A serious mistake in your academic or personal life could damage your career before it even begins. This article on ethical standards and behaviour for medical students outlines the potential pitfalls, and how to avoid them.
Congratulations on starting your career in medicine!
As a doctor, lives will be in your hands – the consequences of a medical mistake can be very serious. It’s this responsibility and challenge, combined with the exhilarating and sometimes terrifying prospect of patients trusting you with their health, which draws thousands of students to medical school every year and makes competition for places so fierce.
You have worked hard to get here, so we hope this article will help you to build on your success and to enjoy your career in medicine. Fear of making a mistake shouldn’t deter you from your aim of becoming a good doctor – even experienced medics can slip up. However, what may be less obvious is that a serious mistake in your academic or personal life could harm your prospects before you’ve even qualified.
Combined with the reputed ‘work hard, play hard’ culture of life as a medic, and the tough academic pressures of the course, it’s perhaps not surprising that Medical Protection hears from many students who are worried they may have got into difficulties.
Medical Protection provides advice and guidance for students on how to avoid situations that could affect your career or your future as a doctor. If you are struggling with your work, or think your health may be affecting your studies, do talk to someone, and let your medical school know, before things escalate.
1. Good medical practice
Medicine is a continuous process of learning. As a doctor, you will be assessed throughout your career and be expected to keep up-to-date with the knowledge and skills required for good clinical care.
This process begins at medical school, where you are responsible for your own learning and need to be aware of the latest guidelines on standards of practice. As a medical student, you are expected to:
• Attend compulsory teaching sessions
• Complete and submit coursework on time
• Show respect for the knowledge and skills of those involved in your education
• Reflect on feedback and respond constructively
• Make sure you can be contacted and respond to messages.
Survival tips
If you are struggling with your studies, speak to a tutor sooner rather than later. It’s better to ask for help before things get worse.
Let someone know if you are ill and cannot attend teaching or clinical sessions, or if you are being affected by a major life event which may impact on your studies, eg. a bereavement.
Recognising your own limitations is the key principle behind competency. When providing care, you must work within your own competency, and ask for advice if you feel out of your depth.
2. Personal conduct
The Health Professions Council of South Africa (HPCSA) takes probity very seriously. Probity means being honest, trustworthy and acting with integrity, which is at the heart of medical professionalism, and equally important for students as for qualified doctors.
You could be the most brilliant student of your year, but your hard work could be in vain if your conduct raises concerns about your professionalism. As a student, you are not subject to HPCSA’s fitness to practise procedures, however, even a single incident, if serious enough, could harm your chances of obtaining registration. Therefore, you should conduct yourself in a way which is appropriate for a future medical practitioner.
Examples of things which will concern the HPCSA include: alcohol misuse affecting clinical work, misuse of drugs (even if there are no legal proceedings), drink driving, bullying and physical violence.
Survival tips
Own up to your mistakes – it is your responsibility to ensure you discharge any obligation in respect to probity in completing an application to medical school or employment.
As a student member, you have access to Medical Protection’s advice line, including our emergency service outside normal hours. Let us know as soon as you think you may be in trouble, and our experienced advisers can give you confidential, professional information on what to do next.
Do not let your personal beliefs affect your clinical work. Medical students should make care of their patients their first concern.
3. Social media
In today’s media-driven society, the boundaries between private and professional life are blurred. In such a fast-moving environment, it’s all too easy to forget that the advice about personal behaviour and patient confidentiality applies equally online.
Students should never discuss individual patients – or partners, relatives and friends of patients – even anonymously, within earshot of the general public. Of course, such discussion extends to the virtual world, and the use of social networking sites such as Facebook, Twitter, LinkedIn and Whatsapp and emails. It is inappropriate to post informal, personal or derogatory comments about patients or colleagues on any public platforms.
The crucial thing to remember when interacting with medical blogs and social networking sites, or when taking part in forum discussions, is that anonymity is a myth. You should write everything as if you are signing it with your name. When posting online, bear in mind who could be reading what you write. Unguarded comments about patients, your lecturers or fellow students could lead to disciplinary action by your medical school, or, if qualified, the HPCSA.
Beware of jokes or activities that can seem like harmless fun online, but could backfire in reality.
Survival tips
Be aware that defamation law applies to comments posted online. You could face trouble if you harm someone’s reputation by publishing incorrect or potentially damaging information.
Use privacy settings on social networking sites where available – but be aware that not all information can be protected on the web.
Do not accept social media ‘friend requests’ from patients. It’s too easy for the doctor–patient boundary to become blurred.
Avoid behaviour that might affect your future career or reputation as a doctor, eg. excessive drinking, drugs – and certainly don’t publicise such behaviour online.
Scenario
Sean, a fourth-year medical student, chose to complete a module in the Emergency Department. He was working one Friday night when a young female patient was brought in by two of her friends, having had a fit in a local bar. Sean took a history from the patient and realised that she was a first-year geography student at the same university. Sean visited her the following day on the medical ward to follow up on her medical management. They seemed to get on well, so Sean invited her to be a friend on Facebook. After a while, the relationship soured, and the patient complained to the medical school about Sean’s conduct in contacting her and starting a relationship as a result of meeting her as a patient.
Learning points
As a student, professional boundaries may seem blurred. Students may feel that, since they are not the professional caring for a patient, the limits around personal relationships do not apply. The HPCSA says: “If the health practitioner performs a non-medical role in their community, maintaining appropriate professional boundaries may be difficult as they may
receive requests on social media from patient’s they know in a non - professional capacity. In these instances, health practitioners should consider the circumstances and implications before accepting these requests.”
4. You and colleagues
Good doctors are good communicators – it’s that simple.
The more traditional “communication skills” teaching has focused on the doctor-patient relationship, yet communication between colleagues in hospital and primary care settings is equally important.
Medical Protection’s experience over many years is that some of the biggest mistakes in hospitals are the result of poor communication. Although there are often many factors leading to adverse outcomes, it is undoubtedly the case that poor communication and handover can result in inappropriate prescriptions, incorrect diagnoses and patients lost to follow-up. These have clear potential for patient harm, and an associated impact on the team arising from complaints, claims and disciplinary investigations.
Developing both your teamwork and communication skills at medical school will stand you in good stead as a doctor.
The HPCSA states that in interactions with colleagues (including academic staff, healthcare and administrative staff) you should:
• Behave in a courteous and professional way
• Refrain from speaking ill of colleagues or other health care practitioners
• Work together with colleagues in a way that best serves patients’ interests.
Communicating well in a team demands more than merely listening and passing on messages. Doctors must work within their competence, seeking advice and assistance from senior clinical colleagues where appropriate.
On occasion, doctors may need to act to protect patients from potential harm caused by inadequate systems or procedures, or as a result of a colleague’s behaviour, performance or health. Medical Protection recognises that this is never an easy decision. If you need advice on the appropriate action to take, you should usually raise this with your educational supervisor and you can always access expert medicolegal advice via Medical Protection’s helpline.
Survival tips
You may feel as if you are at the bottom of a long chain – but in fact you are part of a wide communication network, including the voluntary and social sectors. Try to think about your individual role – what information should you convey to assist in protecting the patient’s health?
Be willing to work as a team and take on appropriate responsibility.
However, never work outside your competence, or recommend medical treatment or any particular action that might be interpreted by patients or others as medical advice. If in doubt, always ask.
If you are concerned about a fellow student, colleague or other health worker or if an adverse incident occurs, you must inform your supervisor without delay.
Scenario
Anele was a final year medical student. She had always wanted to pursue a career in emergency medicine and had arranged a placement in the trauma unit at a major hospital in Cape Town. Anele had read up on advanced trauma life support techniques and had spent time in her local emergency department.
One evening while on call, a number of patients were brought to the department following a road traffic accident involving a minibus and a truck. Four patients were injured, requiring immediate resuscitation. The two registrars in the department led the assessment of the patients. Anele was one of three medical students in the department and assisted in the management of one young female, obtaining venous access and taking blood.
After the initial assessment of the patient, it became clear that she would require a chest drain. The registrar asked Anele if she would insert the drain while he continued to attend to other patients. Anele had never performed a chest drain but had seen it done once before. She agreed to perform the drain, not wanting to pass up the opportunity.
After making a skin incision with a scalpel, Anele struggled to insert the drain. She applied more and more pressure but was unable to force the drain through the chest wall. She tried to cut through the intercostal musculature with the scalpel, inadvertently causing the patient to bleed. Fortunately, the nurse recognised that Anele was out of her depth and called the registrar urgently.
Having witnessed these events, another medical student expressed concern to her personal tutor and Anele was disciplined by the medical school.
Learning points
While it can be tempting to gain new clinical experiences, and other healthcare staff may be grateful for your assistance, your patients’ safety must always be your primary concern. Working within your competence, or training within an appropriate environment supported by senior colleagues, will ensure maximum benefit for both you and your patients.
5. You and your patients
Consent and respect
Patients, especially when sick, anxious or distressed, will not necessarily be in a position to differentiate between you, as a medical student, and a ‘real’ doctor – so it’s up to you to make sure they know who you are.
The HPCSA advises that patients must be informed whether students will be involved, and the extent to which students may be involved in an investigation or treatment. It can be tough when doctors introduce you to patients simply as a ‘colleague’, but it is important that you identify yourself as a medical student and check that patients are aware of your role. Wear a name/identity badge at all times during your clinical practice. Respect the right of a patient to decline to be seen by a medical student.
Presenting yourself professionally, dressing appropriately, and being punctual, smart and alert are simple but important ways of showing patients and colleagues that you care. Be aware of and respect cultural differences in dress and presentation and adhere to the highest standards of personal hygiene.
Try to be aware of your body language and take every opportunity to develop your skills of empathy. Don’t forget about relatives and those close to the patient, who should also be treated with consideration and offered support when needed.
Confidentiality
It might seem obvious that patients’ health information must be kept confidential, but what may be less obvious is that this duty of confidentiality applies to all the information you hold about them. This includes dates or times of appointments they’ve attended, or even the fact they are registered with a certain practice or have attended a certain hospital. It can be easy to ‘let your guard down’, particularly when away from the clinical setting, or out with friends.
Remember that discussing clinical care in public may appear unprofessional and give the impression of breaching confidentiality, even if patients’ names are not used.
Survival tips
Take care to avoid breaking patient confidentiality unintentionally, for example by ensuring consultations with patients cannot be overheard.
Be aware of high-risk situations and places where confidentiality is easily breached, eg. computer screens, tablets, printers, and conversations in canteens, corridors and lifts.
Memory sticks and other electronic storage devices are a particular problem – make sure you know and follow your medical school policy, especially about encryption and the use of such devices.
Bear in mind that even if you are clearly identified as a student, patients may see you as being in a position of responsibility and attach added importance to your opinions or comments.
Scenario
Sello, a fourth-year medical student, was completing a placement in an inner-city general practice. He was asked to take a history and examine a female patient in her early 30s, who had presented with upper respiratory symptoms of a few days’ duration. He took a full history, examined the patient’s chest, ears, nose and throat, and presented the case to the clinician.
The day after the consultation, Sello was contacted by the practice. The patient had complained about an inappropriate examination being performed. As part of their investigation, they required a written statement from Sello. The medical school was also involved, and Sello was told that he would not be allowed to undertake clinical work until the investigation had concluded.
Fortunately, Sello had kept clear records of the consultation, including documentation of the respiratory and ENT examinations that he had performed. With Medical Protection’s assistance, Sello was able to provide a written statement that satisfied the practice and the medical school of the proper nature of the examination. It appeared that the patient had misinterpreted his examination of the lymph nodes in her neck and axillae as being something more sinister. Sello was allowed back to the practice two weeks later, and was successfully signed off for the placement despite the time out.
Learning points
This case highlights the need for good communication with patients, who might genuinely misunderstand the purpose of an examination, particularly when a medical student performs it differently to a more experienced clinician. Clear documentation of the consultation and examination will help to provide evidence where concerns arise. However, all doctors and students should consider the need for chaperones, even if no intimate examination is performed.
6. Your work
The HPCSA expects medical students to be honest and trustworthy both personally and professionally. This also applies equally to academic work.
Copying others’ work and passing it off as your own is clearly wrong, but many medics have been tempted to take ‘short cuts’ when under the pressure of large workloads, high competition and tight deadlines.
However pressured you feel, remember that plagiarism and falsifying data is completely unacceptable. Make sure you include references for any quotes or information gained from other publications or authors. Be especially careful when using material sourced online – although the information may appear to be freely available, you must reference everything that is not your original work.
Even a single episode of plagiarism or dishonesty, for example in CVs and applications, could harm your future career and land you in trouble with the HPCSA. Employers will consider dishonesty on an application form as a disciplinary matter, which may ultimately lead to termination of a doctor’s contract of employment.
Survival tips
You must be honest about your experience and qualifications when applying for posts.
You should bring to the attention of your medical school any mistakes or concerns about your own work, and take action if you think someone else may be acting dishonestly.
Scenario
Philip and Ben were medical students in the fourth year of their studies. They were attached to the gynaecological oncology firm at the main teaching hospital in their city. Since the firm’s intern and registrar were both away, the students had been asked to assist with the operating list the following day. They had both been told to read up on the procedures before the list. The afternoon before, Ben and Philip asked their consultant’s secretary to print off copies of the theatre list before catching the bus home. Excited by the prospect of assisting, the two students discussed the operations that they would see the following day. They were so engrossed in their conversation that they almost missed their stop. In the ensuing rush to disembark, Ben dropped his copy of the list. Following a complaint from a passenger on the bus, an investigation was launched by the hospital and medical school.
Learning points
While it is important to be enthusiastic and to prepare properly for any learning opportunity, such as a theatre list or clinic, be careful where you discuss patients, procedures that you have been involved with, or conditions that you have seen. Most hospitals have strict policies surrounding the distribution and use of theatre lists or other documents that include patients’ information. Be careful that you do not inadvertently breach these. Generally, patient notes or other records should not be removed unless specifically authorised. If in doubt, don’t remove any patient identifiable information from the hospital ward or department concerned.
7. Your health
You have probably heard the biblical proverb “physician, heal thyself”. However, doctors are notorious for being poor at looking after their own health. Staying well is important for both you and your patients, so get into good habits while you’re at medical school, and avoid putting patients at risk.
It’s important both to seek independent and objective advice about your own health. Register with a doctor and ask for advice from your doctor or occupational health department at university – or both, if you are worried about your health. This includes mental health as well as physical.
Medicine is a stressful career, and this can begin at medical school. The first advice for dealing with stress is to get help early. Being unaware of the depth of the problem can cause it to escalate and lead to more serious issues such as depression, or drug or alcohol dependency.
Survival tips
Protect patients, colleagues and yourself by being immunised appropriately.
Disclose to an appropriate academic or clinical adviser if you have a relevant long-term medical condition or disability (eg. epilepsy, diabetes, severe allergies).
Never consume alcohol or recreational drugs (legal or illegal) at a time when it could impair your reason or judgment, or otherwise impact on your professional responsibilities.
Be aware that after graduating you are responsible for informing your employer of any health issues.
Scenario
Fawad was a second-year medical student on a graduate course. He had previously completed an English degree and had always been something of a high flyer. Fawad found the first year at medical school somewhat different, struggling to adapt to the more scientific way of thinking and making few friends. In the lead-up to the summer exams, he had become increasingly irritable and withdrawn. Fawad’s GP diagnosed him with depression and referred him for cognitive behavioural therapy. Despite this help, Fawad began to drink heavily, and his attendance at lectures and tutorials started to suffer. His pastoral tutor asked Fawad to meet with him, but he missed several appointments.
Towards the end of the first semester, Fawad was called to attend a formal interview with the Dean of the medical school. Unfortunately, he turned up smelling of alcohol, giving the excuse of having been at the pub with friends. As a result of ongoing concerns, disciplinary action was instigated at the medical school. Medical Protection was able to show that Fawad’s poor attendance and apparent attitude problems related to an underlying health issue. Fawad acknowledged that he had an issue with alcohol and depression, and the medical school allowed him to take a break from his studies and provided him with help and support via occupational health.
Learning points
Health issues can arise at any time in your medical career, from the early days at university to the final years of clinical work. It is always important to seek help – the sooner the better.
Medical Protection offers support and advice, via our team of expert medicolegal advisers, and through access to a confidential, independent counselling service. Sometimes things can get out of hand, and occasionally formal investigations or procedures will be the first occasion that health issues come to light. Even at this stage, as the above scenario shows, getting appropriate advice and support can help to get your health and career back on track.