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Supervisory Responsibilities of Specialists
Paper delivered to Auckland
Healthcare Conference for Medical Staff
16 February 2001
Ron Paterson
Health and Disability Commissioner
Introduction
The public hospital system in New
Zealand is heavily reliant on junior doctors (meaning house
officers and registrars) for the day-to-day provision of medical
care to hospital patients. These junior doctors work as part of a
clinical team, under the leadership and supervision of a specialist
under whose name patients are admitted to hospital. After hours,
this role of leadership and supervision passes to the on-call
specialist. The supervisory responsibilities of specialists appear
to be ill defined, and yet failure to understand and fulfil these
responsibilities can have significant consequences for junior
doctors, specialists and patients.
This article discusses changes in
the nature and practice of supervision in New Zealand over the past
20 years and examines the impact of the Code of Health and
Disability Services Consumers' Rights ("the Code") in this area.
Medical disciplinary cases and reports from the Health and
Disability Commissioner are used to illustrate key principles.
Definition of
supervision
The term "supervision" can have
different meanings in the medical context. For example, many of the
professional Colleges have some requirement for formal supervision
as part of their registrar training programmes.[1] The
Medical Practitioners Act 1995 requires that doctors on the
probationary register practise under supervision, while doctors on
the general register must receive oversight from a vocationally
registered colleague. The Medical Council may also impose
supervision as a condition of a competence programme, and the
Medical Practitioners Disciplinary Tribunal may impose a form of
supervision following disciplinary action.[2]
The focus of this article is on the
day-to-day issues of supervision that arise when a specialist leads
a clinical team including junior doctors, both during the day and
after hours as the specialist on call. Supervision in this sense is
a broad concept that incorporates many aspects of the clinical
oversight of a patient's care.
Changes in the nature and
practice of supervision
There has been a tremendous change
in the level of specialist supervision in the past 20 years, with
specialists becoming more available to junior doctors, and more
involved in acute work. Under the traditional model, a specialist
would work closely with a small number of junior doctors trained in
a common system, and become very familiar with their competencies.
Delegation would be based on the specialist's knowledge and
interpretation of the junior doctor's experience and ability. A
junior doctor beginning work in a new speciality would be expected
to have relatively little experience of that speciality area and
would be provided with close supervision. As the junior doctor
gained experience in the area, senior staff would gain confidence
in his or her ability to do more, and the level of supervision
would decrease. A junior doctor would be expected to carry out many
tasks independently, and to ask for help if feeling out of his or
her depth. Patients were unlikely to question the involvement of
junior doctors in their hospital care.
The changing nature of hospital
medicine is undermining this traditional model in a number of ways.
Changes to rosters and junior doctor staffing shortages have
resulted in less continuity within each clinical team. These days,
specialists work with a greater number of junior doctors for
shorter periods, providing fewer opportunities to become familiar
with their individual competencies. Due to frequent roster changes,
consultants may even be unaware that they are supervising a night
shift doctor who is not known to them.
In the past, senior staff had a
clear understanding of the expected competencies of recent
graduates. New Zealand hospitals are increasingly staffed by
overseas-trained doctors whose clinical strengths and weaknesses
may not be well understood. According to the Medical Council's 2001
annual report, 47 per cent of probationary registrants and 36 per
cent of general registrants trained at an overseas medical
school.[3] The problem of a different form of training
may be compounded by cultural and communication difficulties. Dr
Jenny Westgate gave expert evidence to the Medical Practitioners
Disciplinary Tribunal on this issue in 2001. She stated that
although the experience of some overseas-trained doctors may
suggest that they have comparable training and skills to doctors
trained in New Zealand, that is not always the case. In addition,
it was her observation that many overseas-trained doctors have
great difficulty in seeking assistance, possibly because it may be
viewed as a sign of weakness. Dr Westgate concluded: " ...
[W] hatever the reason, this fundamental difference and
the understanding of the model of supervision means I have had to
significantly alter the way in which I interact with some
overseas-trained doctors."[4]
Ideally, junior doctors should carry
out only tasks within their competency, and have a responsibility
to contact senior staff if they get out of their depth.
Unfortunately, due to their lack of experience, junior doctors may
fail to recognise when they are out of their depth. The Medical
Practitioners Disciplinary Tribunal recently noted that "the system
used for teaching junior staff is potentially dangerous - junior or
at least inexperienced, practitioners 'don't know what they don't
know'".[5] As a result they may take on more
responsibility than is appropriate, involving senior staff too
late, or failing to contact them at all. Several recent studies
have confirmed that junior doctors have difficulty in identifying
or reporting their own clinical limitations.[6]
,[7] ,[8] Thus, it seems likely that more
mistakes will occur if junior doctors are not supervised by
specialists who know them well and recognise their clinical
limitations.
Another factor impacting on the
level of specialist supervision required is the increasing
complexity of patient management. New and more complex drug regimes
and surgical techniques take more time to master than older,
simpler treatments. For example, it takes at least twice as long
for gynaecology registrars to become competent in laparoscopic
surgery compared with open surgery.[9] This obviously
means that a greater investment of specialist time is required to
provide trainees with direct supervision until they master these
skills.[10]
There has been a significant change
in public expectations in recent decades, and hospitals now operate
in an environment of consumer-focused health and disability
services. There is a perceived increase in the number of medical
practitioners facing disciplinary charges, prompting some
specialists to practise defensive medicine, although it is
debatable whether this increase is myth or
reality.[11]
No wonder, then, that a senior
specialist recently commented:
"Most of us spent our training years
aspiring to be specialists who did not have to keep unsociable
registrar hours and now we find the rules have
changed."[12]
The Code of Health and
Disability Services Consumers' Rights
The Health and Disability
Commissioner Act 1994 (NZ) ("the Act") was passed as consumer
protection legislation in 1994 in the wake of the 1998 Report of
the Cervical Cancer Inquiry.[13] The Act is the primary
vehicle for dealing with complaints about any health or disability
service provider in New Zealand. The purpose of the Act is to
promote and protect the rights of consumers of health and
disability services and to facilitate the fair, simple, speedy, and
efficient resolution of complaints.[14]
The Code of Health and Disability
Services Consumers' Rights[15] took effect from 1 July
1996, and sets out ten rights of consumers and corresponding duties
of providers. The Rights in the Code are all subject to the
qualification that a provider is not in breach of the Code if he or
she has taken reasonable actions in the circumstances to give
effect to the Rights in the Code.[16] The onus is on the
provider to show that he or she took reasonable
actions.[17]
Although patients are unlikely to
complain about the standard of supervision of junior doctors, it is
an issue that not uncommonly arises in the course of investigations
into more general complaints. In several cases, a specialist's
failure to provide appropriate supervision has resulted in a breach
of the Code of Health and Disability Services Consumers' Rights.
The Code rights with particular relevance to supervisory
responsibilities are Right 4(1), Right 4(2), Right 4(5) and Right
6.
Right 4(1): Right to have
services provided with reasonable care and skill
Right 4(1) states that every
consumer has the right to have services provided with reasonable
care and skill. This right reflects the common law standard for
medical negligence whereby a doctor is held to have provided a
reasonable standard of care if he or she acted in accordance with a
practice accepted as proper by a responsible body of medical
doctors skilled in that particular form of
treatment.[18] Consistent with the common
law,[19] it would be open to the Commissioner, in rare
cases, to reject the view of medical experts as unreasonable and
logically indefensible.
Unlike the law of medical
negligence, a doctor can be found to have breached the Code even if
no actual harm can be proven.
The following case from the Medical
Practitioners Disciplinary Committee illustrates the harm that can
result when specialists do not exercise their supervisory
responsibilities with reasonable care and skill.
A 14-year-old boy was taken to the
Whangarei Base Hospital with an injury to his right leg following a
trampolining accident. In two telephone calls on the day of
admission, the duty house surgeon advised Dr Baylis, the consultant
in charge of the case, of his serious concern about the nature of
the injury. The committee found that during these two telephone
conversations, Dr Baylis "exhibited inadequate communication with a
very conscientious and concerned junior house surgeon". The
committee also found that following the second telephone call "a
reasonable orthopaedic surgeon would have been prompted by
[the house surgeon's ] expression of concern and
description of this patient's condition to attend the hospital to
examine the patient and to institute such treatment as he then
considered appropriate". The following day, Dr Baylis diagnosed a
clot in one of the arteries in the boy's leg. Despite operation by
a vascular surgeon, the boy's leg required amputation six days
after his admission to hospital. The Medical Practitioners
Disciplinary Committee found Dr Baylis guilty of professional
misconduct.[20]
A critical issue in cases involving
supervisory responsibilities will often be whether a specialist
acted reasonably in relying on the actions of a junior doctor. In
deciding this issue, the Commissioner will consider several factors
including the junior doctor's stage of training and the
specialist's past experience with that particular junior doctor.
For example, a first-year house officer not previously known to the
specialist would require close supervision. At times, this may
involve the specialist personally confirming key aspects of the
history and physical examination and reviewing the appropriateness
of diagnoses, investigations and management plans. Conversely, if a
specialist has worked closely with a very competent senior
registrar for several years, it would usually be reasonable for the
specialist to rely on the accuracy of that registrar's history
taking and physical findings, and the appropriateness of his or her
management plans. The risks associated with delegating a task to a
junior doctor about whom little is known are illustrated by the
recent Medical Practitioners Disciplinary Tribunal case of Director
of Proceedings (Mrs Vinuela) v Dr K McKenzie.[21] ,
[22]
Mrs Vinuela was admitted to hospital
for the delivery of her seventh baby. She was 42 years old, obese,
with high blood pressure, had a history of large babies and had had
a previous emergency Caesarean section for foetal distress. Dr
McKenzie, the registrar on call, delegated management of Mrs
Vinuela's labour to Miss Killeen, a senior midwife, and Dr Karim, a
senior house surgeon from Iraq. Dr McKenzie had never worked
directly with Dr Karim, but had been told that Dr Karim was a very
experienced doctor who would soon be considered for a registrar's
position.
During the labour, Dr McKenzie
relied on reports from Dr Karim and Miss Killeen and did not
personally assess Mrs Vinuela until urgently summoned when the CTG
indicated that the baby's heartbeat had ceased. Dr Karim appears to
have departed from the agreed management plan and missed warning
signs of fetal distress. The baby was born without a heartbeat and
could not be resuscitated. The Tribunal found that Dr McKenzie
failed to take responsibility and fulfil the role expected of a
registrar when supervising junior staff, but that her conduct in
this regard did not fall so far short of acceptable standards as to
warrant the sanction of an adverse disciplinary finding. The
Tribunal commented that any person bearing professional
responsibilities must be "both cautious and diligent in delegating
those responsibilities to more junior practitioners. This is
especially the case when the person to whom responsibility is
delegated is not well known to the delegator, and the delegator has
had no opportunity to personally assess the expertise, experience
and judgment of the delegatee."
The Medical Practitioners
Disciplinary Tribunal recently held that a private specialist
responsible for a private patient admitted under the public
hospital system also has a duty to provide supervision with
reasonable care and skill.[23]
Mrs Marinkovich was a private
patient under the care of Dr Parry during her pregnancy with twins.
Late in the pregnancy she developed pre-eclampsia, and Dr Parry
performed a Caesarean section at Whangarei Hospital. From the time
of the Caesarean section, Mrs Marinkovich came under the public
hospital system but it was agreed that Dr Parry continued to be
responsible for her care. During the post-operative period Mrs
Marinkovich's urinary output was not closely monitored and no blood
tests were taken to check for biochemical changes. Mrs Marinkovich
developed a rare complication resulting in renal failure and she
required admission to an intensive care unit.
The Tribunal found Dr Parry guilty
of conduct unbecoming a medical practitioner for failing to ensure
that the doctors and nurses in the Whangarei Hospital obstetric
team on duty after Mrs Marinkovich's Caesarean section
appropriately monitored and reported her progress to him. In
particular, the Tribunal found it unacceptable that Dr Parry had
not communicated with any of the medical staff on call even though
he knew that he was going to be out of Whangarei for the whole of
the day following the Caesarean section. His stated expectation
that he would be called if there was a problem was not a
satisfactory discharge of his professional obligations.
Hospitals are also health care
providers with a duty to act with reasonable care and skill. In the
following case a hospital was found in breach of the Code for
failing to have appropriate policies and procedures in place to
deal with issues relating to the supervisory responsibilities of
specialists.[24]
A 19-year-old man was admitted to a
rural accident and emergency department following a 15-metre fall
from a building while intoxicated. The sole doctor covering the
emergency department was a first-year house surgeon, unfamiliar
with the management of major trauma. The house surgeon tried
unsuccessfully for over an hour to contact her registrar for advice
and assistance. She was apparently unaware that house surgeons were
able to call consultants directly if the registrar was unavailable.
The patient subsequently suffered a cerebral herniation secondary
to a large extradural haematoma and died. The Commissioner did not
find the on-call consultant in breach of his supervisory
responsibilities as he was unaware of the admission. However, the
hospital was found in breach of the Code for failing to provide
clear instructions about when junior medical staff should contact
the on-call consultant. The Commissioner recommended that the
hospital develop a written policy stating that where house surgeons
are unable to contact a registrar, a call is to be made to the
on-call consultant.
Right 4(2): Right to have
services provided that comply with legal, professional, ethical,
and other relevant standards
Right 4(2) gives every consumer the
right to have services provided that comply with legal,
professional, ethical, and other relevant standards. Although Right
4(2) makes reference to "standards", the Code is not, and should
not be, the primary mechanism for the establishment of standards.
The Code is a means by which standards set by other bodies can be
enforced. Ultimately, the responsibility for establishing and
maintaining quality standards should lie with the medical
profession itself.
There is no statute law in New
Zealand that sets an explicit legal standard for specialists'
supervisory responsibilities although, as mentioned above, the
Medical Practitioners Act 1995 (NZ) makes reference to various
forms of supervision. The Medical Council has advised that an
overseer may be liable in negligence if he or she becomes aware, or
should have been aware, that the overseen doctor was not competent
or fit to practise medicine for some reason and takes no
action.[25] The key difference between the
responsibilities of an overseer and those of a clinical supervisor
is that a clinical supervisor, as leader of the clinical team, owes
his or her main duty of care to the patients under the junior
doctor's care, not to the junior doctor.
In applying Right 4(2) to the facts
of a complaint, the Commissioner can make reference to any
established professional standards. In a case involving supervisory
responsibilities, the main sources of such standards would be
professional Colleges, the Medical Council of New Zealand, hospital
policies and evidence from expert advisors. If the relevant
standards are unclear, or seem significantly flawed, it is open to
the Commissioner to consider international guidelines.
Many professional Colleges outline
their policies on the responsibilities of specialists in
supervising registrars. As mentioned above, this form of
supervision primarily requires the establishment of a one-to-one
relationship between a specialist and a registrar with the main
focus being the achievement of educational goals, although many of
the College guidelines have broader application. The Medical
Council of New Zealand publishes very useful generic guidelines for
consultants supervising junior doctors.[26] The Medical
Council emphasises that these guidelines are ideals only, not
mandatory standards. The standards discuss general attributes of
supervising consultants, time commitment, orientation programmes
and reporting and feedback. Several hospitals and hospital
departments have also developed policies, guidelines and standing
orders that relate to the issue of supervision.
Expert advisors are consulted by the
Commissioner to give advice on any issue relating to professional
standards. Experts are nominated by the professional Colleges as
people who have extensive knowledge and experience in the
speciality.
In general, specialists have
responsibility for maintaining professional standards in relation
to the patient's overall care, as illustrated by the following
case.
A 44-year-old man was admitted to a
rural hospital with a history of headache, confusion and
incontinence following a fall. The admitting house surgeon recorded
only a cursory examination of the patient's nervous system, and
failed to document whether the patient was oriented. During the
patient's admission, the notes from the ward rounds were brief and
incomplete. The expert advisor advised that the standard of
clinical documentation by medical staff was unacceptably poor. The
advisor also stated that it is the consultant's responsibility to
ensure that the clinical records kept by medical staff comply with
professional standards. The Commissioner found that "by not
ensuring that the patient's clinical records were full and
comprehensive, the physician did not fulfil his responsibilities as
a consultant to ensure that clinical records completed by medical
staff complied with professional standards. ... [T] he
physician therefore breached Right 4(2) of the Code." The
Commissioner recommended that the physician apologise to the
patient and his family in writing, and review his practice to
ensure that accurate and comprehensive records are kept for all
patients under his care.[27]
Professional standards also require
that specialists respond appropriately to requests by junior
doctors for assistance. The following case was recently decided by
the Medical Practitioners Disciplinary Tribunal.
A surgical registrar at Dunedin
Hospital diagnosed a patient with appendicitis. In accordance with
hospital policy, she informed Mr Phipps, the consultant surgeon on
call, of her plan to excise the appendix. At operation, when the
registrar was unable to locate the appendix, she contacted Mr
Phipps to advise him of the difficulties she was experiencing. She
advised the Tribunal: "I left Mr Phipps in no doubt about the need
for him to come back and help me." Rather than go to the hospital,
Mr Phipps gave telephone instructions for the registrar to insert a
drain in the patient's abdomen, sew her up and start antibiotics.
The patient consequently required a second operation, was off work
for 16 weeks, and suffered extensive scarring. The Tribunal found
that Mr Phipps, as the consultant surgeon on call, had a duty to be
available while the operation was undertaken, supervise his
registrar in an appropriate way, and attend the operating theatre
when he was informed of the difficulty she was having. The Tribunal
found that he failed to discharge each of those duties, and was
guilty of conduct unbecoming a medical professional.
[28]
The Tribunal noted that the
following statement from a Dunedin Hospital protocol properly
reflects the obligations that consultant surgeons have when
supervising trainees:
"While we have the privilege of
training juniors and benefiting from their assistance in looking
after our patients we have a responsibility to them and to our
patients to provide close supervision. While this will vary with
the ability and maturity of these doctors and how well we know
their attributes and our confidence in them the responsibility and
consequences of delegation is ours ... Surgeons should be aware at
all times of the responsibilities being taken by juniors on their
behalf in particular when significant events occur or decisions
need to be made with their patients especially when they are
particularly sick. Similarly there should be a low threshold to
attend these patients and to be available to the juniors when they
express concern or are dealing with problems beyond their
experience or ability. Assistance should be offered when there is
any sense of doubt by the trainee - it should always be provided
where the surgeon has any doubt."[29]
Right 4(5): The right to
co-operation between providers
Under Right 4(5), every consumer has
the right to co-operation among providers to ensure quality and
continuity of services. This right includes co-operation among
providers within a clinical team, as well as between different
health and disability services. The following case involved a
specialist who failed to co-operate with other providers within a
hospital setting.
A patient on renal dialysis was
admitted to an orthopaedic ward for knee surgery. After the surgery
she had difficulty with her dialysis. The orthopaedic surgeon
advised that on three occasions he requested his house surgeon to
transfer the patient to the care of the medical team. This was not
done, and the patient's condition deteriorated. The Commissioner
found that " ... there is no evidence, in the medical notes, that
the surgeon followed up to find out who was managing the consumer's
medical care, or why she remained in the surgical ward undertaking
her own dialysis ... The consultant's failure to ensure overall
management of the consumer's needs, and to co-operate with other
providers at the hospital as demanded by Right 4(5), led to a
deterioration in Mrs B's condition." The Commissioner recommended
that in future the orthopaedic surgeon should communicate
effectively with other providers within the hospital to ensure
appropriate management of orthopaedic patients with co-existing
medical conditions. A written apology to the patient's family was
also recommended.[30]
Right 6 - The right to be fully
informed
Right 6, the right to be fully
informed, reflects the common law standard for informed consent
formulated in Rogers v Whitaker.[31] Right 6(1) gives
every consumer the right to the information that a reasonable
consumer, in that consumer's circumstances, would expect to
receive, including notification of any proposed participation in
teaching. Right 6(3) states that every consumer has the right to
honest and accurate answers to questions about the identity and
qualifications of the provider.
Appropriate information will
sometimes include advice that an assessment or treatment will be
carried out by a junior doctor under specialist supervision, as in
the following case.[32]
In a 1997 Medical Practitioners
Disciplinary Tribunal case a urology registrar was asked to take
over a consultant's operating list at the last minute due to
illness. The registrar, who had limited experience in performing
hydrocoele operations, carried out surgery on a young boy to repair
a hydrocoele. When the registrar ran into difficulties during the
operation, he called for a consultant, who was involved in an
outpatient clinic, to come and assist. (The supervising consultant
was carrying out his own list at another hospital, and was less
quickly available.) While waiting for the consultant to arrive, the
registrar continued with the operation, and unintentionally divided
the spermatic cord, resulting in loss of the testicle. The child's
mother had been under the impression that a consultant would be
performing the operation. She stated that "if she had known that a
registrar was going to be performing the operation unsupervised,
she would have asked for the operation to be delayed until a more
experienced doctor was available". The charge against the registrar
was dismissed, but the Tribunal commented that in situations where
there is an expectation that the surgery will be performed by a
consultant, the patient or parents should be informed if the person
performing the operation will be a registrar.
Ethical tensions in setting
standards for supervision
In the area of specialist
responsibility for junior doctors, the main ethical tensions are
between the quality of patient care, the training needs of junior
doctors, and resource constraints. Although requiring the most
experienced specialist in the hospital to provide all clinical care
might provide the best care in the short term, this would not be
practical or desirable.
A fine balance must be maintained
between ensuring that patients receive a reasonable standard of
care, while giving junior doctors increasing leeway to make
decisions and carry out treatment in preparation for independent
specialist practice. There must be a clear recognition of the
specialist's duty of care to his or her patients, but there is also
a duty to society to train the next generation of specialists. If
supervision is too close, junior doctors do not acquire independent
decision-making skills. On the other hand, if supervision is not
close enough, patient safety may be jeopardised.
Hospitals rely on the ability of
junior doctors to carry out certain tasks independently, and
specialists should be able to expect a certain level of competence
from junior staff. Larger hospitals are staffed on the basis that
much of the work, particularly out-of-hours work, will be done by
junior doctors with access to advice, but not direct supervision.
If specialists spend too much time supervising or doing the work
themselves, wider service requirements cannot be met. In some
overseas countries, there are moves towards having more specialists
in hospitals 24 hours a day. For example, in some European
Intensive Care Units specialists sleep in the hospital when it is
their night to be on call to support their junior.[33]
This sort of "gold standard" of supervision may simply be
unaffordable in our current health system.
Clause 3 defence
One of the leading texts on medical
law[34] takes the approach that "each member of the team
of doctors will be deemed to have separately undertaken the care of
the patient ... However, the consultant as leader of the team
remains responsible throughout." This statement suggests that
specialists may be liable for the actions of junior members of the
team, regardless of any fault element. However, under Clause 3 of
the Code a specialist who establishes that he or she took
"reasonable actions in the circumstances" - including the
particular context of supervision of a junior doctor - will not be
found in breach of the Code.[35]
It is impracticable for a specialist
to oversee every decision made by junior doctors, and tasks may be
delegated where appropriate. If a junior doctor makes an error
while carrying out a task within his or her core duties, and the
specialist had good reason to believe the doctor was competent to
carry out such duties, the specialist would be unlikely to be held
responsible for the error.
An after-hours house surgeon wrote a
discharge prescription for 500mg warfarin instead of 5mg warfarin,
and was found to have breached Right 4(2) and Right 4(4) of the
Code. The Commissioner did not investigate the involvement of the
consultant.[36]
A junior doctor also has a
responsibility to seek assistance when needed, and may be found in
breach of the Code for failing to consult with the supervising
specialist appropriately, as in the following
case.[37]
A consumer with advanced cancer of
the oesophagus was assessed as requiring radiotherapy. The
consultant oncologist filled in a Radiotherapy Planning Request
Form, and indicated on the form that he wished to personally
oversee the treatment. Two days later, a junior oncology registrar
met with the consumer and prescribed an incorrect dose of
radiotherapy. The consumer suffered a disabling spinal cord injury.
The registrar was found to have breached Right 4(1) of the Code by
failing to consult with the consultant, or review the consultant's
notes prior to prescribing the consumer's treatment. (The hospital
policy has since been changed to require all prescriptions for
radiotherapy to be countersigned by a consultant.)
A mere lack of knowledge about the
patient will not necessarily be sufficient to exonerate a
specialist, as illustrated by the following case from the Medical
Practitioners Disciplinary Committee.[38]
A woman with a history of a previous
Caesarean section was admitted to hospital in labour. A ten-hour
trial of labour, managed by a house surgeon and registrar, resulted
in a ruptured uterus and a brain-damaged baby. The registrar did
not inform the consultant at any time of the trial of labour. The
Committee found that "the failure of the registrar to contact the
consultant was because the consultant had not laid down a policy of
regular consultation". Following the birth, the consultant failed
to adequately communicate with the mother about the problems at the
birth, and did not carry out a review of the labour to identify
where management problems arose. The Medical Practitioners
Disciplinary Committee made a finding of professional misconduct,
and expressed "great concern about specialist services where a
patient was admitted under a consultant and managed totally by
junior staff without reference to a consultant".
Clause 3 can also be used to ensure
that an undue focus on the rights of individual patients does not
impair specialists' ability to adequately train the next generation
of doctors to meet the needs of future patients. Consider the
scenario where, in accordance with right 6 of the Code, a patient
facing a hernia operation is told that there are three members of
the team:
a) the specialist who has been in
surgery for 20 years, is a Fellow of the Royal Australasian College
of Surgeons and has performed 1000 such operations;
b) the fourth-year advanced trainee
who has passed the Part 1 exams towards becoming a Fellow of the
Royal Australasian College of Surgeons and has done 60 operations;
and
c) the basic trainee in his first
year of surgery who has done two (heavily assisted) hernia
operations.
There would be little doubt that
given a free choice of surgeon the patient would choose the
specialist.[39] However, the reality of staff
availability and registrar training schemes within the public
hospital system is that patients do not have a free choice of
provider. If an operation is to be carried out by a trainee under
specialist supervision, the patient may make an informed choice to
refuse or delay treatment, but does not have the right to demand
that the specialist perform the procedure where this is not
reasonably practicable.
Right 7(8) of the Code recognises
that a patient has the right to express a preference about who will
provide services, and have that preference met "where
practicable".
Some keys to good
supervision
Ensuring that the next generation of
doctors is adequately trained and suitably experienced without
compromising patient care has been described as "perhaps the
greatest professional challenge" facing doctors.[40]
The following suggestions for
improving supervision emerge as common themes from information
provided by the Medical Council,[41] the Medical
Practitioners Disciplinary Tribunal, the professional Colleges,
hospitals and expert advisors.
Junior doctors should participate in
an orientation programme whenever they move to a new speciality or
a new hospital. The Medical Council suggests that such an
orientation programme should include information on "how the
consultant likes things to be done on their particular run and in
that hospital, with a clear indication of the consultant's
expectations". Those practitioners charged with supervising
inexperienced or junior staff need to be diligent at the outset of
the teaching relationship about the need for close supervision and
regular checking.[42]
The Medical Council also recommends
that junior doctors be informed about lines of communication with
their specialist during normal working hours and on-call hours.
Ground rules for communicating with other team members should also
be set out and, in the case of house officers, it should be made
clear that if they are not satisfied with the response they get
from their registrar, they should contact the specialist
directly.
The Medical Council recommends that
specialists have a regular and well-understood timetable so that
junior doctors know where and how to contact them. Junior doctors
should be encouraged to contact specialists early, rather than
battle on alone until the situation is irretrievable. Junior
doctors should be encouraged to preface phone conversations with
clear indicators of why they are calling - for approval of a
management plan, advice, or active assistance.[43]
The expected response of a
specialist to calls for advice profoundly affects the behaviour of
junior staff.[44] A recent literature review confirms
that the supervision relationship is probably the single most
important factor in the effectiveness of supervision, and is more
important than the supervisory methods used.[45] If
specialists are available and approachable, junior doctors are far
more likely to contact them when they need advice or hands-on
help.
Clear clinical notes, including
comprehensive management plans, can be an invaluable aid to junior
doctors. Such management plans help to ensure that the patient is
treated in accordance with the specialist's wishes, and can include
parameters clarifying when specialist involvement is required for
that particular patient. These plans serve as an aid to, rather
than a substitute for, the junior doctor's clinical judgement.
The Medical Council recommends
regular feedback to junior doctors as an integral part of the
supervision process. In particular, it is recommended that
specialists seek the opinion of other ward staff, including the
charge nurse, on the junior doctor's performance, and do not let
poor performance go unaddressed.
The development of written policies,
based on established professional standards, help to protect the
interests of the patient, the specialist, and the junior doctor.
Several hospital departments have already developed guidelines
defining the specific duties of junior doctors, and suggestions on
when it is appropriate to contact specialists. These guidelines can
be issued during the orientation process. For example, in Dunedin
Hospital, the on-call cardiologist must be advised when any patient
is admitted to the Coronary Care Unit. At Waikato Hospital an
obstetrics and gynaecology registrar must contact an obstetrician
before carrying out a surgical procedure more complicated than a
forceps or ventouse delivery. At the Rotorua Woman, Child and
Family Unit, standing orders state that it is the duty of the house
surgeon to examine all patients coming under his or her care
immediately after they have been admitted. The house surgeon must
as a minimum notify his or her senior officer of all emergencies,
unforeseen complications and cases where the question of operation
arises. The timing of such notification can be varied by agreement
depending on the experience of the junior doctor. The standing
orders state that once notified of a problem, the senior medical
officer becomes responsible.[46]
If junior doctors are well tutored
and given clear criteria for seeking assistance, there should be
little or no adverse effect on patient care.[47]
Conclusion
Due to changes in the health system
over the last 20 years, there has been a change in the nature and
level of supervision required.
The Code of Health and Disability
Services Consumers' Rights provides that every consumer has the
right to services of an appropriate standard. If a specialist fails
to supervise junior doctors adequately, he or she may be found in
breach of the Code. The relevant standards are primarily those set
by the medical profession itself, and will vary depending on the
setting in which the specialist is based.
The basic principle in New Zealand
appears to be that a specialist has responsibility for the overall
clinical care and management of the patients under his or her care.
However, he or she may delegate aspects of care, and is entitled to
rely on information and assessment from junior doctors, so long as
he or she has good reason to believe that they are competent to
carry out such tasks. Where aspects of clinical care are delegated
to junior doctors, specialists have a duty to provide supervision
with reasonable care and skill and in accordance with professional
standards.
Due to changes in the health system
over the last 20 years, there has been a change in the nature and
level of supervision required. The development of written
guidelines helps to clarify the professional supervisory
responsibilities of specialists, and will benefit patients, junior
doctors, and specialists.
Acknowledgements
Dr Debbie Antcliff Dr Johan
Morreau
Ms Gay Fraser Dr Ray Naden
Dr Malcolm Futter Dame Norma
Restieaux
Dr Peter Holst Dr Ron
Trubuhovich
Dr Sharon Kletchko Dr Marie van
Wyk
Dr David McHaffie Dr Jenny
Westgate
--------------------------------------------------------------------------------
[1] See, eg, Australia
and New Zealand College of Anaesthetists, Supervisors of Training
in Anaesthesia (ANZCA, 1997).
[2] I St George (ed),
Cole's Medical Practice in New Zealand (Medical Council of New
Zealand, Wellington, 2001), p 155.
[3] Medical Council of
New Zealand, Annual Report for the year ending 31 March 2001, p
21.
[4] Medical Practitioners
Disciplinary Tribunal: Director of Proceedings v McKenzie, Decision
No 177/01/77D (2001).
[5] Ibid.
[6] R A Fox, C C L
Ingham, A D Scotland and J E Dacre, "A Study of Pre-registration
House Officers' Clinical Skills" (2000) 34(12) Medical Education
1007.
[7] A W Wu, S Folman, S J
McPhee and B Lo Bernard, "Do House Officers Learn from their
Mistakes?" (1991) 265(16) Journal of the American Medical
Association 2089.
[8] D C Yao and S M
Wright, "National Survey of Internal Medicine Residency Program
Directors regarding Problem Residents" (2000) 284(9) Journal of the
American Medical Association 1099.
[9] Personal
communication, Dr Jenny Westgate, Associate Professor in Obstetrics
and Gynaecology, University of Auckland, 31 January 2001.
[10] On the positive
side, some surgical skills that were previously learned on patients
can now be acquired in skills laboratories in which surgeons can be
trained using synthetic materials, animal tissues and computer
simulations. Personal communication, Mr John Simpson, Royal
Australasian College of Surgeons, 16 October 2001.
[11] Annual Report of the
Health and Disability Commissioner for the year ended 30 June 2001,
pp 6-8.
[12] Personal
communication, Dr Jenny Westgate, Associate Professor in Obstetrics
and Gynaecology, University of Auckland, 31 January 2001.
[13] S Cartwright, The
Report of the Cervical Cancer Inquiry (Government Printing Office,
Auckland, 1988).
[14] Health and
Disability Commissioner Act 1994 (NZ), s 6.
[15] Health and
Disability Commissioner (Code of Health and Disability Services
Consumers' Rights) Regulations 1996 (NZ).
[16] Ibid, Clause
3(1).
[17] Ibid, Clause
3(2).
[18] Bolam v Friern
Hospital Management Committee [1957] 1 WLR 582.
[19] Bolitho (Deceased) v
City and Hackney HA [1998] AC 232 House of Lords per
Lord Browne-Wilkinson.
[20] Medical
Practitioners Disciplinary Committee, "Failure to Assess Leg
Injury" (1990) 103 New Zealand Medical Journal 284.
[21] Medical
Practitioners Disciplinary Tribunal, Decision 177/01/77D
(2001).
[22] Dr McKenzie was a
registrar, delegating tasks to a house surgeon, but the same
principles would apply to specialists delegating to junior
doctors.
[23] Medical
Practitioners Disciplinary Tribunal, Decision 179/00/69C
(2001).
[24] www.hdc.org.nz/opin,
98HDC13685 (2001).
[25] Medical Council of
New Zealand, Statement on General Oversight (Wellington, 2001).
[26] See, eg, Medical
Council of New Zealand, Statement on Supervision for Class 1
Probationary Registrants in Emergency Departments and on Night
Cover (1996).
[27] www.hdc.org.nz/opin,
98HDC21016 (2000).
[28] Medical
Practitioners Disciplinary Tribunal, Decision 156/99/43C
(2001).
[29] Medical
Practitioners Disciplinary Tribunal, Decision 156/99/43C, 13-15
(2001).
[30] www.hdc.org/opin,
97HDC10799 (1999).
[31] Rogers v Whitaker
(1992) 175 CLR 479.
[32] Medical
Practitioners Disciplinary Tribunal, Decision 18/97/10C (1997).
[33] Personal
communication, Dr Ron Trubuhovich, Honorary Consultant Intensivist,
Auckland Hospital, 20 January 2001.
[34] I Kennedy and A
Grubb, Medical Law (Butterworths, London, 1994), p 69.
[35] Clause 3 of the
Code.
[36] www.hdc.org.nz/opin,
98HDC15093 (1999).
[37] www.hdc.org.nz/opin,
98HDC15902 (2000).
[38] Medical
Practitioners Disciplinary Committee, "Inadequate Obstetric
Supervision at a Base Hospital" (1990) 103 New Zealand Medical
Journal 330.
[39] Personal
communication, Mr John Simpson, Royal Australasian College of
Surgeons, 16 October 2001.
[40] Personal
communication, Mr John Simpson, Royal Australasian College of
Surgeons, 16 October 2001.
[41] Medical Council of
New Zealand, Guidelines for Consultants Supervising Resident
Medical Officers (MCNZ, Wellington, 1999).
[42] Medical
Practitioners Disciplinary Tribunal: Director of Proceedings (Mrs
Vinuela) v Dr K McKenzie, Decision Number 177/01/77D (2001).
[43] Personal
communication, Dr David McHaffie, Cardiologist, Wellington
Hospital, 21 January 2001.
[44] Personal
communication, Dr Ron Trubuhovich, Honorary Consultant Intensivist,
Auckland Hospital, 20 January 2001.
[45] S M Kilminster and B
C Jolly, "Effective Supervision in Clinical Practice Settings: A
Literature Review" (2000) 34(10) Medical Education 827.
[46] Personal
communication, Dr Johan Morreau, Service Director, Woman, Child and
Family Service, Rotorua, 9 February 2001.
[47] Personal
communication, Mr John Simpson, Royal Australasian College of
Surgeons, 16 October 2001.