Concluding our two-part piece on risk management issues, more members of the MDU's expert team of advisers look at how to manage and minimise the risk of complaints as part of your day-to-day practice.

Responding to criticism of your clinical practice

Dr Ed Nandasoma, medico-legal adviser

Medicine is not an exact science and sometimes clinical judgments or decisions will not result in the outcome the patient or the practitioner wanted. While clinical decisions are often taken in pressured situations, the critique of these decisions is done in much less fraught circumstances. This can lead to frustration, anger and an appearance of being overly defensive.

If you face a situation where you have to explain your practice, you should not feel inhibited in giving an explanation of the circumstances you faced and why you took the decisions you did. Even where you are convinced that the criticism is unwarranted, a response that engages with the concerns raised and shows you understand the concern, but explains professionally why you disagree, is likely to be much better received than one that shows (perhaps understandable) frustration or indignation.

Seeking honest constructive feedback

Dr Oliver Lord, medico-legal adviser and clinical risk manager

If you have received a complaint or been involved in a significant incident it can be very helpful to have an honest, constructive discussion with an experienced colleague. Complaints and investigations can be extremely stressful and without help it can be hard to clearly think through what should have happened.

To acknowledge that there are other ways the situation could have been managed is in itself unlikely to lead to criticism. If there has been a departure from relevant guidelines or accepted practice there is an advantage to showing early on that you recognise there has been an error. Explaining and fully justifying your actions doesn't mean there is not also an even better way of dealing with a situation, once you have had the time to talk it through.

It is important to consider the patient's confidentiality, so an anonymised discussion would be advisable. To be useful to you, minutes should be taken of the discussion in most cases, and because of this a regular SEA meeting with colleagues would be a good forum to consider.

Be certain of your indemnity position

Dr Emma Cuzner, underwriting committee lead

Junior doctors may be familiar with the concept of medical indemnity, and may have joined a medical defence organisation (MDO) whilst still at medical school. But it's vital that all doctors understand the need for appropriate indemnity from their first encounters with patients until their retirement, and beyond.

It is a GMC requirement to, '…make sure you have adequate insurance or indemnity cover so that your patients will not be disadvantaged if they make a claim about the clinical care you have provided in the UK,' but fulfilling this obligation may not, in itself, be enough to provide reassurance and support to a doctor in difficulty.

NHS indemnity may satisfy the GMC's requirements, but it won't help a doctor with hospital discipline, GMC investigations, good Samaritan acts or other medico-legal dilemmas. Make sure you understand exactly what is - and what is not - included in any employer's indemnity.

As your medical career develops, your MDO will need to be kept fully informed of all your duties and tasks, such as out-of-hours, locum, online or prison work for GPs, private work for NHS hospital doctors, medico-legal work or sporting event medicine. Without being kept up to date, just as for other forms of insurance your subscription may be found to be inappropriate for the scope of your practice at the point of assistance being requested, with potentially huge financial implications.

The best way to avoid pitfalls is to carefully check the terms of your indemnity at renewal each year and to contact your MDO's membership team if your circumstances change.

Finally, be aware that not all indemnity providers function in the same way, or provide the same level of support with advisory assistance. The claims terminology used may also seem confusing, and policies may refer to such things as 'claims made' or 'occurrence based' cover as well as 'nose payments' and 'run off cover'.

It's important not to inadvertently create indemnity gaps when switching between jobs or organisations, and to be aware that the price quoted for the first year of a policy may not reflect the ongoing costs of indemnity for future years with some insurers.

Forewarned is forearmed, and our membership advisers are on hand to try to demystify any uncertainties you may face.

Alcohol and drugs

MDU medico-legal adviser

Doctors generally have easier access to drugs than the general public. Combined with the stresses of a high pressure job, this means there is the potential for a doctor under pressure to turn to drugs or alcohol to deal with the strain.

This can have devastating consequences on both the doctor's career and health, and an addicted doctor can pose a significant threat to patient safety. Doctors with addiction problems come to the attention of the GMC in a number of ways, and while the GMC has processes to deal with sick doctors compassionately, supervision can last for years.

If you feel you are developing a drink or drug problem, do not ignore it. Seek help sooner rather than later and get the support you deserve and need.

Summary

Dr Pierre Campell, head of underwriting

My colleagues' insights into areas they feel can make a difference in terms of reducing medico-legal risk come from their experience in dealing with thousands of complaints, claims and other medico-legal matters over the years.

A significant proportion of cases being notified to the MDU occur as a result of diagnostic errors, but it is interesting to note that despite this, my colleagues' insights instead concern issues around communication, keeping up-to-date and personal wellbeing, which trumped the traditional mantra of 'get the diagnosis right'.

Of course, we recognise that we are all human and it's not possible to get the diagnosis right all the time. The above advice focuses on trying to manage the uncertainties that arise from clinical medicine, aside from the specific clinical aspects of cases.

It is also interesting to note that there were are number of notable omissions including the subjects of consent, revalidation, confidentiality, disclosure and the use of chaperones as well as the notification of criminal matters.  These are all areas in which the MDU sees a lot of cases and all matters that have been the subject of MDU articles and advice in the past.

Finally, I leave you with what I feel are some highly relevant and timely comments from my colleague Dr Judith Clark...

Get some rest

Dr Judith Clark, clinical risk manager

One thing many of us don't do is rest. We fill some of our non-work hours by having fun, we socialise, we play sport, we sleep. But we don't always rest.

So what is rest? Rest is something different for each of us. It's when we switch off, often in solitude. Recent research undertaken by Durham University in the Rest Test revealed the top ten rest activities to include reading, walking, doing nothing and listening to music. Those who rest appear to have higher well-being scores. It's something we really ought to try and squeeze in to every day.

I know that I function better at work if I have had my daily rest by walking the dog. Will rest help you avoid medico-legal issues? I hope it might, and I don't think you'll regret trying it.