It is perhaps an understatement to say that teamwork is integral to the safe delivery of care within medicine, and the professional approach to good teamwork centres on good communication, mutual respect for others and proactively responding to any deficiencies in the team. Working with colleagues formed 7% of the fitnessto- practise hearings conducted in 2011 and the GMC provides comprehensive guidance on the topic.
In 1999, the BMJ published research that had looked into bullying at a community NHS trust. It found that 38% of staff had reported being on the receiving end of bullying, while 42% said they had witnessed it.14 Your relationships with your colleagues should be comparable with those you have with your patients. As a healthcare professional, you set an example to others and are a role model to the rest of society – malicious behaviour has no place in the conduct of the meticulous, upstanding professional person.
Safe delegation and referral is another area of your work with colleagues where your professionalism can be called into question. When delegating a task – or, as a junior doctor, when a task has been delegated to you – all parties must be sure that the doctor to whom the task has been assigned has the competency to carry it out. Inappropriate delegation can lead to grave errors of judgment and, in some cases, adverse patient outcomes – MPS has experience of many such cases.
When delegating a task, the GMC says in paragraph 45 of Good Medical Practice: “When you do not provide your patients’ care yourself, for example when you are off duty, or you delegate the care of a patient to a colleague, you must be satisfied that the person providing care has the appropriate qualifications, skills and experience to provide safe care for the patient.”
Continuity of care is essential and you must ensure any transition of care, including referrals, is properly handled. This relies on clear lines of communication with colleagues and an equally clear line of responsibility.
CASE STUDY: We don’t talk anymore
Allowing personal rivalries and feuds to fester in the workplace is unprofessional in the first place; allowing them to interfere with the care of the patient is serious misconduct. This case highlights how such an incident didn’t just land the doctors involved before the GMC – it also landed them in court.
Mr Y, a 35-year-old marine engineer, was undergoing surgery in the posterior compartment of the thigh to treat a congenital vascular lesion. Mr O, consultant vascular surgeon, was carrying out the procedure. The lesion was closely related to the sciatic nerve and some of its branches, and Mr O was hoping to avoid damaging the sciatic bundle, if possible.
The anaesthetic was given by Dr A, consultant anaesthetist. During the induction phase Mr Y had suffered repeated generalised muscular spasms, so Dr A had given a muscle relaxant, to prevent intraoperative movement of the surgical field.
During the course of surgery, Mr O used tactile stimulation to attempt to determine whether a nerve which was likely to be compromised by his surgical approach was the sciatic nerve, or a branch of the peroneal nerve. Reassured by a lack of contraction of relevant muscle groups, he continued to operate under the impression that the structure about which he was concerned was not the sciatic nerve.
Unfortunately, in the context of neuromuscular blockade there was no rationale for this approach. It transpired that Mr Y suffered severe foot drop as a result of extensive damage to the sciatic nerve. Mr Y sued Mr O as a result of his injuries.
The case hinged on whether Mr O had taken sufficient care in establishing the relevant anatomy during surgery. Dr A had documented in the anaesthetic record that he had given the muscle relaxant, and was adamant that he had told Mr O this fact. Mr O was insistent that Dr A had not informed him about the administration of the drug and thus had left him open to the error that he made.
During an investigation of events surrounding the case it became clear that there was a history of animosity between the two clinicians. There were unresolved investigations into allegations of bullying and harassment between Mr O and Dr A. In the context of how Mr Y suffered his injury, and the clinicians’ apparent failure to communicate, it was impossible to defend the case, which was settled for a moderate sum with liability shared equally between the two doctors.
MPS advice: It is a professional obligation of a doctor to, as the GMC says, “respect the skills and contributions of … colleagues and communicate effectively with colleagues within and outside the team”.
Effective communication between healthcare professionals is essential for safe patient care. In the context of an operating theatre, where there are anaesthetic factors that may have an impact on the surgical outcome (and vice versa), it is vital that this information is imparted.
Unresolved personal or professional disagreements between healthcare professionals who share responsibility for patients is potentially prejudicial to patient care. It is the responsibility of all who work in the clinical team, and those who manage them, to make sure that patients are protected from any adverse outcome that results from doctors not working properly together. The wellbeing of patients must always significantly outweigh the personal problems of doctors.
Independent, external professional assistance with conflict resolution may sometimes be necessary and can be extremely effective.
This case originally appeared in Casebook Vol 16 No 2, May 2008.