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Practising within your expertise

It is easier than you think to stray outside your competency, with numerous opportunities across a range of scenarios. Dr Janet Page, MPS medicolegal adviser, charts your path through the pitfalls

The duty of a doctor to act within his or her expertise has its origins in the Hippocratic Oath, believed to have been written nearly 2,500 years ago, when a physician promised to prescribe in the interests of his patients according to his ability and judgment.

Today, the same ethical principles are captured in the codes of professional conduct for doctors laid down by Medical Councils throughout the world.

A doctor shall not persist in unsupervised practice of a branch of medicine without having the appropriate knowledge and skill or having the required experience

The Singapore Medical Council’s (SMC) Ethical Code and Ethical Guidelines states: “A doctor shall practise within the limits of his own competence in managing a patient. Where he believes that this is exceeded, he shall offer to refer the patient to another doctor with the necessary expertise. A doctor shall not persist in unsupervised practice of a branch of medicine without having the appropriate knowledge and skill or having the required experience.”

Similarly, the Malaysian Medical Council’s Code of Professional Conduct advises: “It is good medical practice to refer a patient for definitive management by a colleague who has special training or expertise in dealing with a complex clinical problem. A doctor must accept his own limitations in professional competence in these special instances and be prepared to refer a patient to another doctor.”

This article highlights the way in which the duty to act within expertise impacts on a number of key areas of a doctor’s professional practice.

Practising within specialty boundaries

All doctors should be aware of the limitations of their training and experience and confine their practice to those areas in which they have the appropriate expertise. It is particularly important for doctors in training to be aware of their limitations and seek advice and guidance from senior colleagues where appropriate.

Knowing the boundaries of one’s practice is not always as straightforward as one might anticipate. With the advent of super-specialisation, new hybrid specialties have developed; for example, oncological surgery and bariatric surgery. Some procedures may fall within the purview of different specialties – for example, endovascular procedures may quite properly be undertaken by both vascular surgeons and radiologists. What matters are that the doctor concerned has undergone the necessary training and has the appropriate skills and knowledge to carry the proposed role, and that their background specialty is relevant.

GPs carrying out cosmetic procedures need to be particularly mindful of their responsibilities in this regard and ensure that they are not undertaking procedures that should properly be the remit of a cosmetic or plastic surgeon.

Doctors in Singapore should refer to the Guidelines on Aesthetic Practices 2008and subsequent versions for further details of eligibility criteria, and be mindful that a breach of the guidelines could result in disciplinary action being taken against them.

GPs carrying out cosmetic procedures need to be particularly mindful of their responsibilities

Consent issues

If you propose to recommend to a patient a course of treatment or an intervention with which you have limited personal experience, you should make this known to the patient as part of the consent process. You must answer honestly any questions put to you by your patients about your expertise in any given area.

Before embarking on the proposed treatment you should ensure you have access to appropriate specialist advice and support. Valid consent is particularly important when undertaking a new procedure or treatment which has not yet been fully evaluated or established.

Valid consent is particularly important when undertaking a new procedure or treatment which has not yet been fully evaluated or established
The Medical Council of Hong Kong (MCHK), in itsCode of Professional Conduct, emphasises the importance of valid consent in these circumstances and places an obligation on the practitioner to ensure that there are good grounds to expect results equal to or better than alternative treatments. Doctors are required to ensure that they are properly prepared and have the appropriate facilities to meet the undertaking, as well as to deal with any complications that may arise.

Responsibility for ensuring expertise of others

In addition to being bound to act within his expertise, a doctor also has, to a limited extent, a responsibility to satisfy himself that those colleagues to whom he refers patients have the necessary expertise to provide the service requested. This also applies to referrals for medical tourism or telemedicine, where the operator or clinician giving the advice may be located in another jurisdiction. On this issue, the MCHK advises:

“A doctor may refer a patient for diagnostic or therapeutic services to another doctor, a practitioner with limited registration, or any other provider of health care services permitted in law to furnish such services, if in his clinical judgment this may benefit the patient. Referrals to medical specialists should be based on their individual competence and ability to perform the service needed by the patient. A doctor should not so refer a patient unless he is confident that the services provided on referral will be performed competently and in accordance with accepted scientific standards and legal requirements.”

Treating patients who refuse referral

What should a doctor do if he feels he is straying outside the boundaries of his professional competence in managing a patient but the patient refuses to accept referral to another doctor? In this situation the doctor should explain to the patient why he wishes to obtain a specialist opinion and the limitations of what he personally can do for them.

The doctor should explain to the patient why he wishes to obtain a specialist opinion and the limitations of what he personally can do for them
He should try to persuade the patient to agree to the referral, but if he can’t, the SMC advises that the doctor may continue to treat the patient but should do so in consultation with a specialist, provided he believes he is acting in the patient’s best interests.

Prescribing unfamiliar drugs

One situation that occurs from time to time is when a specialist colleague asks a GP to prescribe a drug with which the GP is unfamiliar. In these circumstances, it is acceptable for the GP to prescribe under the supervision of or in consultation with the specialist, having familiarised himself with the proposed prescribing regime, potential side effects and any arrangements for monitoring that may be necessary.

If the GP does not feel confident that he has the necessary skills or support to enable him to prescribe safely under these circumstances then he is not obliged to do so, and should advise the specialist of his concerns so that alternative arrangements can be made for the patient’s treatment. This is a particular issue with off-label prescribing, for which the prescribing doctor retains legal responsibility.

Care and treatment in an emergency

In an emergency, doctors are expected to offer assistance, whether or not they feel that they are the best person to provide treatment. In these circumstances, a doctor is expected to do what he can in terms of providing first aid or immediately necessary treatment, within the limits of his competence, to ensure that the patient’s condition is stabilised and, at the very least, to prevent others from doing harm.

In an emergency, doctors are expected to offer assistance, whether or not they feel that they are the best person to provide treatment

Case example

Dr Lim, a dermatologist, is walking along a busy street when a cyclist comes out of a side road and is hit by a car. Dr Lim runs over to give first aid. The cyclist is unconscious. Dr Lim prevents the other bystanders from trying to move the patient, checks the cyclist is breathing and asks someone to call for an ambulance. The cyclist’s leg is bent awkwardly, suggestive of a probable fracture. Dr Lim hasn’t done any trauma work since he qualified 20 years ago. He checks distal pulses are present but does not attempt to straighten or otherwise manipulate the fracture, instead waiting for the ambulance crew to take over.

Acting as a professional or expert witness

The duty to act within one’s expertise extends beyond the remit of day-to-day clinical practice and is equally applicable to writing reports and giving evidence in court. As in clinical practice, when giving an opinion in these circumstances, doctors should ensure that they confine themselves to matters within their expertise and that they are prepared to justify their opinion and support it with evidence if called upon to do so. Before accepting instructions to act as an expert, doctors should ensure that they have the appropriate skills and knowledge to fulfil the requirements of the proposed brief.

Case example

Dr Ho, a family physician, is approached by solicitors acting on behalf of relatives of Madam Ng, a former patient with progressive vascular dementia, who recently died. There is a dispute over Madam Ng’s will and Dr Ho is asked to write a report about her testamentary capacity. He provides the report, stating that in his opinion Madam Ng had capacity at the time she made her will.

He is called to give evidence in court, where it becomes evident that Dr Ho did not make a formal assessment of Madam Ng’s capacity when he wrote the report, nor can he recall the elements of the tests he should have applied when assessing testamentary capacity. Dr Ho’s credibility is called into question and, as a result, the relatives’ claim fails. They complain to the Medical Council, who reprimand Dr Ho for acting outside his expertise.

Acting outside one’s own experience and knowledge, even with the best of intentions, is rarely in the patient’s best interests

Finally, one of the basic tenets of medical ethics is primum non nocere (first do no harm), another element of the Hippocratic Oath. Acting outside one’s own experience and knowledge, even with the best of intentions, is rarely in the patient’s best interests. Doctors should know their limitations and, when faced with matters beyond their personal expertise, refer patients to those with the appropriate knowledge and skills. In an emergency or where the patient refuses specialist referral, the doctor should do the best he can for the patient within the limitations of his capability.

Important MPS update

Your specialty: are you paying the right subscription?

There is unsurprisingly no general agreement within the profession about specialty boundaries and the procedures they can do. Nevertheless we expect a member to have been appropriately trained, be competent and work within his/her limitations.

Another difficulty arises when a member from a low risk specialty performs the same procedures that are normally performed and would be reasonably expected to be within a higher risk specialty. Members in such a situation must inform MPS so that we can assess whether in fact it would be appropriate to charge a higher subscription in the interests of fairness to all members since the risk would be that of the other high risk specialty group.

Over the years, MPS has been involved in a number of cases where members have been carrying out procedures for which they are not appropriately indemnified. These doctors often may have been paying a lower rate of subscription to MPS but are carrying out high-risk procedures. MPS would like to remind all members to inform us when the scope of your medical practice changes in any way.

If you did find yourself in the position of asking us for assistance after a complaint has been made, and you have not been paying the appropriate indemnity rate at the time of the incident, it may well call into question if we would be able to assist and ultimately you could be liable for covering the costs of any claims that ensue. If you think you may not be paying the correct subscription rate, please contact us to discuss by emailing wendyh@hkma.org, quoting your MPS membership number.

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