Is there any benefit in longer patient-centred consultations?
Dr Richard Stacey of the Medical Protection Society provides a checklist of what GPs should do to avoid legal pitfalls
do to avoid legal pitfalls
Providing minor surgery gives GPs the opportunity to provide a quality service to patients in a convenient, familiar setting. It also gives GPs a refreshing practical challenge, which can be an enjoyable diversion from a busy day in practice. The medicolegal pitfalls of minor surgery are predictable and in most cases largely preventable.
Training and accreditation
You must ensure you have had the appropriate training and accreditation and any procedure is within your sphere of competence. Make sure you continue to update your skills and be realistic with respect to what can be done in the general practice setting.
GPs must demonstrate they have carried out a certain number of operations within a recent period in order to remain skilled. Some practices choose to have just one or two partners do minor surgery to concentrate expertise.
You are responsible for the clinical care you provide and acting outside your knowledge and experience could result in a complaint or claim that could be hard to defend. Remember your work will be judged by the same standards as a full-time surgeon's, should a claim be made.
As some skin types, particularly Afro-Caribbean, are more prone to keloid scarring it is worth discussing the appearance of the skin after the procedure to patients who may be at risk of bad scarring.
·It is best to avoid removing lesions on the face leave them to the plastic surgeons.
The new GMS contract states curettage, cautery and cryotherapy are to be provided as core services, but other procedures will be provided under direct enhanced services.
·You should ensure you are on your PCO's minor surgery list.
Facilities and resources
All surgery should take place in an appropriate room with adequate lighting.
A full range of high-quality instruments should be available with a robust mechanism for their sterilisation. Ensure appropriate drugs and equipment are available to treat a cardiac arrest or anaphylactic shock. Do not overlook your most valuable resources a doctor's time and nurse support.
·Make sure all drugs are in date.
·Ensure sterilisation equipment is regularly serviced and tested in accordance with manufacturers' instructions.
·Undertake regular training and updating of resuscitation skills.
·Be prepared to deal with all reasonably foreseeable consequences of the procedure, including resuscitation.
The consent process is vital to enable the patient to make an informed choice about their treatment. A well-documented consent process that notes all relevant conversations helps protect GPs in the event of a complaint or claim.
Consent forms are at best only some evidence that consent was obtained. But remember it is the explanation of the pros and cons of treatment that is paramount to the defence. Consent can be given in three ways:
·Implied if a patient requests you remove a lesion and then allows you to remove it, there is an implication of consent.
·Verbal if a patient verbally agrees to a procedure.
·Written if a patient signs a consent form, although a signed form alone is not enough. The form should be the end-point of a process.
From a medicolegal perspective it is important to fully explain the risks and benefits of the procedure, including the option of adopting an expectant approach. The process should be comprehensively documented and supported by written material where possible. Remember to tell the patient about practical issues such as the effects of the local anaesthetic and when any sutures require removal. Obtaining written consent alone is not a complete defence against any allegations of negligence but it is useful corroborative evidence of the consent process.
·Give advice about wound infection.
·Warn patients about the risks of scarring.
It is important to check for contraindications and allergies including possible allergic reactions to dressings. You should also ensure the correct drug is being used and that it is in date.
Medication errors are a common problem in health care and can result in serous problems for the doctors involved. Depo-Medrone sounds very much like Depo-Provera and one of the most common problems encountered with respect to soft tissue injections is Depo-Provera being used instead of Depo-Medrone. And, perhaps not surprisingly, one of the most common problems we see with respect to injectable contraceptives is the reverse.
When using injections it is advisable to:
·Record the name, batch number, expiry date, dose, strength and manufacturer.
·Warn the patient that local anaesthetic may give rise to a stinging sensation.
·Allow enough time for the anaesthetic to take effect.
·Avoid using local anaesthetic with adrenalin in digits.
If samples are not sent the GP may be vulnerable to criticism if a malignant lesion subsequently arises at the same or similar site. It is important to have robust procedures in place for following up results.
Richard Stacey is an MPS medicolegal adviser
Case study: skills not up to date
The MPS was contacted by a 51-year-old GP who had given up his partnership and worked as a locum to give him more time to spend with his family. While working at a practice he saw a female patient who was concerned about a mole over her sternum. The mole was benign but she wanted it removed as she felt it was unsightly.
All the other GPs in the practice were skilled in minor surgery and the locum did not mention he had not carried out an excision for years and that his skills were not up to date. He went ahead and removed the mole and sent the tissue for histology. A keloid scar developed and the patient had to be referred to a dermatologist who treated her with corticosteroid injections.
The locum had not been aware the triangle between shoulder tips and xiphisternum is a common site for keloid scarring and surgical excision of benign lesions is best avoided. The patient made a succesful claim.