The workplace based assessment element of GP training is designed to test trainees’ competence in 13 key areas, one of which is ‘maintaining an ethical approach to practice’. But how can trainees best present evidence of their learning and development in this area?
This article discusses the ‘four quadrants’ approach, developed by the Americans Albert Jonsen, Mark Siegler and William Winslade in the early 1980s to help doctors structure their thoughts about clinical situations that raise ethical questions. This systematic approach to ethical decision-making has become known as Jonsen's grid.
Jonsen, Siegler and Winslade identified four 'topics' that are present in every clinical encounter:
- Medical indications
- Patient preferences
- Quality of life
- Contextual features
Focusing discussion around these topics gives doctors a way to organise the facts of the particular case.
A trainee's reflective learning log below is provided to illustrate how Jonsen's grid could be used to sort through a case and connect the circumstances of the case to their underlying ethical principles. In this example, the trainee is applying the grid to a non-clinical scenario.
Reflective learning log
Subject title: A hard day at the office
What happened? My 38-year-old sister-in-law telephoned me on Sunday. She was scared and wanted support in her first, much awaited pregnancy. She had presented to her GP with bleeding in early pregnancy on Friday and he had arranged a scan at the hospital on Monday (tomorrow). She asked if I could accompany her to the hospital. I explained that I was scheduled to do a duty doctor shift and Mondays are extremely busy.
My husband, overhearing this, said I had covered for colleagues on several occasions in the past, so I should approach my colleagues, which I knew would be an unpopular move. My husband felt that his sister, who rarely asks much of us, wouldn't have approached me if she felt she could have turned to anyone else. He felt in this case, charity should begin at home.
What, if anything, happened subsequently? I texted my clinical supervisor who called me back. She tried to arrange a swap but nobody else could cover the duty day at such short notice. My sister-in-law was disappointed but understood. My husband was cross with me. I was distracted during my duty doctor shift and felt quite resentful towards some patients. I kept thinking, 'You are wasting my time. I am needed elsewhere’.
I know that I have a care of duty towards my patients but I also feel that I have responsibility towards my family. I experienced a conflict of interest. The GMC states that I should make the care of my patients my first concern, but it also says that if I am distressed, I should act quickly to protect patients from risk if I have good reason to believe that I may not be fit to practice.
What did you learn? I had recently learnt about the four quadrants approach to ethical decision-making but this had been used for a clinical case. I decided to apply it to my situation.
What are the medical indications (beneficence and nonmaleficence): My sister-in-law was, at worst, having a miscarriage. She wanted me present to support her; her medical team would be providing care. Medically, management was straightforward. Emotionally, this was a much wanted baby and she didn't want her parents to know and mourn. Had I attended, I would be the least emotional family member and, as a health professional, a trusted guide. If I didn't attend, she would bear the burden of grief and decision-making with more emotional, less expert family members.
My patients have medical needs and I cannot abandon my responsibility to them. Leaving the practice short-staffed puts patients at higher risk than normal.
What are the patient preferences (respect for autonomy): My patients (who consulted me in duty doctor clinic) would have preferred a doctor who was capable to setting aside their personal distractions and who got on with the job. Had my personal life intruded into my ability to make clinical judgements, and their care could have been jeopardised, I assume that they would have preferred that I declared myself unfit to practice and that alternative care is provided.
What is the effect of the proposed intervention on the quality of life (beneficence; nonmaleficence and respect for patient autonomy): Not doing duty-doctor clinic, or doing it to lower than usual standards, could adversely affect several patients and potentially damage several therapeutic relationships. Doing the job well, at first encounter, would benefit patients, me, my team and possibly utilise limited NHS resources more effectively. By not being with my sister-in-law, my family would be disappointed but safe.
What are the contextual features and other relevant factors (loyalty and fairness): My sister -in-law and my husband may have felt that having a doctor accompany her might give her better care. While I cannot say this would have been the case, I acknowledge that clinicians, like all people, do have prejudices and biases that could influence decision-making and resource allocation. However, on the issue of resources, my medical knowledge and skill is a resource and I am paid to provide this for my patients.
By using Jonsen's grid, I systematically worked through my dilemma. It helped me to resist my 'gut temptation' and I soon realised that my resentful feelings towards patients, while human, were also quite immature, petulant and potentially damaging.
I was able to apply Jonsen's framework to a non-clinical case.
What further learning needs did you identify? Like all models, this four quandrant ethical model should become easier to apply when practised. I need to practice, perhaps in case-based discussions or in future learning logs.
At what point will I consider myself, in the words of the GMC, 'unfit to practise'? Being ill and physically unable to practise is one scenario but what happens when I have poor sleep, because I am anxious or I am kept awake by a sick family member? How would I feel towards a colleague who declared herself unfit to do duty doctor because her sick baby kept her up all night?
As an educationalsupervisor, I would cite this reflective entry as evidence for the domains ‘Maintaining an ethical approach to practice’; ‘Fitness to practise’; and ‘Working with colleagues and in team’.
- Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP Paperback was published in January 2016.
- Jonsen A, Siegler M, Winslade W. Clinical ethics: a practical approach to ethical decision in clinical medicine. 6th ed. New York: McGraw-Hill, 2006.
- Sokol, D. How to think like an ethicist. BMJ 2010; 340: c3256.
- Schumann JH, Alfandre D. Clinical ethical decision making: the four topics approach. Semin Med Pract 2008; 11: 36–42.