In many ways, some of the ethical issues medical students face during patient examinations are relevant to GP registrars.
A recent survey of 260 medical students in the UK revealed that over 80 per cent of those questioned said they had noticed patients feeling uncomfortable at their presence during an examination. Nearly 40 per cent felt that there were no adequate systems in place to obtain patients' consent to the presence of medical students.
Identify yourself as a registrar
The GMC's consent booklet, Seeking patients' consent: the ethical considerations, points out that before deciding whether to consent to treatment, patients may want to know 'whether doctors in training will be involved, and the extent to which students may be involved in an investigation or treatment'.
The MDU advises GP registrars to make their status clear, especially when meeting a patient for the first time.
It is important for patients to understand, for example, that you may wish to discuss the patient's management with your trainer. Also, the trainer may wish to see the patient personally.
Consent for using patient information and video
Careful consideration should also be given to confidential information relating to the patient, but not directly related to clinical care, and the extent to which this might be used for academic or training purposes. Such uses could include audit or case presentations.
The GMC states, in its booklet Confidentiality: protecting and providing information, that if patient-identifiable information is to be used in anything other than a therapeutic context, it is important to obtain the patient's consent for each separate use.
You also need to be aware of relevant GMC guidance if you wish to make video recordings of patients for training purposes. The GMC states in the booklet Making and using visual and audio recordings of patients: 'You must seek permission to make any recording for the assessment or treatment of patients... You should explain that a recording will be made, and why. You only need give an oral explanation. You should record in the medical notes that the patient has given permission.'
On a practical point, it may be helpful for registrars to see patients in pre-booked clinics, where they are told in advance that they will see a registrar. This allows patients to say if they would prefer to see another doctor and for that to be arranged (see case history).
In the case of emergency appointments or 'extras' that might be booked in by receptionists, it is still advisable to give patients as much notice as possible if they are to be seen by a registrar.
Dr Devlin is a medicolegal advisor for the MDU
This topic falls under Section 2 of the GP curriculum, 'The general practice consultation': www.rcgp-curriculum.org.uk/PDF/curr_2_The_GP_Consultation.pdf; www.rcgp-curriculum.org.uk/PDF/curr_2_The_GP_Consultation.pdf; and Section 3.3, 'Clinical ethics and values-based practice': www.rcgp-curriculum.org.uk/PDF/curr_3_3_Ethics_2006.pdf
A GP registrar saw a woman with a vasculitic rash on her torso. On examination, the registrar thought that the woman's rash was not serious and told her to come back in a couple of weeks if it had not cleared up.
At the end of surgery, the registrar discussed the case with her trainer, who suggested that it may be appropriate to arrange some tests.
The registrar rang the patient to explain that her trainer had suggested carrying out some tests and asked the patient to return to the practice. The woman was upset at having to return to the surgery because she would need to take time off work.
She said she had not realised the GP registrar was a 'trainee' and, if she had known, she would have asked to see a 'proper GP' instead.
The registrar was taken aback by the woman's reaction, but apologised for any misunderstanding. She arranged for the patient to see one of the GP partners when she returned. The GP partner saw the patient at an evening surgery, to avoid her needing to take time off work, and apologised again for any inconvenience.
He also explained that the practice had instigated a system whereby the receptionist would explain to patients that their appointment was with a GP registrar and offer them an alternative GP if they objected.
The patient thanked the GP and said she was grateful for the explanation.
When to gain patient consent as a GP registrar
- Make sure patients know you are a GP registrar, especially at your first meeting.
- Patients may want to know whether doctors in training will be involved, before consenting to treatment.
- By organising pre-booked registrar clinics, patients can be told in advance that they will see a registrar.
- Patient consent is also needed before using patient-identifiable information for a non-therapeutic purpose, and for video recordings for the assessment or treatment of patients.
Student BMA News, October 2005, p4.
GMC. Seeking patients' consent: the ethical considerations (1998): www.gmc-uk.org/guidance/current/library/consent.asp#presenting
GMC. Confidentiality: protecting and providing information (2004): www.gmc-uk.org/guidance/current/library/confidentiality.asp
GMC. Making and using visual and audio recordings of patients (2002): www.gmc-uk.org/guidance/current/library/making_audiovisual.asp.