No stone left unturned
In this post I will spend some time understanding the power of medications, then extract some fundamental principles from the GMC’s guidance on prescribing (April 2021). I then analyse two real-world scenarios in prescribing that I have experienced and reference each against the GMC’s guidance. [The scenarios do not contain information that identifies any patient. ...
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In March of 2001, Mr Jones sustained physical and psychological injuries after being struck by a motor vehicle. Intending to pursue a personal injury claim against the driver, Mr Jones sought supporting medical evidence. Dr Sue Kaney, a clinical psychologist, was retained to provide expert medical opinion and subsequently diagnosed Mr Jones with post-traumatic stress disorder. The defendant driver also retained a medical expert, whose opinion differed from Dr Kaney’s. Consequently, the presiding judge directed the two experts to prepare a joint statement.
Allegations of negligence against Dr Kaney stemmed from her participation in formulating this joint statement. Mr Jones asserted that Dr Kaney acted negligently by signing a joint statement that inaccurately reflected her professional opinions and the discussions conducted between the experts. This joint statement purportedly proved detrimental to Mr Jones’s claim, ultimately leading to an unfavourable settlement. Mr Jones subsequently initiated legal proceedings against Dr Kaney, seeking damages for the alleged undervaluation of his claim resulting from her actions.
The Supreme Court found that the expert had failed to provide adequate reasoning for these concessions and had acted in a manner that favoured the defendant. This case demonstrates the potential consequences for expert witnesses who do not fulfil their duties to the court.
Semmelweis Reflex: A reflex-like tendency to dismiss or reject new evidence, information, or thinking -outright because it contradicts established beliefs, norms, or paradigms. This rejection occurs pre-emptively, avoiding the mental discomfort that might arise from having to reconsider or challenge one’s existing views.
Optional: See a comparison of four mechanisms of mind.
Historical Context:
1689 Bill of Rights: Established the supremacy of Parliament over the monarchy, laying the foundation for modern Parliamentary sovereignty.
None of the following automatically voids or nullifies Parliament’s laws.
This explains how S62(1) should be applied and not.
25.40 These are strict tests. It is not enough for there to be an urgent need for treatment or that the clinicians involved believe the treatment is necessary or beneficial.
25.41 Urgent treatment under these sections can continue only for as long as it remains immediately necessary. If it is no longer immediately necessary, the normal requirements for certificates apply. Although certificates are not required where treatment is immediately necessary, the other requirements of parts 4 and 4A of the Act still apply. The treatment is not necessarily allowed just because no certificate is required.
When we refer to the high taxes on tobacco, that encompasses the specific duties, ad valorem duties, and VAT. This combined tax burden is a significant factor in the final price of tobacco products.
It typically falls within the range of 70-75%.
Note: The exact percentage will vary slightly depending on the retail price of the cigarettes. The calculations below are the most conservative estimates arising from a manufacturer’s cost price of £2/pack and profits of only £2/pack.
| Stage | Cost/Price (£) | Tax/Duty (£) | Tax/Duty Type | Calculation | Calculation |
|---|---|---|---|---|---|
| 1. Manufacturer’s Cost | 2 | 0 | N/A | This is a hypothetical cost of production. | |
| 2. Specific Duty Added | 2 | 5.89 | Specific Duty | £294.72 per 1000 cigarettes / 1000 * 20 | Fixed amount per pack. |
| 3. Manufacturer’s Profit | 7.89 | 0 | N/A | (Assumed to bring the total to £7.89) | This is a hypothetical profit margin. |
| 4. Ad Valorem Duty Included | 9 | 1.11 | Ad Valorem Duty | 16.5% of £9.00 (approx. retail price before VAT) | Included within the retail price, not added separately. |
| 5. Retailer’s Profit | 10.11 | 0 | N/A | (Assumed to bring the total to £10.11) | This is a hypothetical profit margin. |
| 6. Final Retail Price (excl VAT) | 13 | 0 | N/A | (Includes specific duty and ad valorem duty) | This is the price displayed on the shelf, excluding VAT. |
| 7. VAT Added | 13 | 2.6 | Value Added Tax (VAT) | 20% of £13.00 | Applied at the point of sale. |
| Total | 15.6 | 9.6 | Approximately 61.5% of the final price (£15.60) is tax – due to the simplified conservative assumptions about manufacturer and retailer costs and profit margins. | ||
It’s undeniable that chronic smoking wreaks havoc on the body. Patients who interface with psychiatric services often ask, “So why are they selling it legally if it’s causing so much harm?” That is very good question but the answer should come from politicians – not doctors.
The scale of physical harm backed by facts and figures:
These figures highlight the devastating impact of chronic smoking on physical health.
BIRP format documentation
Behaviour: Known to have EUPD. Patient presented in a distressed state, reporting feelings of emptiness and fears of abandonment. She expressed difficulty managing her emotions and described intense anger triggered by a minor disagreement with a family member.
Interventions: Explored coping mechanisms for distress tolerance. Discussed strategies for managing anger and interpersonal conflict. Provided psychoeducation on emotional regulation.
Response: Patient engaged in the session and expressed some understanding of the concepts discussed. She reported feeling slightly calmer by the end of the session but remained concerned about her ability to manage her emotions effectively.
Plan: Continue to work on developing distress tolerance skills and anger management strategies. Encourage the patient to practice the techniques discussed between sessions. Monitor the patient’s emotional state and risk of self-harm.
| Documentation Issue | Critique |
|---|---|
| Vague Descriptors | Terms like “distressed state,” “emptiness,” and “intense anger” lack specific behavioural anchors. The descriptions are mere observations without any real substance. How was the intensity of the anger manifested? What did the patient say? How did she appear? Was she grimacing? Without concrete examples, these descriptors are open to interpretation and do not provide a clear picture of the patient’s presentation. |
| Generalised Interventions | Phrases like “explored coping mechanisms” and “discussed strategies” are so general that they amount to padding. No one will know what specific coping mechanisms were explored. How did this worker actually attempt to help the patient? What exact strategies were discussed? How were these tailored to the patient’s individual needs and the nature of their emotional instability? |
| Lack of Measurable Outcomes | The record mentions the patient feeling “slightly calmer” but lacks objective measures to assess the effectiveness of the interventions. How was this improvement gauged? Is it just ‘your’ word for saying so? Many services will accept such records as ‘standard’ because of cultural norms. |
| Ambiguous Plan | The plan to “continue to work on developing skills” and “encourage the patient to practice techniques” is vague and lacks specific, measurable goals. What specific skills will be targeted? What techniques were discussed ‘between sessions’? How will progress be monitored? What constitutes “practice” in this context, and how will adherence be assessed? |
| Omission of Risk Assessment | Given the nature of EUPD and the potential for self-harm, the record should include a formal risk assessment. What specific risk factors were considered? How was the risk of self-harm evaluated and managed? |
| Limited Patient-Specific Insight | While the record mentions EUPD, it does not provide specific insights into how this diagnosis informs the interventions or the plan. How were the chosen strategies tailored to the patient’s unique challenges related to their personality disorder? |
Annex A | Characteristics of high quality data
The following is a summary of the characteristics of high-quality data (CARAT) as suggested by organisations such as PRIMIS:
1. Complete | Data can be considered complete when all the required data for a particular purpose is present and available to be used. Completeness relates to determining that the patient’s record has all diagnoses, allergies, vaccinations, operations, or events present within the record. Consider a patient record with missing allergy information. The consequences of this could be profound, and the omission clearly constitute an incomplete record.
Completeness for an individual patient could reflect that it contains all the relevant codes for all diagnoses, allergies, vaccinations, operations, or events. Across a population it means that all patients with a particular condition diagnosed have it correctly coded in all the records.
2. Accurate | This is when the data reflects reality or a genuine real-world occurrence. Accuracy can be quite challenging as it can change over time and is, therefore, difficult to monitor. An example may be a patient that presents with chest pain and is coded as such. At that point in time there is no clear cause for the chest pain, and this is, therefore, an accurate reflection in the data. That diagnosis may, however, change from chest pain to myocardial infarction following further investigations. Uncertain symptoms can become certain diagnoses.
Recording a diagnosis of stroke based on clinical symptoms and then later being it being proved not to be the case would render the initial diagnosis inaccurate and would need evolving/correcting.
This highlights the transient nature of accuracy especially when the diagnosis is uncertain and also the importance of maintaining and evolving problems.
3. Relevant | When considering data quality, relevance implies there is a reason to collect or record the information in the patient record. You must consider whether you really need this information, and for what purpose. Relevant data is usually closely linked to the purpose for which it is being collected. For example a diabetic review might record blood pressure as this is relevant in the context of diabetes. Recording the patient’s temperature in the record during the diabetic review would not, however, be relevant as it adds nothing to the diabetic review and is unrelated to diabetes in this context.
4. Accessible | Data may be recorded completely and accurately, but if we cannot extract information that we need this can been seen as an accessibility issue. Accessibility describes how easy it is to retrieve the required information as and when it is needed. Coded data is typically more accessible than free text and can be displayed and organised in various ways by the GPIT system as the codes themselves are understandable to the system. With modern GPIT systems there can also be vast qualities of information being drawn into the record from multiple sources, how this information is organised and coded can aid accessibility.
5. Timely | Data that is available when expected and when needed is timely. The purpose determines what would be considered timely. In the context of a clinical interaction, most professional bodies consider the contemporaneous entry of medical information as one of the most important aspects of healthcare. Contemporaneous entry of clinical information also supports the other aspects of data quality including accuracy and completeness.
| Cognitive Activity | Description |
|---|---|
| 1. Information synthesis | Gathering and integrating diverse information; evaluating reliability and relevance of each piece |
| 2. Evidence evaluation | Critically assessing quality and strength of available evidence; identifying gaps |
| 3. Principle balancing | Weighing competing ethical principles; reconciling guidelines with case-specific considerations |
| 4. Stakeholder consideration | Analysing individual patient needs/rights; considering regulatory and societal requirements |
| 5. Consequence projection | Anticipating potential outcomes; assessing short-term and long-term consequences |
| 6. Risk-benefit analysis | Systematically evaluating risks; weighing risks against potential benefits |
| 7. Legal framework integration | Incorporating relevant legal standards; ensuring compliance with statutory obligations |
| 8. Ethical reasoning | Applying ethical frameworks; resolving ethical dilemmas in forensic psychiatric practice |
| 9. Interdisciplinary integration | Synthesising perspectives from various disciplines; reconciling conflicting viewpoints |
| 10. Decision refinement | Iteratively reviewing and adjusting decisions; fine-tuning to address all relevant factors |
| 11. Uncertainty management | Acknowledging areas of uncertainty; developing mitigation strategies |
| 12. Prioritisation | Determining relative importance of factors; focusing on critical elements |
| 13. Cognitive bias recognition | Identifying potential biases; implementing strategies to minimise their impact |
| 14. Justification formulation | Developing clear, logical rationale; ensuring transparent and defensible reasoning |
| 15. Contextual adaptation | Tailoring approach to specific case factors; recognising unique case influences |
