The majority of doctors maintain high standards throughout their careers, but the nature of medicine makes it almost certain that at some point, each of us will get something wrong.
A number of things can flow from errors at work and 'remediation' may not be a word that many would be able to define or one that all doctors would be immediately familiar with. Nevertheless, it is a concept that we feel doctors should consider whenever they are concerned that something has not gone as they would wish in a patient's care.
Remediation is the overall process agreed with a practitioner to redress identified aspects of underperformance. The Department of Health's 'Tackling Concerns Locally: report of the Working Group (2009)' defines remediation as, 'a broad concept varying from informal agreements to carry out some reskilling [such as meeting identified training or educational needs], to more formal supervised programmes of remediation or rehabilitation.'
In a broader context, remediation can be seen as part and parcel of a reflective and insightful approach to day to day practice that is perhaps drawn in to sharper focus when things go wrong - particularly so when there is an associated patient complaints matter to be discussed at appraisal, disciplinary processes or GMC investigation.
The GMC's stated public purpose is to protect patients. This means that when a complaint is made to the GMC they take a view as to whether it calls in to question a doctor's fitness to practice. When assessing this the GMC or MPTS will take into account the doctors actions since the incident leading to the complaint.
When a doctor has made a mistake, evidence that they have taken steps to remediate can mean that a GMC investigation can be concluded at an early stage without the need for a public hearing.
Even where the matter is referred to a hearing, evidence of remediation can have a very significant impact on the outcome for the doctor.
A doctor who demonstrates insight into the impact of their actions both on patients and on the profession more widely, who has expressed regret and apologised, who has undergone appropriate reflective learning with an expressed commitment to do better, and who (ideally) has evidence of improved practice is, in our experience, less likely to have actions taken on their registration.
This is borne out by a GMC analysis of cases heard at MPTS panels relating to conduct and performance. Of 60 cases in which the doctor apologised or had remediated since the events, 5% were erased from the register. In contrast, where the panel considered that the doctor had not demonstrated insight, 59% were erased. Remediation activity appeared to be an effective way to demonstrate insight.
Even where the doctor considers that the treatment given to a patient was appropriate, evidence of having reflected on the issues raised in a complaint can be helpful - it does not imply wrongdoing and is viewed positively.
We know that GMC decision makers take account of remediation at every stage of the FTP process, not just at FTP tribunals. We have been supporting members in responding to the GMC at the early stages of an investigation in cases where we think it will assist, particularly when the doctor has evidence that they have reflected and remediated shortcomings that have been identified in their practice.
In our own analysis we reviewed a hundred cases files where members had been told the GMC were investigating a complaint made against them in which the final outcome was known. This showed that in cases where we sent response on behalf of the member, the case was closed by the GMC with no further action in over 80% of the files reviewed. The great majority of these included evidence of remediation.
Clearly our study is limited to MDU members and in some cases the doctor may have been advised not to respond in detail where the issues were not clear or where we considered that the matter would inevitably be referred to the next stage of GMC proceedings.
There is no 'one size fits all' remediation. It has to be tailored to the issues at hand.
What form might remediation actually take?
As outlined above, there is no 'one size fits all' remediation. It has to be tailored to the issues at hand.
It might be as simple as reviewing, reflecting on and discussing national guidelines (for instance NICE or SIGN guidelines), applying these to the instant case and considering what should have been done differently. Alternatively (or often in addition) it might take the form of discussing matters with senior colleagues and undertaking to doing things differently, or actively seeking out learning opportunities with other doctors with particular expertise.
In the context of serious concerns it may well involve mentoring or supervision of a doctor's practice and attainment of clearly defined outcomes.
In a publication on undergraduate remediation the GMC identifies key elements of remediation as:
- reflection and self-assessment
- sincerely expressing remorse
- taking steps to improve by learning from mistakes
- putting measures in place to prevent similar events from recurring
- having evidence of the steps taken and measures put in place.
These apply equally well to doctors in practice and hoping to return to practice.
It is, however, important that these aren't just 'box-ticking' or 'certificate-printing' exercises. They should demonstrate that the doctor has seriously considered the information and undertakes to do things differently if they get the opportunity to do so. Evidence of actual reflection on the learning is therefore crucial.
Although remediation might not be a well-known term, it is of fundamental importance to doctors whether they face a GMC investigation or whether they are simply responding to an adverse patient outcome that we will all inevitably experience over the course of a career.