Professionalism in Anaesthesia, Intensive Care and Pain Medicine

24 Pages·2017·1.48 MB·English

PATRON: MICHAEL D. HIGGINS, PRESIDENT OF IRELAND
Professionalism in Anaesthesia,
Intensive Care and Pain Medicine
COLLEGE OF ANAESTHETISTS OF IRELAND, 2018
PARTNERSHIP
PRACTICE
PERFORMANCE

Contents
President’s Foreword 05
Introduction 07
The Anaesthestist 08
The Intensivist 09
The Pain Medicine Specialist 09
The Anaesthetic Department 10
The Intensive Care Unit 11
The Pain Medicine Team 11
The Three pillars of Professionalism 12
- Partnership 14
- Practice 17
- Performance 20
Final thoughts 21
Bibilography 22
Acknowledgements 23
COLLEGE OF ANAESTHETISTS OF IRELAND, 2018 03

President’s Foreword
It is my pleasure to introduce the speciality specific guide In pain medicine, discussing chronic pain issues, the
to professionalism and ethics to sit alongside the Medical ramifications of pain behaviour and therapeutic options, as
Council’s Guide to Professional Conduct and Ethics (8th well as their limitations, demands special skills.
Edition).
We must be advocates for our patients, bearing in mind
Professionalism is the cornerstone of professional integrative that some will be at both extremes of life and possess the
practice that has its roots in a robust training and education, “quietest voice” in the room. As patient advocates, it is our
underpinned by current and innovative research, scrutinised duty to listen, carefully and fully explain the benefits and risks
by appropriate tests of knowledge and competencies to of procedures.
ensure the highest standards of patient safety throughout the
At all times, we strive to uphold and cherish the dignity of
discipline and related specialties in the operative department,
those in our charge. We aim to treat pain and suffering in
intensive care unit, pain clinic, PACU and the wards.
all areas of practice, peri-operatively, in ICU and though the
Anaesthetists are recognised as natural team leaders, speciality of pain medicine. Symptom relief may supress vital
moderators and good decision makers. They work well in reflexes, but we must never set out a priori, or with the aim,
teams, providing support for their non-anaesthetic colleagues to shorten or extinguish life. However, at times withdrawal of
but can also assist each other sharing specialist knowledge life-support, in an arena of futility, may be the appropriate
and skills. We should respect other colleagues, interacting therapeutic choice.
with them professionally.
The Advanced Healthcare Directives have now been
Anaesthetists care for patients from the time of contemplation introduced into Irish law as part of the Assisted Decision
of surgery to their discharge home and beyond as such and Making (Capacity) Act 2015. These will provide a roadmap
may be regarded as perioperative physicians. Consultant for patient’s healthcare choices, so we can treat them in
anaesthetists make up approximately 12% of the consultant accordance with their “will and preferences”
workforce in Ireland and is the largest in-hospital speciality.
While the apothegm of the speciality is patient safety, we
Anaesthetists will engage with almost 70% of patients
also have a duty to “those who watch” – the anaesthetists
during their clinical pathway in the hospital setting. Through
and intensivists themselves. Wellness and mindfulness,
anaesthesia, critical care and pain medicine, we are challenged
self-care and that of colleagues is a fundamental principle of
to deal with such difficult areas as breaking bad news and end
professionalism.
of life issues, which must be treated with due assiduousness,
respect and diligence.
We are dedicated to on-going education, life-long learning, to
maintain our knowledge and skills at the highest level.
The doctor patient-relationship is a fundamental unit of care
and interaction and it demands integrity, altruism, compassion,
As specialties of Anaesthesia, Intensive Care and Pain Medicine,
patience, respect, tolerance and an understanding of diversity.
we are committed to the three pillars of professionalism:
Excellent communication skills, including the ability to listen,
partnership, practice & performance. As a College, we purport
and recognition of the anxious patient with the ability to allay
that these are continually revisited in a structured way through
their fears are essential.
a specialised curriculum from medical school, through specialist
training and throughout one’s career as a specialist to ensure
We have a duty to preserve patient confidentiality not only
the highest professional conduct at all times.
undertaking not to divulge confidential information but also
to ensure written information and data is kept in a secure
manner.
Dealing with patients whose treatment has had an unpredicted
outcome can be challenging, but must be dealt with Prof Kevin Carson
empathically by senior, appropriately skilled anaesthetists BSc(Hons) MB BS FFARCSI FFPMCAI FJFICMI FAMM FFSEM
and intensivists, embracing the tenets of open disclosure, President
acknowledging and apologising for adverse outcomes. College of Anaesthetists of Ireland

COLLEGE OF ANAESTHETISTS OF IRELAND, 2018 05

Introduction
The College of Anaesthestists of Ireland (CAI), and The Guide contains general guidance that provides broad
it’s Faculties, is committed to promoting the highest assistance and direction for doctors, but clearly cannot
standards of professional conduct and performance address the needs of particular specialties. In response,
amongst its fellows and trainees. It aims to deliver excellent the CAI has produced this framework document to provide
training to future fellows, and to support consultants in for greater detail and clarity on professionalism in respect
maintaining and improving knowledge and skills through of the practices of Anaesthesia, Intensive Care Medicine
lifelong continuing professional development. Outlining how and Pain Medicine. CAI recognises that the medical landscape
it expects all doctors to practice and perform, the Irish Medical has changed in recent times, with greater societal and
Council updated its Guide to Professional Conduct and Ethics regulatory expectations in respect of medical transparency,
(8th Edition - hereafter referred to as The Guide) in 2016. accountability and behaviour. It also acknowledges that
Within it, the Medical Council has defined eight domains of these expectations can sometimes pose particular challenges
good medical practice, one of which is professionalism. While for anaesthetists. In order to set out some specific guidance
there is no agreed definition of medical professionalism, this document will use the principles and values laid out in
most professional bodies share the view that at its core the Medical Council’s three pillars of professionalism
is the principle of absolute commitment to patient care. (Partnership, Practice and Performance), identifying areas
This is underpinned by a set of foundational values: clinical of particular relevance to the provision of good care by
competence, effective communication, and an understanding doctors practicing in Anaesthesia, Intensive Care and Pain
of physician ethical and legal obligations. Medicine.
“The College of Anaesthestists of Ireland (CAI), and it’s Faculties, is committed to
promoting the highest standards of professional conduct and performance amongst
its fellows and trainees.”
COLLEGE OF ANAESTHETISTS OF IRELAND, 2018 07
The Anaesthetist
As a professional, every doctor is expected to have that are important to all aspects of patient welfare. Whilst
expertise in the skills of their specialty, acquired the perioperative anaesthetic care of the surgical patient
through study, training and practice, and evidenced by is the core of specialty work (this includes wide variety of
relevant accreditation and qualifications. An anaesthetist is a procedures performed by all types of surgeons, and some
qualified medical practitioner who specialises in Anaesthesia physicians), many anaesthetists have a wider scope of
and Perioperative Medicine. Following the awarding of a practice which may include:
basic medical degree an anaesthetist undertakes a minimum
six-year specialist training programme in Anaesthesia, • The preoperative preparation of surgical patients
including Intensive Care and Pain Medicine. Training comprises • Pain relief in labour and obstetric anaesthesia
a combination of theoretical learning and practical experience
• Pre-hospital emergency care
in clinical and non-clinical aspects of practice. Doctors who
are registered on this specialist training programme are • The resuscitation and stabilisation of patients in the
subject to close supervision, and formal assessment and Emergency Department
examination, throughout their training. Following completion
• Transport of acutely ill and injured patients
of their specialty specific training, trainees can apply for
a consultant role in Anaesthesia, Intensive Care or Pain • Intensive care medicine
Medicine.
• Pain medicine including:
Anaesthetists form the largest single in-hospital medical - The relief of post-operative pain
specialty, and interact with two-thirds of all patients admitted
- Acute pain medicine and the management
to hospital. Anaesthetists, intensive care doctors, and pain
of acute teams
specialists play a unique and valuable role in caring for acutely
- Chronic and cancer pain management
unwell patients throughout the hospital, with particular skills
08 PROFESSIONALISM IN ANAESTHESIA, INTENSIVE CARE AND PAIN MEDICINE
The Intensivist
An intensivist, the majority of whom in Ireland are also They provide complex therapies to these patients. Honest
anaesthetists, is the doctor responsible for the care of and open communication with patients and their families is
the critically ill patient in the acute hospital setting. The an essential component of their competencies. They must
intensivist leads the multi-disciplinary team of doctors, nurses also be cognisant of limits of therapy and end of life care
and allied health professionals in the care of the critically ill of their patients. Their practice also encompasses the issue
patients admitted under their care to the Intensive Care Unit. of organ donation in cases where brain death has occurred,
They also provide a consultation service for their colleagues where empathy and sensitivity are essential.
throughout the hospital and in the Emergency Department.
The Pain Medicine Specialist
Consultants in pain medicine, the majority of whom are Chronic Pain Ireland and the Irish Patients Association.
also anaesthestists, function in the traditional consultant
Research and education is a crucial part of Pain Medicine
led model. Consultants in Pain Medicine have their own
as there is a growing understanding of the mechanisms of
outpatients, theatre operating lists and admission rights.
pain chronicity in vivo and a number of new immune based
Consultants in Pain Medicine diagnose, manage and follow up
therapies about to enter clinical use.
patients with chronic painful conditions as well as caring for
those at the end of their lives, frequently in conjunction with
The Consultant in Pain Medicine must demonstrate a high
oncology and palliative care services.
degree of partnership and collaboration to allow them to work
with other medical and surgical specialties and healthcare
Medications used to treat chronic painful conditions need to
professionals. They must also have specific communication
be carefully monitored and most medications have significant
skills to achieve consent from patients and surgical skills
side effect profiles. Thus much of pain medicine treatment
to perform complex interventions such as rhizotomy and
is theatre based interventional techniques which requires a
neuromodulatory techniques as well as compassion for
specific skill set.
patients when cure is unlikely.
There are also recognized complications and the potential
for permanent disability after neurodestructive techniques
which focus attention on the decision to perform these
“The Consultant in Pain Medicine must
techniques and the core issue of patient consent. This
demonstrate a high degree of partnership
demands effective communication skills both with the patient
and their families. and collaboration to allow them to work with
other medical and surgical specialties and
Patient advocacy is a core part of the Consultant in Pain
healthcare professionals.”
Medicine’s function. The Faculty of Pain Medicine has
established links with patient advocacy groups such as
COLLEGE OF ANAESTHETISTS OF IRELAND, 2018 09
The Anaesthetic Department
Anaesthesia is different to most hospital specialities in occasions for departmental learning. The aim should be to
that it does not operate with an independent clinical encourage all members to participate in a compassionate,
unit lead by a consultant as its fundamental component. no-blame manner focused on harm reduction and the
Instead, the majority of anaesthetists practice within a improvement of patient safety.
department, which essentially functions as an anaesthetic
team. In most cases a designated head of anaesthesia • Thirdly, a culture of respect encourages openness,
services will be responsible for co-ordinating the activities and allows members of an anaesthetic department
in which the department is engaged, and usually serve as a to have challenging discussions. Diversity of opinion
focal point for communication with other clinical teams, and and dissensus can be healthy, and critical analyses of
the organisation’s administrative service. In some instances, performance and goals are drivers of success. Civility in
the department will have a clinical director with defined discourse encourages both the delivery and acceptance
bureaucratic responsibilities. While it is incumbent upon the of feedback as a mechanism of effective learning. In a
individual anaesthetist to perform and behave according to respectful environment, feedback will be more frequent,
professional standards, how a department is structured, and specific, focused on behaviours rather than personalities,
the atmosphere that pervades it, are particularly influential and more likely to be beneficial.
determinants of an anaesthetist’s conduct.
• Fourthly, departmental culture is a key determinant of
In medical practice, effective team working reduces whether individuals will be able to come forward and to
medical error and increases patient safety, and also leads to seek help when needed. Like many doctors, anaesthetists
improved staff outcomes by reducing stress and improving have higher than average rates of mental health and
job satisfaction. The culture of an individual anaesthetic substance abuse problems. Physical health issues may
department creates a set of (generally unacknowledged) also impact upon an anaesthetist’s capacity to perform
rules, beliefs and attitudes that governs that department’s complex technical tasks. Historically, there has been a
perception of professionalism. This impacts upon how tendency for departments to tacitly ignore such problems,
anaesthetists see their role within the hospital, and regard and for individuals to mask them. A highly functioning
their obligations in respect of learning, teaching, and department will encourage its members to seek help
delivering a service. The departmental culture influences how when needed, and be supportive of anaesthetists
its members interact and communicate with each other, with in difficulty. It is part of the professional duty of all
trainees, with other clinical teams, and with patients, and is doctors to acknowledge any health issues that impair
a central factor in determining patient safety and outcomes. their performance, and to seek appropriate advice and
A department that fosters collegiality, civility and collective treatment. When an anaesthetist discloses health issues to
functioning, and overtly values training, reflective practice and the department, they should be treated compassionately
good patient outcomes will thrive and maintain high-quality and non-judgmentally, and the information considered
care. The converse results in a corrosive atmosphere that confidential. If an anaesthetist appears to have impaired
leads to low morale, diminished motivation, decreased job judgement or performance, and refuses to acknowledge
satisfaction, and disengagement by consultants and trainees. this, it must be remembered that patient welfare remains
Professionalism in anaesthesia demands that individual the overriding consideration. Members of the department
practitioners strive to cultivate and promote a cohesive and should consult with the relevant institutional structures
effective departmental team. and follow appropriate guidance.
An environment in which all team members are shown • Finally, a department with a positive supportive culture will
respect and courtesy is likely to have particular benefits. challenge, and be intolerant of unprofessional behaviours:
of rudeness, discrimination, bullying or harassment.
• Firstly, it allows for better communication, particularly Acceptance of these behaviours creates a dysfunctional
between trainees and consultants. A steeply hierarchical environment that negatively impacts on departmental
relationship leads to hesitancy in communication, with performance and is particularly harmful to those on the
the possibility of insufficient information transfer and a receiving end. CAI regards bullying, discrimination and
consequent increased risk of error, adverse event and harassment to be completely unacceptable, and expects
patient harm. Flattening the hierarchy allows all team anaesthetic departments to foster an environment free of
members to have the confidence to speak up, and these behaviours.
verbalise uncertainties.
• Secondly, anaesthetists are more likely to come forward
and discuss mistakes, near misses and adverse outcomes
in a supportive culture that regards such events as
10 PROFESSIONALISM IN ANAESTHESIA, INTENSIVE CARE AND PAIN MEDICINE