Consulting Others & Consulting Others & Medicolegal Risk ReductionMedicolegal Risk Reduction

Max Brinsmead MB BS PhDMax Brinsmead MB BS PhD

May 2015May 2015

Consultation advice for JMOs Consultation advice for JMOs First know how to find your consultantFirst know how to find your consultant When to consult depends upon…When to consult depends upon…

The experience of the JMOThe experience of the JMO The wishes of the consultantThe wishes of the consultant

In the beginning report EVERYTHINGIn the beginning report EVERYTHING And this will change with timeAnd this will change with time Thereafter in life, if in doubt, CONSULTThereafter in life, if in doubt, CONSULT Always record consultation in the notesAlways record consultation in the notes If you want the consultant to come then ask If you want the consultant to come then ask

unequivocally and write that in the notesunequivocally and write that in the notes If the consultant does not come then ask If the consultant does not come then ask

againagain

Who to Consult?Who to Consult? Out of courtesy, consult first with your line Out of courtesy, consult first with your line

managermanager Thereafter consult the person most likely Thereafter consult the person most likely

to be able to helpto be able to help This can occur at any time…This can occur at any time…

At the end of the day or weekAt the end of the day or week From the bedsideFrom the bedside From an operating theatreFrom an operating theatre

And by any means…And by any means… PhonePhone LetterLetter E-mailE-mail

Preparing for ConsultationPreparing for Consultation

First ask yourself these three questions…First ask yourself these three questions… What is the problemWhat is the problem What do you want from the consultation?What do you want from the consultation? What information is relevant?What information is relevant?

Then make sure that you have all relevant Then make sure that you have all relevant information ready…information ready…

History, examination, testsHistory, examination, tests Significant negative factsSignificant negative facts

Find a suitable time and place to make the Find a suitable time and place to make the consultationconsultation

How to ConsultHow to Consult Courtesy is of the essenceCourtesy is of the essence

Identify yourself and the consultantIdentify yourself and the consultant Ask if you can proceed with a consultationAsk if you can proceed with a consultation

Put the problem up front…Put the problem up front… Summarise in one sentence and with one breathSummarise in one sentence and with one breath Indicate the degree of urgencyIndicate the degree of urgency

Then give background as requestedThen give background as requested Don’t tell the consultant what you want Don’t tell the consultant what you want

him to dohim to do This is a consultation, not an orderThis is a consultation, not an order

If possible, have your own management If possible, have your own management plan ready for discussionplan ready for discussion

Consulting with another DisciplineConsulting with another Discipline

Obtain consentObtain consent From your line managerFrom your line manager From the patientFrom the patient

Follow local protocol…Follow local protocol… But courtesy suggests that you consult first But courtesy suggests that you consult first

with your peerwith your peer

Medicolegal Risk Reduction during Medicolegal Risk Reduction during Patient Consultation Patient Consultation

Review previous notesReview previous notes PrivacyPrivacy InterruptionsInterruptions EmpathyEmpathy Making assumptionsMaking assumptions Boundaries in the therapeutic Boundaries in the therapeutic

relationshiprelationship A second opinion?A second opinion?

Examination Examination

Obtaining consentObtaining consent Specific adviceSpecific advice PrivacyPrivacy ChaperoneChaperone BoundariesBoundaries

Consent to Procedure Consent to Procedure

General and specific risksGeneral and specific risks Dealing with patient’s specific concernsDealing with patient’s specific concerns Options discussedOptions discussed Relatives welcomeRelatives welcome Diagrams and brochuresDiagrams and brochures Patient to feedbackPatient to feedback DocumentationDocumentation Who signs the form?Who signs the form?

In Theatre In Theatre

Check equipmentCheck equipment Check with the staffCheck with the staff Check the patientCheck the patient Position the patientPosition the patient Check the notesCheck the notes Supervising juniorsSupervising juniors

Postoperative carePostoperative care

Following protocolFollowing protocol Patient told what to expectPatient told what to expect Patient knows what to do if something goes Patient knows what to do if something goes

wrongwrong Role delineationRole delineation

SurgeonSurgeon AnaesthetistAnaesthetist

Review the patient before dischargeReview the patient before discharge Special circumstances e.g. patient to travelSpecial circumstances e.g. patient to travel

MedicationsMedications

Explain risks and side effectsExplain risks and side effects Patient must know what to do if Patient must know what to do if

questions or problems arisequestions or problems arise Review notes before prescribingReview notes before prescribing Monitor response to therapy Monitor response to therapy Review medication regularlyReview medication regularly

Difficult PatientsDifficult Patients

Personality disorderPersonality disorder Psychiatric disorderPsychiatric disorder Those with unrealistic expectationsThose with unrealistic expectations Communication difficultiesCommunication difficulties

Low intelligenceLow intelligence LanguageLanguage CulturalCultural

You have bad newsYou have bad news

Colleagues and StaffColleagues and Staff

Roles and responsibilities delineatedRoles and responsibilities delineated Working collaborativelyWorking collaboratively Don’t undermineDon’t undermine Make yourself available for consultationMake yourself available for consultation All staff to understand privacy and All staff to understand privacy and

confidentialityconfidentiality A multidisciplinary approach to complex A multidisciplinary approach to complex

problemsproblems Requires good communicationRequires good communication

Antenatal Care and DeliveryAntenatal Care and Delivery

Explaining care plan and testsExplaining care plan and tests Written guidelines for midwivesWritten guidelines for midwives Reviewing a CTGReviewing a CTG Labour reviewLabour review

Review all available dataReview all available data Record the timeRecord the time Document any differences to midwife obs.Document any differences to midwife obs.

Document your adviceDocument your advice Involving the patient in the decisionsInvolving the patient in the decisions Documenting special casesDocumenting special cases

General measuresGeneral measures

Ensuring patient follow upEnsuring patient follow up Communication with othersCommunication with others Dealing with testsDealing with tests

NormalNormal AbnormalAbnormal

Medical RecordsMedical Records ““If it isn’t written down it didn’t happen”If it isn’t written down it didn’t happen”

When things go wrong…When things go wrong…

Timely responseTimely response Empathy but not liabilityEmpathy but not liability Make contemporary notes in detailMake contemporary notes in detail Review protocolsReview protocols Root cause analysisRoot cause analysis Have a mechanism for handling Have a mechanism for handling

complaintscomplaints