Atrial Fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia. It is rarely a one-time event. Patients who develop AF once tend to be predisposed to developing it again & again. Current research indicates that this is primarily due to a change in the expression of ion channels that is caused by fibrillation (which may be mediated by changes in intracellular calcium caused by rapid pacing). This electrical remodelling creates an electrical “substrate” that is conducive to producing reentry. Some of the characteristics associated with AF are:

• 
  
  Symptoms: palpitations, dyspnea, fatigue, decreased exercise tolerance, chest pain
  
  


• 
  
  ECG: lack of P waves, “irregularly irregular” timing between QRS complexes & pulse pressure. The QRS complex & T waves are typically normal in duration & shape
  
  


• 
  
  Risk factors: hypertension, age, CHF, previous AF
  
  


• 
  
  Associated Pathology: atrial dilation, fibrosis, myocyte apoptosis
  
  


• 
  
  Complications: thromboembolism (due to vascular stasis in left atrium) & stroke
  
  


• 
  
  Common Origin & Mechanism: in patients with heart failure, an electrical focus around a left pulmonary vein combined with an abnormal atria; ablation of tissue around the pulmonary vein is one form of current therapy for patients with combined AF & heart failure (Khan et al., 2008).
  
  

There are two approaches to the treatment of AF:

• Rate control, allowing AF to persist but controlling the ventricular rate by drugs affecting the AV node ERP (Effective Refractory Period), and


• Rhythm control – with cardioversion to normal sinus rhythm & chronic treatment with antiarrhythmic drugs to prevent the reoccurrence of AF.

Arguments in favour of rate control include:

1. Its easily achievable in most patients


2. Avoidance of use of antiarrhythmic agents with less desirable side effects/toxicity


3. Risk of stroke can be reduced by anticoagulant therapy

Arguments in favour of rhythm control include:

1. Rhythm control reduces the odds of thromboembolism


2. It was thought that patients who remain in AF have a worse outcome than those treated with drugs that maintain a sinus rhythm.

What does the evidence say?

In 2008, the results of two studies, one in North America, and one in Europe were published in the New England Journal of Medicine. In both studies, rhythm control provided no advantage over ventricular rate control with respect to survival (Fig 15A). On the basis of these results, rate control is currently considered an equally “safe” approach for the treatment of AF, and rhythm control (if it is used) can be abandoned early if it is not fully satisfactory (e.g. the patient cannot tolerate the side effects of the drugs used to suppress AF). Surgical procedures (e.g. Mini Maze procedure) involving catheter ablation of ectopic foci around the pulmonary veins may also be successful in patients with otherwise relatively normal hearts.

Figure 15. Panel A: Kaplan-Meier Estimates of Death from Cardiovascular Causes (Primary Outcome). Among 1376 patients with atrial fibrillation and congestive heart failure who were followed for a mean of 37 months, 182 patients (27%) in the rhythm-control group died from cardiovascular causes, as compared with 175 patients (25%) in the rate-control group (hazard ratio, 1.06; 95% confidence interval, 0.86 to 1.30). (From Roy et al, 2008). Panel B: Kaplan-Meier Estimates of the Percentage of Patients Remaining Free of Recurrence of Atrial Fibrillation in the two treatment groups (hazard ratio for recurrence among patients in the amiodarone group, 0.43 [95 percent confidence interval, 0.32 to 0.57]). Follow-up began 21 days after randomization (designated day 0). (From: Roy et al, 2000).

Currently amiodarone appears to be superior to other antiarrhythmics in preventing the reoccurrence of AFib (Figure 15B).

Initial conversion from AF to sinus rhythm can be achieved by either DC defibrillation or by an i.v. bolus of Amiodarone or Flecainide. Patients who are placed on rate control treatment are typically given maintenance therapy with either verapamil, diltiazem, a beta blocker or digoxin (digoxin use is more common if the patient has systolic HF).

NICE Recommendation (2014)

Perform manual pulse palpation to assess for the presence of an irregular pulse that may indicate underlying atrial fibrillation in people presenting with any of the following:

• Breathlessness/dyspnoea


• Palpitations


• Syncope/dizziness


• Chest discomfort


• Stroke/transient ischaemic attack. [2006]

Perform an electrocardiogram (ECG) in all people, whether symptomatic or not, in whom atrial fibrillation is suspected because an irregular pulse has been detected. [2006]

Assessment of stroke and bleeding risks

Use the CHA₂DS₂-VASc stroke risk score to assess stroke risk in people with any of the following:

• Symptomatic or asymptomatic paroxysmal, persistent or permanent atrial fibrillation


• Atrial flutter


• A continuing risk of arrhythmia recurrence after cardioversion back to sinus rhythm. [new 2014]

Use the HAS-BLED score to assess the risk of bleeding in people who are starting or have started anticoagulation.

Stroke prevention

• Do not offer stroke prevention therapy to people aged under 65 years with atrial fibrillation and no risk factors other than their sex (that is, very low risk of stroke equating to a CHA₂DS₂-VASc score of 0 for men or 1 for women). [new 2014]


• Consider anticoagulation for men with a CHA₂DS₂-VASc score of 1


• Offer anticoagulation to people with a CHA₂DS₂-VASc score of 2 or above, taking bleeding risk into account.


• Anticoagulation may be with apixaban, dabigatran etexilate, rivaroxaban or a vitamin K antagonist.

When to offer rate or rhythm control

Offer rate control as the first‑line strategy to people with atrial fibrillation, except in people:

• Whose atrial fibrillation has a reversible cause


• Who have heart failure thought to be primarily caused by atrial fibrillation


• With new‑onset atrial fibrillation


• With atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm


• For whom a rhythm control strategy would be more suitable based on clinical judgement.

Rate control

Offer either a standard beta‑blocker (that is, a beta‑blocker other than sotalol) or a rate‑limiting calcium‑channel blocker as initial monotherapy to people with atrial fibrillation who need drug treatment as part of a rate control strategy.

Consider digoxin monotherapy for people with non‑paroxysmal atrial fibrillation only if they are sedentary (do no or very little physical exercise).

If monotherapy does not control symptoms, and if continuing symptoms are thought to be due to poor ventricular rate control, consider combination therapy with any 2 of the following:

• A beta‑blocker


• Diltiazem


• Digoxin.

Do not offer amiodarone for long‑term rate control.

Rhythm control

Consider pharmacological and/or electrical rhythm control for people with atrial fibrillation whose symptoms continue after heart rate has been controlled or for whom a rate‑control strategy has not been successful.

Cardioversion

For people having cardioversion for atrial fibrillation that has persisted for longer than 48 hours, offer electrical (rather than pharmacological) cardioversion.

Consider amiodarone therapy starting 4 weeks before and continuing for up to 12 months after electrical cardioversion to maintain sinus rhythm, and discuss the benefits and risks of amiodarone with the person.

For people with atrial fibrillation of greater than 48 hours" duration, in whom elective cardioversion is indicated:

Both transoesophageal echocardiography (TOE)‑guided cardioversion and conventional cardioversion should be considered equally effective.

Management for people presenting acutely with atrial fibrillation

Rate and rhythm control

• Carry out emergency electrical cardioversion, without delaying to achieve anticoagulation, in people with life‑threatening haemodynamic instability caused by new‑onset atrial fibrillation.


• In people with atrial fibrillation presenting acutely without life‑threatening haemodynamic instability, offer rate or rhythm control if the onset of the arrhythmia is less than 48 hours, and start rate control if it is more than 48 hours or is uncertain.


• Consider either pharmacological or electrical cardioversion depending on clinical circumstances and resources in people with new‑onset atrial fibrillation who will be treated with a rhythm control strategy.


• If pharmacological cardioversion has been agreed on clinical and resource grounds for new‑onset atrial fibrillation, offer:


• Flecainide or amiodarone if there is no evidence of structural or ischaemic heart disease or


• Amiodarone if there is evidence of structural heart disease.


• In people with atrial fibrillation in whom the duration of the arrhythmia is greater than 48 hours or uncertain and considered for long‑term rhythm control, delay cardioversion until they have been maintained on therapeutic anticoagulation for a minimum of 3 weeks. During this period offer rate control as appropriate.


• Do not offer magnesium or a calcium‑channel blocker for pharmacological cardioversion.

Anticoagulation

In people with new‑onset atrial fibrillation who are receiving no, or subtherapeutic, anticoagulation therapy:

• In the absence of contraindications, offer heparin at initial presentation


• Continue heparin until a full assessment has been made and appropriate antithrombotic therapy has been started

Useful Videos

Useful Videos

 

Atrial Fibrillation

OSCE - Cardiovascular Examination

For systemic examinations we need to go down to the basics of examinations. I found the following videos uploaded by medical students and very junior doctors very useful for my OSCE preparation.

The first video done by Geeky Medics (they are amazing group of guys) and this level will be enough for FCEM OSCE. The second video shows examination of different murmurs.

I will add more videos if I come across and also try to add a marking sheet.

 

OSCE - Cardiovascular Examination

Critical Appraisal Practice Paper 4 (Diagnostic)

Total marks: 23
Time allowed: 90 mins

You might wish to download the paper. Do it in 90 minutes and then compare with the answers provided here.

Paper: Mallampati test as a predictor of laryngoscopic view

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2010 Dec;154(4):339-43.

Download (PDF, 65KB)

1. Provide a summary / abstract for the paper. (Up to 5 marks)

Answer

Answer

This should include all or some of the following points:

Aim. To determine the accuracy of the modified Mallampati test for predicting the difficulty of subsequent tracheal intubation.

Design. A cross-sectional, clinical, observational, non-blinded study. A quality analysis of anaesthetic care.

Setting. Operating theatres and department of anaesthesia in a university hospital in the Czech Republic.

Material and methods. Following local ethics committee approval and patients’ informed consent to anaesthesia, all adult patients (> 18 yrs) presenting for any type of non-emergency surgical procedures under general anaesthesia requiring endotracheal intubation were enrolled.

Prior to anaesthesia, Samsoon and Young"s modification of the Mallampati test (modified Mallampati test) was performed.

Following induction, the anaesthetist described the laryngoscopic view using the Cormack-Lehane scale. Classes 3 or 4 of the modified Mallampati test were considered a predictor of difficult intubation. Grades 3 or 4 of the Cormack-Lehane classification of the laryngoscopic view were defined as impaired glottic exposure.

The sensitivity, specificity, positive and negative predictive value, relative risk, likelihood ratio and accuracy of the modified Mallampati test were calculated on 2x2 contingency tables.

Results. Of the total 1,518 patients enrolled, 48 had difficult intubation (3.2%).

We failed to detect as many as 35.4% patients in whom glottis exposure during direct laryngoscopy was inadequate (sensitivity 64.4%).

Compared to the original article by Mallampati, we found lower specificity (82.4% vs. 99.5%), lower positive predictive value (0.107 vs. 0.933), higher negative predictive value (0.986 vs. 0.928), lower likelihood ratio (3.68 vs. 91.0) and accuracy (0.819 vs. 0.929).

Conclusion. When used as a single examination, the modified Mallampati test is of limited value in predicting difficult intubation in elective surgery patients.

2. Give three weaknesses of the study design and suggest improvements for these (up to 3 marks)

Answer

Answer

Strengths - there aren’t that many!

• They did get ethical approval


• The sample size was large


• Sample recruited from a good cross section of patients undergoing elective surgery

Weaknesses – there are lots of these!

• Patients studied are elective not emergency patients, so use in emergency situations cannot be inferred.


• It’s unclear who assessed the Mallampati Score but it’s likely to be the same anaesthetist who also assessed the outcome (laryngoscopic grade).


• It’s unclear what grade of anaesthetist assessed Mallampati or laryngoscopic grade.


• ? only one person assessed Mallampati Score.


• The person assigning the Cormack / Lehane grade was not unaware of the previously assigned Mallampati Score. In diagnostic studies it is important that the outcome is assigned without knowledge of the intervention test result.

The study could have been improved (for an EM readership) by:

• Studying a group of patients needing emergency airway control.


• The authors could have described in more detail who exactly was assigning the Mallampati Score e.g. grade, level of training etcc.. and how this was done.


• More than one assessor could have done this. The authors could have got two people to do this to ensure consistency and assessed agreement using a Kappa statistic or similar. This would help the reader to assess if the Mallampati Score was reproducible enough to make it worth doing amongst a wider range of clinicians.


• Someone else (who didn’t do the Mallampati Score) should have assigned the Cormack & Lehane Grade. The C&L grade given could have been influenced by knowledge of the Mallampati Score.

3. Name one checklist which is useful in evaluating the quality of diagnostic papers such as this. Give two further questions / points within this checklist not covered by the weaknesses you have mentioned in question 2. above. (up to 3 marks)

Answer

Answer

Common checklists include QUADAS and STARD (see below)

The STARD statement can be found here (it is similar to QUADAS):

http://www.stard-statement.org/

In this study the “index test” is the Mallampati Score and the “reference standard” is the Cormack & Lehane Grade. You should go through this checklist with the study and see how many weaknesses you can now identify!

4. The table 3 below is taken from the results section.

 Summarise the results in the table in one sentence. What is the Mann-Whiney U test? (Up to 2 marks)

Answer

Answer

Men are taller and heavier than women!

The Mann Whitney U Test is a test used to compare continuous (or ordinal) data in two independent groups, when the data is non parametric (i.e does not follow a normal distribution). It is analogous to a t-test which does the same thing but for normally distributed data.

 5. Construct a 2 x 2 table illustrating the main data from the current study (not Mallampati’s original). (Up to 2 marks)

Answer

Answer

		Actual Difficulty of Intubation(by Cormack Lehane Grade)
		Difficult (3/4)	Easy (1/2)
Predicted Difficulty of Intubation (Mallampati Class)	Difficult (3/4)	31	258	289
	Easy (1/2)	17	1212	1229
		48	1470	1518

6. Use your table in 5. above to demonstrate how the positive likelihood ratio and the accuracy were calculated. Explain how you would interpret the positive likelihood ratio in this study. (4 marks)

Answer

Answer

Positive LR = Sensitivity / 1 – Specificity

Sensitivity = a / a+c = 31 / 48 = 0.646

Specificity = d / b+d = 1212 / 1470 = 0.824

Positive LR = 0.646 / 0.176 = 3.67

Accuracy = total number (%) of “correct” predictions = a + d / a + b + c + d

Accuracy = 1243 / 1518 = 81.9%

LR+ above 10 means that a positive test (i.e. a higher Mallampati Score) will significantly increase the post test probability (of a difficult intubation) enough to make the test worth doing. Figures below 10 (like 3.67) mean that a positive test doesn’t really alter your chances of predicting the outcome enough to make it worth doing.

 

7. The authors used Fishers Exact Test to statistically compare their results with the results of Mallampati. Describe the indications for using this test as opposed to a Chi Squared Test? (Up to 2 marks)

Answer

Answer

Fishers Exact Test is used for 2 x 2 data when the expected count in any of the 4 boxes is “low”. The rule of thumb is if the expected number is less than 10 in any box then Fishers Exact Test should be used.. The expected number in any box can be calculated by multiplying the total of the column by the total row value and dividing by the overall number of patients / data points.

The authors appear to have used 2 x 2 tables for each of the possible outcomes. An example for “true negative” is illustrated below.

		Study
		Adamus et al	Mallampati et al
Observed Result	True Negative	1212	181	1393
	Not True Negative	306	29	335
		1518	210	1728

Thus for box d (value 29), the expected value is 210 (the total column value) x 335 (the total row value) / 1728 (the overall total). This is 40.1. In this case all the expected values are greater than 10 and so Chi Squared could have been used. However, for some of the others (e.g. false positives), the expected values will be low so I suppose the authors went for Fishers Test for consistency!

8. What are your conclusions overall? Is this paper going to influence your practice? Briefly suggest any ideas for future research in this area? (Up to 2 Marks)

Answer

Answer

Overall this paper is not great and is unlikely to influence your practice. There are multiple weaknesses and potential areas of bias. In addition the results are very different from the original Mallampati Study.

The authors hint at the other factors which allow a good assessment of the airway (e.g. weight or patients etc..). A better study might look at the whole LEMON acronym which you are probably familiar with from ATLS. It could be done in an ED setting with independent assessment of LEMON and the final C&L grade / ease of intubation.

Finally given that the study results are so different from the original Mallampati Study you could propose some secondary research (a systematic review, Best BET or even CTR!) to answer the question posed.

Mallampati test as a predictor of laryngoscopic view. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2010 Dec;154(4):339-43.

A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J. 1985 Jul;32(4):429-34.

 

Critical Appraisal Practice Paper 4 (Diagnostic)

Management Viva - Complaint related documents

The following documents are freely available in the internet which I found important for the understanding of NHS complaints.

Few important points to remember:

• Time frame to make a complaint is one year.


• The acknowledgement of a formal complain should be sent out within 3 days.


• If complaint comes directly to the department, it should be diverted to the Complaint Manager.


• Complaint Manager in most NHS Trust are located in PALS


• Investigating officer (nominated ED consultant) will draft a formal response after gathering available information mentioned in the complaint.


• The formal response will be typed and then signed by Chief Executive and send out to the complainant.


• The time frame of the formal response will depend on the complexity of the case.


• If the complainant is happy, it will stop there. And if not happy with the process they will have to contact Health Service Ombudsman.


• The Health Service Ombudsman will review the case before accepting.

1. Clinical Negligence Litigation: A very brief guide for clinicians

NHS LA Document

NHS LA Document

Download (PDF, 221KB)

2. Department of Health guidance on NHS Complaints

A Guide to Better Customer Care

A Guide to Better Customer Care

Download (PDF, 880KB)

Dealing with serious complaints

Dealing with serious complaints

Download (PDF, 133KB)

3. MPS Series on Complaints

NHS Complaints in England: Regulations and Principles

NHS Complaints in England: Regulations and Principles

Download (PDF, 1.5MB)

Complaints: FAQ

Complaints: FAQ

Download (PDF, 486KB)

4. MDU Series on Complaints

Introduction

Introduction

Download (PDF, 66KB)

Local Resolution

Local Resolution

Download (PDF, 82KB)

Writing a Response

Writing a Response

Download (PDF, 60KB)

Health Service Ombudsman

Health Service Ombudsman

Download (PDF, 44KB)

5. Procedure for Investigation and Resolving Complaints

The Leeds Teaching Hospitals NHS Trust

The Leeds Teaching Hospitals NHS Trust

This document is slightly older but gives a good overview of hospital complaints process.

The time frame for complaints is 12months now.

The time frame for sending out acknowledgement letter in response to a complaint is 3 days.

Download (DOC, 64KB)

6. NHS Complaints Procedures in England

Information for the Member of Parliament

Information for the Member of Parliament

Download (PDF, 119KB)

Management Viva - Complaint related documents

Doctors in Difficulty - Drugs and Alcohol

A reasonable number of trainees can become ill during training: of these, most have a psychiatric or stress-related problem. Many can be ill for some time, & either not recognised that they were ill or decided against reporting this. A small number use drugs or alcohol.

There are several things to consider. Immediate patient safety must come first; a person currently under the influence of drugs or alcohol must be removed from the clinical situation.

Once this is done, & assuming the person is sober enough to talk, it’s important to find somewhere appropriate to hold a confidential conversation. As I’m doing this, I run through a mental check-list: what would it be like to be this doctor, who is the best person to have this conversation, what skills must I demonstrate, & what practicalities need sorting out?

What it would be like to be the doctor in difficulty?:
In most circumstances, doctors who abuse drugs or alcohol have begun the habit as a coping strategy because of stress or illness. Doctors who are ill, particularly those with psychological or stress-related illness are concerned about being stigmatised. They describe a feeling of shame, of letting themselves down by not meeting their own high personal standards, worries about confidentiality & loss of control & fears about damage to their livelihood because of disciplinary action or referral to the General Medical Council (GMC). Particular concerns for those in training grades are that they may lose the respect of others, & that disclosing a mental illness, especially alcohol or drug use, may threaten their career & job prospects. So the person is being very brave in talking at all. He or she will have mentally rehearsed this situation many times & reached the conclusion that it’s safer to say nothing about his or her problem. Even if the person wanted to talk, deciding who to tell is difficult.

Who is best to have this conversation?:
It is important that the doctor speaks to someone he or she respects & trusts to keep the matter as confidential as possible. So I ask “You need to talk to someone about this. Should this be me or is there someone else you would prefer to talk to?” I offer the trainee the option of bringing someone with them. Sometimes, but in my experience rarely, they will want to.

What skills must I demonstrate?:
The conversation will only be useful if the trainee feels that the conversation is confidential & he or she is being treated with respect, empathy & genuineness. I need to make sure I demonstrate these qualities, not just feel them. I start with a comment such as “We need to talk about what’s happened, & how you are. The most important thing we need to do is explore & understand what’s going on from your perspective.” The first thing I do is to listen. It might seem a rather weak response when you have a hundred questions going round in your head. But just listening actively to everything the person says, summarising & being sure to notice the trainee’s feelings & reflect them back accurately, is likely to achieve most. You’re not the person’s doctor – you don’t need to know what substances, how often, where or when.

Caught in the act, most people acknowledge events. Those who refute what is described or deny their involvement are almost always using a coping strategy of putting blame on others or on circumstances; they know they’ve got a problem but don’t feel safe to talk about it. If this happens, I start by explaining what I saw or has been reported to me as having occurred, outline what happens to doctors with drug & alcohol problems & what we are required to do to meet governance & GMC requirements. I also make clear that they are not alone, & that many colleagues who have found themselves in this sort of difficulty return to work &/or to training. There are a number of services for doctors with health difficulties & for doctors with drug & alcohol problems* & I make sure the trainee is made aware of these.

What practicalities need sorting?

Three aspects need to be managed; the doctor’s health & treatment, governance, & informing those who need to know that a trainee has a drug or alcohol problem. 

Health & treatment:

The outcome I aim for is that the trainee gets to the right services to treat & support them, but in a way that preserves his or her dignity & keeps the details of his or her situation as confidential as possible. Treatment of their underlying problem might be achieved through their GP, via the consultant occupational physician or through direct contact with the local drug & alcohol service. As many such people have an underlying illness which also needs treatment, a consultation with the GP can be helpful. However there are a group of doctors for whom the GP is a family friend, or part of a social, ethnic or religious community, when the problem of disclosure & potential stigma can be a significant barrier.

If there is a good Occupational Physician in the Trust or available via the Deanery, it is very useful for the trainee to see this person. It is the responsibility of the Occupational Physician to advise the trainee, Trust & Deanery as to whether the doctor is well enough to continue working & if so, what adjustments are needed to their duties or working pattern. In practical terms this usually means the doctor is “given permission to be ill”, & to take time away from work to address the underlying causes of their problem as well as their drug or alcohol usage. If the doctor is well enough to remain at work in some capacity, the Occupational Physician acts as the doctor’s advocate in making sure the duties &/or training requirements expected of a trainee are realistic in the context of their health difficulties. The Occupational Physician may also refer them on to the appropriate clinician (often a psychiatrist) & to the drug & alcohol service, as they will know which doctors are used to treating fellow professionals.

Governance:

The GMC requires every doctor to:

• Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk.


• Consult a suitably qualified colleague if your judgement or performance could be affected by a condition or its treatment & ask for & follow their advice about investigations, treatment & changes to your practice that they consider necessary.

In practice, this means that every doctor has a responsibility to remove a colleague from the immediate clinical situation if the doctor is under the influence of drugs or alcohol. The doctor him or herself must not put patients at risk, & must consult & follow the advice of the Occupational Physician, their GP & the consultant who treats them as a patient.

When identified, matters relating to ill-health or to substance misuse should be dealt with through employers’ occupational health processes & outside disciplinary procedures where possible. Thus, the Trust in which a trainee works & the Deanery in whose programme he or she is training both have a responsibility to provide the trainee with the means to get treated & to address their tendency to use drugs or alcohol as a coping strategy.

In the medium term, the Trust & Deanery should support the trainee in returning to work, & returning to training, once they are well enough. Many such situations fall under the disability discrimination act, which places a duty on employers to make ‘adjustments’, such as to working hours, place of work or by modifying procedures for assessment. Again this is something for which the advice of a consultant Occupational Physician is important.

Who else will need to know?

The Postgraduate Dean, Trust Medical Director & Clinical Director will need to know of the trainee’s drug or alcohol problem because of their accountability for patient safety, & the GMC must be informed because of its fitness to practice responsibilities. I find this part of the discussion quite tricky to phrase well & introduce at the right time. If the earlier conversation has gone well, & I have managed to demonstrate respect, concern & empathy with the trainee, trust should be starting to develop between us. But this is often tenuous & can be easily broken. By introducing the need to inform those responsible for patient safety & fitness to practice too early in the conversation, I might add to their feelings of embarrassment & disgrace.

Sometimes this is too much of a challenge & the trainee resists. The worry for me is that, quite often, the underlying reason for the drug or alcohol use is depression, & further disempowerment could have dire consequences. Doctors with psychiatric conditions & particularly those who use drugs or alcohol describe feelings of shame at not meeting their own high standards & humiliation at being found out, & unfortunately, faced with discovery, there is the possibility of self-harm or suicide.

On the other hand, if the trainee can be brave enough to seek the help they need & to inform someone senior in the Trust & the Deanery, then this is likely to set them on a better footing. They can then be seen as someone who has taken ownership of their problem, & is doing something about it. If the trainee is known to be seeking & complying with treatment, & using appropriate support, this will also stand them in better stead with the GMC.

When discussing the trainee’s health with third parties, I myself, the Clinical Director, Medical Director, Postgraduate Dean & GMC must each provide the same standard of confidentiality as is afforded to patients. The trainee must not become the subject of corridor gossip or the matter discussed where you can be overheard.

The GMC guidance on confidentiality makes clear that expressed consent must be sought if details about the trainee’s health are disclosed to third parties, unless the disclosure is required by law or can be justified in the public interest. Such disclosures should be kept to a minimum. The trainee must have access to or copies of information exchanged about them & be informed about how information will be used. In practical terms this means that informing the Clinical Director & Medical Director that the trainee has a health issue, is possibly not well enough to work & has told you that he or she has been using drugs or alcohol, is in the public interest, but saying that the doctor is depressed & binge drinking is not, unless the trainee has consented to revealing this information.

The situation is slightly different if the trainee has been arrested for drunk driving or has been obtaining drugs fraudulently by self-prescribing. Both of these are illegal activities which should be disclosed to those in authority.

The GMC will need to be informed at an appropriate point if the doctor has a drug or alcohol problem. The psychiatrist from the drug & alcohol service is often best placed to do this, as they have a better understanding of the clinical picture.

Information about health can be disclosed to the GMC without the trainee’s consent, but the trainee must be informed as to what the GMC is told, even though their consent is not required. When a doctor is arrested or cautioned on a drink driving charge, or has been caught self-prescribing opiates or benzodiazepines by a pharmacist, the Police automatically inform the GMC.

So how do I pick my way through this minefield? I explain that the Medical Director, Clinical Director & GMC will need to know that the trainee has a health problem. Sometimes I find it useful to look together at the GMCs “Good Medical Practice” guidance. If the trainee is feeling brave enough, we draw up an e-mail or letter together, so that the trainee has control over what is said about his or her own health, or we ask the Clinical Director if we can meet urgently in private. When the trainee is too uncertain to inform the Clinical & Medical Director straight away, I ensure that they do not go back to clinical work & they “go off sick”. I arrange to meet them again in the next few days, to agree how we ensure those in authority are informed, & gently point out that, if they don’t turn up, I would still have to tell the Clinical & Medical Director, & Postgraduate Dean & would send them a copy of what I had said. I am lucky in that I can offer the opportunity of talking to someone else who has been in similar circumstances, as some of the many trainees whom I have managed & supported with psychological or stress-related illness, & some with drug or alcohol problems, are willing to share their own experiences.

Many doctors who abuse drugs or alcohol have started the habit as a coping strategy because of other difficulties. If treated fairly & with respect & empathy, many will address their difficulties & get back to safe, effective practice. So first impressions count; a thoughtfully conducted initial discussion can be the gateway the doctor needs to taking ownership of the problem & addressing their difficulties. Any lastly, these are difficult conversations, so do get support for yourself from someone with the skills to help you reflect confidentially about your performance.

Photo courtesy [http://www.generationnext.com.au/]

Doctors in Difficulty - Drugs and Alcohol

OSCE - Shoulder Examination

This is a short OSCE video, but completed most of the test. It can be done slowly and will fit nicely for FCEM OSCE.

OSCE - Shoulder Examination