this approach, applied to informed consent, would produce a different and arguably a superior duty, providing a sounder basis for responding to patient needs.

Embracing diversity: when is it OK to speak languages other than English in the consulting room?

It is well recognised that language is central to good communication in all clinical consultations. The national focus on clinical staff being fluent in English is important and proportionate. Recently, a midwife was suspended from the UK Nursing and Midwifery Council Register because of deficient competency in English1 until she is able to demonstrate that she has reached the necessary standard of English for safe practice.2 The General Medical Council (GMC) similarly expects all licensed doctors to: ‘… have the necessary knowledge of the English language to provide a good standard of practice and care in the UK.’ 3 For those European doctors who are not required by the GMC to pass a national English language test, the current GMC guidance states that: ‘To practise safely in the UK doctors must have sufficient knowledge of English.’ 4 So why, in Central Midlands, has NHS England felt it necessary to develop guidance for clinicians who may be tempted to consult in languages other than English? The answer lies in the language competencies of our international recruits to general practice in Lincolnshire and the patients who consult them. Lincolnshire, a predominantly rural county in the East Midlands of England, where recruitment and retention of GPs has long been a significant challenge to delivery for the NHS, is the site of an innovative collaborative approach to international recruitment into general practice. Since 2016, the Lincolnshire Local Medical Committee, working with NHS England and Health Education England (HEE), has recruited a cohort of 26 doctors from several European Union countries, all of whom were trained in family practice in their home countries and eligible for entry to the …

Foundation forum: developing leadership skills among foundation trainees.

Foundation forums have been adopted over the last few years to provide representation for newly qualified doctors, but they do not develop essential leadership, management and quality improvement skills for those recruited - key attributes that have been formally identified by General Medical Council (2012) guidance. A foundation forum was set up across three Oxford deanery hospitals. Forum members were assigned classical forum roles, but were also tasked to complete quality improvement projects, organize a national quality improvement conference, and undergo formal leadership and management training. Members were surveyed before and after completion of training, revealing statistically significant increases in confidence in leadership, management and quality improvement skills. All members revealed an eagerness to continue formal leadership and management training. The foundation forum proved a successful initiative to improve overall trainee experience and involvement, while providing a platform for leadership and management training to satisfy key domains within the Medical Leadership Competency Framework.