Good Medical Practice - CGCOM

Good Medical Practice Guidelines for a professional performance of excellence

2016 CGCOM

Good Medical Practice

Guidelines for a professional performance of excellence


November 2016 Second revised edition



Editor: Organización Médica Colegial - Consejo General de Colegios Oficiales de Médicos Coordinator of the edition: José Mª Rodríguez Vicente (Treasurer of the CGCOM) Design, Printing & Binding: Graphs LASA, S.L. Legal Deposit: C 391-2014 ISBN: 978-84-695-9875-7





Presentation of the second edition Writer Group Scope of the publication

Introduction 1. Professionalism in medical practice 

Principles inspiring good practice of doctors

2. Medical/patient relationship: a link of confidence   

Show respect for your patients Treat your patients fairly and without discrimination Always act with honesty, integrity, openness and transparency

3. Professional competence   

Maintain and improve the basics of professional competence: knowledge, skills and attitudes Incorporate reflection on professional experience to practice Register your work in a complete, clear, precise and intelligible manner

4. Communication and collaboration    

Communicate efficiently and nicely Get involved in the learning and evaluation of colleagues Enhance assistance continuity and coordination Support partnerships/alliances with patients

5. Intra and interprofessional relations and teamwork  

Collaborate with colleagues to maintain and improve patient care Take care of the health of doctors to protect patients from risks that may entail a possible psychophysical impairment



6. Safety and quality  

Comply with the protection processes of patients Act against the risks that compromise the safety of patients

7. The professional practice/learning relationship: a source of permanent improvement  

Reflect on professional practice to improve care for patients Teaching and research are essential for the improvement of doctors

8. Health organizations and health systems   

Understand the complexity, peculiarities and responsiveness of health systems Use the resources of the system to provide the best possible care Recognize the importance of the National Health System for the benefit of patients

Annex I. Articles quoted from the Code of Medical Ethics Annex II. Critical Reading Group





When I presented the first edition of Good Medical Practice in March 2014, I made a commitment for its content to remain open, in constant transformation and adaptation to the social context. Two years later, in 2016, we launch the second edition, which revives the CGCOM commitment to contribute to the development of the professional responsibility of doctors. Professionals face daily numerous ethical dilemmas and conflicts of values for which there are no magic solutions. This document offers a set of recommendations that will help doctors to deliberate about these conflicts. The novelty, in this second edition, is the contrast between good and bad scenarios of medical practice. Our goal is guiding professionals in their behavior and attitudes as the best guarantee for patient health. We must define the profile of a good doctor in possession of a firm commitment to the patient, the society and the national health system. It is possible that citizens are not familiar with professional terms; however, when a citizen refers to a doctor as a "good doctor" he/she recognizes that, in addition to his/her medical science, he/she has a series of values related to the interests of patients. We should remember at this point that citizens can see clearly that a lack of professional values and professionalism can become a harmful factor for their own interests. We should not ignore the importance of instilling future standards of conduct for all practicing physicians, MIRs and medical students for them to have a reference they can rely on and for them to know how to differentiate good from bad habits in their practice. Physicians must provide optimal care according to their possibilities at all times and always within the standards of quality, efficiency and effectiveness accepted by the profession. In order to achieve excellence in clinical practice, it is necessary to be always up to date and prepared at a formative level. We must be trained to know how to offer answers to our patients based on good practice, always with sufficient independence and autonomy. Dr. Juan José Rodríguez Sendín, President of CGCOM Madrid, November 2016





Arcadi Gual Sala Joan Monés Xiol

Rafael Bravo Toledo1 María Antonia del Valle Martín Jenaro Fernández Valencia1 Damián García Olmo Resu Herranz Luengo (Secretaria) Mónica Lalanda1 Felipe Rodríguez de Castro Guillermo Vázquez Mata





In the first edition of this document we pointed out that from medical schools, as well as from the CGCOM, professional competence and professional values of doctors are perceived as the best guarantee for the health of patients. However, we found out we lack a training in values, pillars of a profession like Medicine. This document, Good Medical Practice (GMP), inspired in part by the Good Medical Practice of the British General Medical Council, has been received with all kinds of congratulations in all areas. That reception pushed us to launch a second edition, revised and expanded. It is the responsibility of professionals to be familiar with the Code of Medical Ethics (CME), which is mandatory. However, the 114 items described by GMP are not obligatory, but should be understood as the ideal that any doctor should achieve. GMP must be a positive contribution for all professionals that facilitates daily professional practice; in no case does it claim to be an academic document. GMP is not a code and, therefore, is not subject to a wording that accurately establishes the standards to be met. GMP is an open document that allows doctors to constantly think and reinterpret it according to both social changes and advances in clinical and technological knowledge. In this second edition, in order to make the document as useful as possible, we have added a series of practical situations, attitudes and acts, which should not be an example of good medical practice. We do not want these propositions to be misinterpreted or to be considered by some collectives as habitual practices. No doubt they are provocative propositions, crude and cliché that only intend to provoke reflection. Medicine involves uncertainty, and in the field of values, uncertainty generates situations of great tension. Professional action always implies a commitment to our values, which may not coincide with those of patients. Guiding action with the necessary prudence in difficult decisions is a clear intention of this document. Providing ethical, deontological and legal references, and identifying elements to be considered in decision making are aspects in which GMP can be an aid to



professionals. However, it will always be doctors who, with their competence, responsibility and ethics, must identify and prioritize the values that determine the behavior that must be followed in each concrete circumstance. At the time, we pointed out our concern with the "language perspective" and therefore with "gender language" or "inclusive language", making it explicit that we did not want to ignore the effects of prevailing androcentrism. We start many items with the phrase, “he” referred to the doctor, only to emphasize the profession, without assessing the gender of the person who exercises it.

These authors have only contributed to the Scenarios of bad medical practice.

1



People need good doctors whose primary concern is healthcare.

Good doctors are responsible, competent, update their knowledge and skills, establish a good relationship with their colleagues1 and act in accordance with the Code of Medical Ethics (CME). Good medical professionals work in collaboration with their patients and respect their rights to privacy and dignity, as stated in Article 21.12 of the CME. Doctors treats each patient as a unique and unrepeatable human being. They make every effort to ensure that all patients receive good care that helps them to improve their quality of life, whatever their illness or disability. Good medical professionals develop a compassionate attitude, care for their patients, seek their well-being, and prevent and treat their illnesses, accompanying them during the whole process. Physicians provide optimal care according to the possibilities at the time, and always within the standards of quality, efficiency and effectiveness accepted by the profession.

1

This includes the whole healthcare team.

2

CME article 21.1. See annex I.



In order to carry out medical practice with responsibility, good doctors must demonstrate, through periodic processes of validation that they perform well, that their professional activity maintains quality according to scientific evidence, is governed by norms established in the CME and follows the values and principles of GMP.

The long experience with my patients is what teaches me; I cannot waste time constantly updating my knowledge.

As a specialist I am responsible for the problem consulted within my specialty; As for the rest of processes ... I do not care.

For the doctor, the professional revalidation and the Periodic Validation of Registration are just another obstacle; schools and politicians are the ones to care about being transparent.

I have spent my whole life tending my patients well without having read the Code of Deontology; therefore, it is irrelevant to know it.

I am tired of so many rights of the patient, but does the patient know my rights?

Deontology commissions are an instrument to monitor, criticize and even punish colleagues; it is better not to consider or participate in them.







The conduct of doctors must justify the trust that their patients place in them and in the profession.

The physician must act at all times with sincerity in setting out his field of competence, his experience, his qualifications and his current position.

The doctor does not have to express personal convictions - political, religious or moral - that allow him to take advantage of the vulnerability of his patients or to cause them restlessness, as indicated in Article 9.13 of the CME.

The doctor must treat the information of his patients in a confidential way, always respecting the established legal and ethical framework.

The doctor must be honest with his patients when complications, mistakes or accidents occur. If his patient suffers any physical or psychic damage while under his care, the physician will promptly seek: To remedy the situation produced, if possible. To explain as soon as possible to his patient, family or both, in a complete and understandable way, what has happened, and the foreseeable short and long term consequences.

3




The physician should not take advantage of his preeminent professional position to seek and/or establish inadequate relationships with patients or people close to them.

I have no limitations in spreading my private life in social networks; its dissemination does not have to affect my professional activity.

If I make a mistake it is logical to hide it; I know what I have to do to remedy it. I do not need to communicate it.

Apologizing for an error or delay in diagnosis or treatment is to open the door to a future problem.

With the little time foreseen for each consultation, I do what I can.

Snooping data from a medical history of a patient or a colleague that I do not treat can be a gossip but not a punishable offense.

When I am asked about the diagnosis or evolution of a patient that I do not treat, it is easiest to check his medical history rather than asking the doctor who is taking care of the patient.



The physician should prioritize patients according to their clinical needs. If the resources, policies or systems prevent this principle from being applied and the patient's safety is or may be seriously compromised, the physician must follow the indications of item 110, section b) of the GMP.

Diagnostic tests or treatments prescribed by the physician are based on the best available evidence, good clinical judgment, and the consensus reached with the patient. The physician should not deny or delay a treatment due to the patient's previous lifestyle.

The doctor should not refuse to treat a patient, although the disease may put at risk his own health. If this possibility is foreseeable, the doctor will take appropriate measures to minimize this risk.

Physicians can never discriminate patients or allow their personal opinions4 to adversely affect their professional relationship or the treatment and care they must provide.

The physician must have a special consideration and response to the needs of patients with a functional disability, and make the necessary changes5 in

This includes their opinions on the lifestyle of patients or colleagues, their culture or their social or economic status, as well as the characteristics protected by legislation: age, disability, gender reassignment, race, marriage or civil union, pregnancy and maternity, religion or beliefs, gender and sexual orientation. 4

Reasonable adjustments do not only mean changes in the physical environment. We may include, for example, being flexible about the time or duration of an appointment, and making arrangements for people with communication difficulties, such as hearing problems. For more information, see www.equalityhumanrights.com/advice-and-guidance 5



his practice so that they can receive the assistance that best suits their circumstances or limitations as established in article 13.16 of the CME.

The physician must respond honestly, promptly and in detail to claims. His patient's claim cannot harm his clinical care or that of future patients.

If the loss of trust between the doctor and his patient jeopardizes good clinical care, the doctor must end his professional relationship, ensuring continuity of medical care and always avoiding the abandonment of his patient.

The physician must have professional liability insurance or adequate coverage so that his patients can enforce their rights or obtain a compensation in the event that a claim regarding clinical practice is sanctioned.

The doctor has the obligation to provide his name, registration number and any other professional registration when requested by people with whom he has had a professional relationship.

I can avoid and discriminate patients that cause me rejection.

I have no problem in prescribing the patient's request. It is what the user and his environment want and I avoid discussions.

6




I do not interfere with additional tests, even if they are not indicated. Patients like them and it saves me time and trouble.

I do not put difficulties to sick leaves although they seem inappropriate to me. Denying them habitually causes dislike.

Ignoring medical mistakes of my colleagues or the health system is the best way to not generate disagreements.

The doctor always has the obligation to make clear the limits of his knowledge and his competences.

The physician must collaborate in the official investigations and in the procedures of complaint, providing all the relevant information, always complying with the CME rules on confidentiality, especially those of article 27.27.

The physician, when summoned before the courts as an expert, must be truthful, sincere and trustworthy, and ensure that all evidence and documents he writes or signs are true; Therefore, he must: a) Verify that the information provided is correct. b) Do not deliberately omit any relevant information.

7




The doctor, if required, has the obligation to inform his college when, in any part of the world and in relation to the professional exercise: a) He has been reprimanded or is under investigation. b) He has been convicted of a felony. c) Another professional body, qualified for it, has issued a judgment against him.

The doctor must inform diligently both the center where he works and his private patients of any restrictions imposed by the professional or judicial authorities in his professional practice.

The physician must act with honesty and transparency in the economic or commercial relations with patients, businessmen, insurance companies and any other organization or person.

The physician should not allow particular interests to influence diagnostics or therapeutic indications, the referral of patients to other health professionals or the commissioning of services.

The physician has an obligation to declare the possibility of a conflict of interest in any circumstance, and must even abstain from participation when the conflict occurs in the context of decision-making.

The physician should not accept or request any incentive, gift or social care that may affect his way of prescribing, treating, referring patients or ordering services. Neither should he offer any kind of incentive to his patients nor to other colleagues according to article 66.68 of the CME.

8

CME article 66.6. See annex I. Guidelines for a professional performance of excellence


My participation in health companies is a private matter; therefore, in my relationships and publications I do not have to declare any conflict of interest.

I derive patients.

I look for sponsors to finance the conferences I attend; the company will be satisfied and I do not hurt anyone.

I reciprocate the number of visits without clinical justification to mitigate the low fees I receive.

I try to refer public health patients to my private consultation.

I do not consider it unacceptable to accept compensation from health companies for the prescription or use of their products.

Deriving my patients unnecessarily allow me to save time and avoid complications.





The doctor has the duty to be competent in all aspects of the professional practice, whether they are welfare, teaching, research or management.

The physician must maintain his competence, updating knowledge and skills and promoting good professional attitudes.

The physician has the obligation to participate periodically in training activities that maintain and develop his competences, abilities, attitudes and performance.

The physician should participate in the support activities offered by the contracting body, such as mentoring.9 The physician should also participate in these activities whenever he joins an organization or whenever, throughout his career, his responsibility changes significantly.

The doctor should know the most relevant clinical guidelines and important advances related to his field of professional activity.

The doctor has the inescapable commitment to update his knowledge, to comply with the law, to know and follow the collegial guidelines, especially the CME, as well as other rules related to his profession. The doctor must Informal transmission of knowledge, social capital or psychosocial support perceived by the recipient as relevant to their work, career or professional development; mentoring involves informal communication, usually face-to-face and over a sustained period of time, between a person who is considered to have more relevant knowledge, wisdom or experience (the mentor), and a person who is considered to have less. Mentoring is more than answering occasional questions or providing ad hoc help as it establishes a permanent relationship of learning and dialogue. 9



evaluate the quality of his work and, when necessary, take the necessary measures to improve it.

The physician must evaluate the quality of his work and, when necessary, take the necessary measures to improve it.

I do not feel compelled to strictly follow scientific evidence; it is a limitation to my professional autonomy and I do not have to fulfill it.

My professional experience is the best evidence. Evidence-based medicine is fiction.

There are many occasions when individual physical exploration can beavoided; even the patient prefers a quick prescription instead of a full scan.

Asking or referring a problem of my specialty is a shame and a sign of incompetence. I never do it.



The physician exercises his profession within the limits of his competence according to article 2410 of the CME.

Professionals must provide care validated by quality standards; therefore, when evaluating, diagnosing and treating the patient, the physician should: a) Value as accurately as possible the state of his patient and his medical history, considering also his opinion and his values, not forgetting the psychological, spiritual, social and cultural factors. b) Facilitate or diligently manage, within his

possibilities,

consultations, diagnostic tests and treatments. c) Consult or refer his patient to another physician, when it is considered useful to get his best care.

The physician, in providing clinical care, must: Make good use of available resources, applying them efficiently and equitably to his patients. Prescribing or renewing treatment to the patient (drugs or any other treatment), when he has a sufficient knowledge of his state of health and is convinced that the medication or other treatment will be positive for his cure or improvement. Prescribe effective treatments based on the best evidence according to article 26.111 of the CME. Take all necessary steps to alleviate pain and suffering, whether or not healing is possible and respect and facilitate the right of his patient to seek a second opinion. 10

CME article 24. See annex I.

11




Check that the care or treatment he provides to each patient is compatible with any other treatment he is receiving, not forgetting self-prescribed and over-the-counter medication. Avoid, whenever possible, treating himself or providing complex assistance to people with whom he has a close personal relationship.

Insisting on training in clinical management has no other intention than to learn how to perform budget cut.

I do not take into account the health expenses that I generate with my professional activity.

If the patient asks me for prescriptions of drugs that are recognized as ineffective, the placebo effect obviates any discussions and explanations.



The doctor must verify that the adequate information has been given, its understanding has been verified and the consent and the necessary authorizations have been obtained before involving patients or volunteers in teaching or research activities, ensuring standards of good clinical practice in research.12

The documents produced by the doctor - especially the medical history must be clear, precise and intelligible, trying to avoid the use of symbols and abbreviations. The doctor should write it when the data is being collected or shortly afterwards, in order to avoid possible forgetfulness or variations over time.

The doctor: Is interested in the safe custody, personal or institutional, of all documents that contain patient information. Complies with data protection standards and Demands his collaborators absolute discretion and secrecy.

44) The doctor ensures that the clinical history, in any format, includes all the data that are established in the regulations as prescriptive and, very specifically: The identification of the doctor who writes the medical history, the person responsible for each patient and the different colleagues who intervene in their care.

12

Standards of Good Clinical Practice. Spanish Medicine Agency

http://www.aemps.gob.es/industria/inspeccionBPC/docs/guia-BPC_octubre-2008.pdf



The relevant clinical findings in the care process. Up-to-date information given to the patient. The decisions made and the actions agreed, and who makes the decisions and agrees to the actions. The analyzes, the complementary examinations, the therapeutic procedures performed and the prescribed medication.

Acronyms and abbreviations facilitate the work of writing a clinical report. If a colleague does not understand them, he should learn them.

When I leave the office, I do not turn off the computer in which the medical records are saved; nobody is going to enter to manipulate it and that way I do not have to restart it again.







The doctor should listen carefully to his patients, take their opinions into account and respond sincerely to their questions.

The physician must explain intelligibly to patients13 what they want to know about their process, and will always do everything possible to satisfy their needs and their communicative and language needs.

The physician should try to be considerate of his patient's relatives, be sensitive and receptive in providing information and help, but always respecting the criterion of confidentiality, contrasting with his patient the information that he will share with third parties.

The doctor must acquire the appropriate skills for a correct communication with his patients in any field, being of special relevance the communication of bad news.

The physician, when on call, should be easy to locate, both for the clinical care of patients and to provide information, advice or help to colleagues who request it.

The doctor must be sincere and gain the trust of patients, family and colleagues in all their communications. This means that he must make clear the limits of his knowledge and must make reasonable checks to ensure the accuracy of his information. Persons with the legal authority to make medical decisions on behalf of a patient are included as patients. 13



The doctor, when informing the media, has the obligation to maintain the confidentiality

of

his

patients.

He

should

remember

that

his

communications to friends and family through social networks can be vulnerable and accessible to others.

The physician, in publicizing his professional services, has to ensure that the information is objective and verifiable, and that he does not take advantage of the vulnerability of his patients or his lack of medical knowledge.

The physician, when reporting, completing or signing forms or other documents, must be sincere and trustworthy, and do everything possible to ensure that they are understandable. Therefore, the doctor should: Verify that the information provided is correct. Not deliberately omit any relevant information.

The physician working in collaboration with his colleagues must recognize and respect his abilities and contributions.

The doctor is obliged to cover his job until continuity of care is guaranteed.

I know that the autonomy of the patient forces me to give bad news but I do not have to exaggerate my efforts to be sensitive.

I want to be comfortable in consultations. Who cares if I go in flip-flops and summer shorts?

Greeting and introducing myself is very polite, but with the time they give me per consultation I am not to waste time with courtesies.



The use of the computer in the consultation generates difficulties in the communication with the patient. We must accept it for the sake of progress without putting any additional effort.



The physician must be willing and prepared to contribute at all stages of the training of physicians. The teaching doctor will also be willing to collaborate in the training of other health professionals.

The physician must act with honesty and objectivity when giving references and when he values and evaluates the performance of his colleagues, including alternates and students. By giving these references, he will include all information related to his competence, professional practice and conduct.

The doctor should help colleagues who have problems in their exercise due to health deficiencies or any other cause, since patient care and safety must always be a priority.

The doctor must ensure that his teaching activity is developed minimizing discomfort for his patients (article 63.5 CME).14

14



It is not my responsibility to teach other colleagues. Let them learn as we all I have done.

My colleague's performance has dropped and he has health or addiction problems; it is best not to interfere because doing so often brings complications.

I am saturated with so many medical students. They are the responsibility of their tutor, not mine.



The physician should contribute to the safe referral of patients to different health providers, and between those and social care providers, therefore they must: Share all pertinent information with colleagues and partners involved in the care of their patients, whether they belong or not to the team, even when they leave the service, or when they delegate the care of their patient or refer their care to other healthcare or social care providers. Check that another professional or team has assumed responsibility when their role in the care delivery has ended. This attitude is especially important when it comes to vulnerable patients.

When the physician cannot personally attend to his patient, for example, when he is not on duty or when he delegates his care, he should be concerned that the colleague in whom he delegates has the experience and skills necessary to provide safe care to his patient. When the substitution is carried out by the managers of the institution, the doctor must report if there have been significant deficiencies in assistance.

Although assistance or teaching are required, I go home after working my hours; I do not get paid more for staying.

My specialist time is for diagnosing and prescribing. For the continuity of the process and other explanations, the family doctor can take care.



If, as a responsible doctor for a patient, I refer him to another doctor, it is no longer my obligation to be interested in him nor to maintain his care continuity.



The doctor must act with education and consideration in his professional practice. He will take care of his physical appearance and maintain good hygiene for his professional practice.

The doctor must treat his patients as equals, respecting their dignity and privacy, beyond the limitations that they may suffer.

The physician is obliged to treat his patients with justice and respect, whatever their lifestyle and beliefs.

The doctor will do everything possible to inform patients correctly and intelligibly, sharing with them the information they need so that they can make the best decisions about their care, including: Their health status, their foreseeable evolution and possible treatments available, as well as the potential risks and uncertainties. The evolution of his care, the role and responsibility that each doctor has in the care team. Who is responsible for the various aspects of patient care, how information is shared within the health teams and among the staff who are responsible for attending him When requesting the participation of patients in training or research activities. The physician has the obligation to treat the information of his patients confidentially, even after their deaths, as indicated in articles 27, 28 and 29 of the CME.15

15

CME article 27, 28, 29. See annex I. Guidelines for a professional performance of excellence


The physician should help to train patients in their health care and take appropriate measures to maintain or improve it. Therefore, he must: Warn and advise patients on the effects of different lifestyles on their health and well-being. Support patients to change their lifestyle when there are reasons to prove that it does not benefit them and even harms them. When the doctor alleges conscientious objection to carry out a certain procedure, he must expose it to his patient and make sure it is correctly understood. By providing this information, the physician cannot express, or even insinuate, disapproval of the patient's lifestyle, choices, and beliefs.

The physician should explain to his patients the right of requesting a second opinion and ensure that they have sufficient information to be able to exercise this right.

Clinical decisions are mine and I do not accept the autonomy of the patient. What does the patient have a right to decide about?

The second opinion is a smear for me and my team; it is best not to give facilities for it and if you can, block it.

I try not to accept a second opinion. It is not useful and it can be a headache; I do not want trouble.

Look, this is a public university hospital. If you do not like the presence of students, go somewhere else.



It is I and not the patient who must know about his illness; a brief summary is sufficient. I do not have time for more.

I have the right to openly criticize certain personal choices of my patients.

I'm already fed up with so much information that some patients bring from the internet; the practical thing is to take a derogatory position on the matter.

There is no reason to prevent a "conspiracy of silence" about a patient's illness if his environment demands it.







The physician must establish the appropriate synergies with other colleagues to maintain, improve the quality of their work and promote the safety of their patients. The doctor must know his responsibilities and those of the other components of the team.

The physician must treat his colleagues in a fair and respectful manner according to articles 37.1 and 37.2 of the CME16. He must be especially cautious in expressing his disagreement regarding the performance of other professionals, considering the confusion and uncertainty he may cause in patients or relatives.

The doctor should be aware of how his behavior influences all areas of his professional activity (hidden curriculum17) and act accordingly.

The physician should not discriminate colleagues whose opinions do not coincide with his own18 or let them affect negatively their professional relationship. 16

CME article 37.1, 37.2. See annex I.

See Rodríguez de Castro F., Proceso de Bolonia (V): el currículo oculto. Educación Médica 2012; 15: 13-22. 17

This includes his opinions on the lifestyle of patients or colleagues, their culture or their social or economic status, as well as the characteristics protected by legislation: age, disability, gender reassignment, race, marriage or civil union, pregnancy and maternity, religion or beliefs, gender and sexual orientation. 18



The physician has an obligation to question colleagues whose behavior does not comply with the principles of the CME. If their behavior goes so far as to abuse or deny the rights of patients or colleagues, he must follow the guidelines of paragraph 82(c).

Nobody prevents me from criticizing my illustrious and competent colleagues for matters related or not to the profession.

As head of the team I do not have to listen to opinions of any of my subordinates.

I am not to tutor and supervise my teammates; if they make mistakes they know what they are exposed to.



Faced with a possible impairment of judgment or technical ability, the physician should seek the advice of colleagues to help him to decide whether to temporarily or permanently suspend or modify his professional activity. The physician should not self-assess his own health because of the potential risk to his patients according to article 22.219 of the CME.

If a physician believes that a colleague's professional performance is putting patients at risk, he will be required to notify the colleague, and if he is not receptive, he should notify the college discreetly in accordance with article 22.320 of the CME.

The doctor should know that communication to the college does not mean that the duty of fellowship is not fulfilled, since the patient's attention must always be a priority and PAIME21 guarantees the protection of the affected colleague, both in terms of medical care and in the social aspect.

19


20


21

PAIME: Integral Care Program for Ill Doctors



Inhibiting when a doctor does not meet the conditions to exercise with guarantees is the easiest and it avoids complications.

I have no idea what the PAIME is, and I do not care.







The doctor has an obligation to ensure that the limits of his professional practice remain within his level of competence.

The physician must participate in systems of guarantee and quality improvement to promote the safety of patients. This includes:

Reflecting periodically on his clinical activity and professional standards. Participating actively in periodic reviews and audits of his work and that of his team, proposing plans or actions to improve and solve problems according to the results. Knowing the clinical history of his patients as a tool for diagnosis and personalization of care, as well as training, research and quality improvement and guarantee of patients' rights. Doing everything possible to minimize risks, damages, errors and adverse effects. The doctor must maintain the safety of his patients and, therefore, he must: Participate in commissions that ensure the quality of care. Contribute to the recognition of adverse effects, complications and errors. Report incidents of medical devices that may endanger the safety of the patient or another person. Respond truthfully and diligently to requests for information from public health control organizations. By providing information for the purposes mentioned above, the physician should always respect the confidentiality of his patients, within the ethical and legal standards according to Article 30.1 of the CME.22

22

CME article 30.1.h. See annex I. Guidelines for a professional performance of excellence


With the excuse of improving patient safety, the only thing intended is to increase control over physicians.

Commissions to improve aspects related to "medical errors" seem to me more dangerous than beneficial to the profession.

I do not need to wash my hands every time I explore a patient; I do not have the time to lose it with nonsense.

If you are asked to write an expert opinion, it is easy: you write what they want and they leave you alone.



The physician should promote and foster a culture that allows all personnel involved in patient care to raise their concerns openly and safely without fear of possible reprisal.

The physician has a duty to act immediately if he believes that the patient's safety, dignity or well-being is or may be in danger:

If a patient is not receiving the basic care to attend to his needs, the doctor must communicate it quickly to whom has the power to act. If the patient's safety is compromised by inadequate equipment23 or organization, the physician should correct this if he can or urge correction. He will communicate his concerns in compliance with the CME and this guide, and will keep track of the steps taken to try to resolve the problem. The doctor must always offer his help in case of emergency, taking into account his own security, his competences and the options of assistance that exist.

The physician should protect and promote the health and well-being of patients, and especially of vulnerable adults, adolescents and children.24 He

23

Follow the guidelines in section 80.c) if a medical device involves a risk of accident.

Some patients tend to be more vulnerable than others because of their illness, disability or frailty, or because of their current circumstances, such as mourning. The physician should consider children and youth under 18 as vulnerable. Vulnerability can be temporary or permanent. 24



must offer his help if he has reason to believe that their rights have been or will be violated or denied.

The doctor should take care of his health and hygiene, using the means that contribute to reduce the risk of contagion to his patients.

The doctor should preferably rely, for the care and monitoring of his health, in a doctor or family doctor.

If a doctor knows that he has, or thinks he may have, a disease that could infect his patients, he should consult a qualified colleague and immediately take the appropriate precautionary measures.

I will not be the one who communicates to the management that the technological equipment of the health center is obsolete. To avoid being pointed out, it is best to remain silent.

I am going to cut complementary tests necessary to avoid overpassing the average expense of the health center.

Patient safety and quality of care are fashionable, but they are not my daily or direct concern. That's what commissions and management are for.







The physician must actively learn from the reflection on his professional practice to introduce changes that improve it.

The physician should act responsibly when collecting the documentation generated in his medical practice and regularly analyze it in the context of guidelines based on the best available evidence.

The physician must include the comments of his patients, their experiences and the results obtained in the analysis of their care activity.

The physician should use the data collected from his professional performance

and

his

analysis

for

the

elaboration

of

scientific

communication works, when the results are a relevant innovative contribution.

The physician must be willing to be evaluated on a regular basis by whoever has the competence.

The physician should regularly participate in activities that maintain and promote his competence.

The physician must incorporate the results of the audits and evaluations or reviews of his activity to the improvement of his professional practice.



Healthcare audits only serve to control doctors more; I will avoid participating.

Commissions, audits and other minutiae only serve to distract us from our main activity, the clinic.

The practice of care is essential for training while continuing education activities are a way of wasting time.

Audits only serve management aspects; I will not change how I treat my patients for what an auditor says.



The physician has an obligation to facilitate the learning of undergraduate, postgraduate, medical specialists and other health professionals.

The doctor directly involved in teaching in any training, must acquire the knowledge, skills, attitudes and practices necessary to train and evaluate with competence.

The physician must ensure that all students under his responsibility are duly supervised and evaluated.

The physician must act with honesty and integrity when planning, organizing or carrying out research activities.

The physician must be committed to national and international ethical and legal standards of clinical research.

The doctor directly involved in research must have the knowledge, skills, attitudes and practices necessary to do so with competence.

I am tired of my colleagues who devote part of their time to research and show off; they do so at the expense of those who really work.

Medical students are a nuisance in the consultations and in the hospitalization rooms; professors need to come to take charge of teaching.





The physician should be involved with health systems and organizations to improve the quality of care.

The doctor must know and adapt to the peculiarities of the different types of medical practice and forms of payment that coexist in his country.

The physician must be interested and know as well as possible the methods available to control health costs and the allocation of resources.

The physician must use resources efficiently and effectively. He should be aware that his professional activity affects the health organization and its maintenance, so he should avoid unnecessary services or defensive medicine.

The physician should participate in the promotion of community health.

The physician should take an interest and help his patients to understand and make the most of the National Health System, including access and payment systems.



It is not my obligation to inform patients of administrative aspects.

It is not my vocation and I do not have time to collaborate in organized events for the promotion of health in the community.



The physician should take an interest and help his patients in the management of the complexities of the health system, and must inform them adequately about the reasonable use of human, material and technological resources available in the health system.

The physician is obliged to support the continuity of patient care in all areas.

The physician should actively participate in reducing errors and improving safety in healthcare organizations.

If his patient's safety may be affected by insufficient resources or by policies or systems of care provision, the physician should: a) Rectify the situation when he can. b) Report the situation to responsible organizations and institutions and, when not addressed, seek help in other instances according to Article 45.2 of the CME.25 c) Leave a record of his concerns and the measures taken to try to resolve them.

25



Health expenditure is none of my business, I do not pay for it nor does the patient, so I never impose limitations on spending.

I do not understand why defensive medicine should be frowned upon; it is always a protection for the doctor, it does not harm the patient and, in addition, the patient is more satisfied.

I do not mess up communicating deficiencies in resources; it is not my obligation; I do what I can with what I have.



The physician must recognize the added value of teaching/learning in health institutions.

The physician must collaborate with health managers and providers in order to improve the National Health System, and must be aware of how their processes affect the system performance.

The physician should participate in the institutional systems of quality improvement and promote the ethical values of his health organization and the health system as a whole.

The physician should inform and provide patients with the avenues and procedures to expose their concerns and demands through the available systems of patient care, being interested in their resolution.

It is not within my obligations to participate in projects aimed at improving the quality and promotion of values based on health ethics in health organizations.





Physicians shall respect the convictions of their patients and refrain from imposing their own.

When doctors treat patients who are legally incapacitated or unable to understand information, decide or give valid consent, they must inform their legal representative or families.

The physician has a duty to provide all patients with medical care of human and scientific quality. Complementary

examinations

should

not

be

performed

routinely,

indiscriminately or abusively. Defensive medicine is contrary to medical ethics. The time required for each medical act must be determined by the professional judgment of physicians, taking into account the individual needs of each patient and the obligation to ensure greater effectiveness and efficiency in their work.

Physicians must refrain from actions that exceed their capacity. In this case, they will suggest the patient to resort to another competent colleague in that field. If a doctor observed that because of age, illness or other causes, his/her judgment or technical ability are impaired, he/she should seek advice immediately from a colleague he/she trusts to help to decide whether to



suspend or modify temporarily or permanently his/her professional activity. If the doctor is not aware of these deficiencies and he/she is warned by another colleague, the colleague is obliged to inform the doctor and, if necessary, the College of Physicians, objectively and with due discretion. This action does not involve failing in his/her duty of fellowship, for the good of patients is always a priority.

Specialized medical acts should be reserved for physicians who possess the appropriate title, without prejudice to any person holding a degree in medicine who may occasionally perform them. No doctor, if they have the skill and knowledge necessary to the level of use required, can be prevented from applying them for the benefit of their patients. In no case doctors may attribute themselves the condition of specialists in this technique or field.

The physician should preferably use procedures and prescribe drugs whose effectiveness has been scientifically proven.

Medical secrecy is one of the pillars on which the doctor-patient relationship and mutual trust is based, whatever the mode of practice. For doctors, the secret implies the obligation to maintain reserve and confidentiality about everything revealed by the patient, what they have seen and deducted as a result of their work related to the health and privacy of the patient, including the contents of the medical record. Being a doctor does not authorize to obtain confidential information about another doctor’s patient.



In health institutions with computerized records, medical managers shall ensure a clear separation between clinical and administrative documentation. Doctors cannot collaborate in any health database if the preservation of the confidentiality of the information stored in it is not guaranteed. The doctor may cooperate in epidemiological, economics, management studies, etc., with the express condition that the information used does not identify directly or indirectly, any patient. The doctor will preserve the confidentiality of patients in their social life, work and family.

The medical director of a health center or service shall ensure the establishment of the necessary controls for privacy and confidentiality of patients and their related documentation. The doctor will ensure that the public presentation of medical documentation in any format, does not include any data to facilitate patient identification. It is permitted the presentation of medical cases that have been photographed or filmed for teaching or scientific disclosure purposes after obtaining explicit authorization to do so or preserving anonymity. When a health problem occurs with people of public notoriety, the doctor responsible for their assistance or specifically designated for it, may provide information with the authorization of the person concerned or responsible for him/her. In any case the doctor should have extreme caution in his/her informative task. The patient's death does not relieve the physician from the duty of professional secrecy.



Doctors should require from their health and non-health collaborators absolute discretion and scrupulous observance of professional secrecy. In the exercise of team medicine, each physician has a duty and responsibility to preserve the confidentiality of all known patient data. The doctor should have a reasonable justification for communicating to another physician any confidential patient information.

In the part of injuries, every doctor is obliged to send to the judge when attending an injured. When acting as expert, inspector, medical examiner, coroner, or the like. Upon the request on trial for alleged offense, which needs the contribution of the patient's medical history, the doctor will inform the judge who is ethically obligated to professional secrecy and he/she will only provide the necessary data for that specific case.

Fellowship among physicians is a primary duty and it only takes precedence to patient rights. Physicians should treat each other with due deference, respect, loyalty, whatever the hierarchical relationship between them. They have an obligation to defend a colleague who is under attack or unfair complaints.

The doctor will inform the health center management of deficiencies of all kinds, including those of an ethical nature, which jeopardize proper assistance. He/she may also denounce them before his/her College, and ultimately to health authorities, before trying other ways.



Those responsible for clinical teaching shall ensure that teaching and learning processes are developed minimizing inconveniences to patients.

Doctors shall not receive any fee for prescriptions or for materials used in patient care. They must not require or accept remuneration from intermediaries.





Álvarez Recio, Albino

López Encuentra, Ángel

Cabrera Navarro, Pedro

Lumbreras Garuz, Lola

Carrillo Díaz, Teresa

Márquez Gallego, Luis F.

Casado Blanco, Mariano

Martín Zurro, Amando

Casan Clarà, Pere

Monés Jiménez, Lydia

de la Torre Aparicio, Miguel Á.*

Morlans Molina, Màrius

de Toca Zavala, Lucas

Murillo Solís, Diego

Daniel del Valle, Elena María*

Nolla Domenjó, María

Díez Picazo, Ignacio*

Oriol Bosch, Albert

Fombellida Velasco, Luis

Palés Argullós, Jordi

Freixinet Gilart, Jordi

Pérez Alonso, Esteban

García Barbero, Mila

Prat Corominas, Juan

García del Río, Manuel

Rigual Bonastre, Ricardo

García Guerrero, Julio

Rodrigo Calabia, M.ª Pilar

Gómez Sancho, Marcos

Rozman Borstnar, Ciril

Juliá Serdá, Gabriel

Silva, Honorio

Junquera de Estéfani, Rafael*

Terribas Sala, Núria*

Labad Alquezar, Antonio

Viñas Sala, Joan

The critical reading group is made up of professionals of medicine with the exception of those marked with *, who are law experts. We would like to thank them again as readers of the first edition.


Good Medical Practice Plaza de las Cortes, 11 28014 Madrid Tel +34 914 317 780 [email protected] www.cgcom.es

Good Medical Practice - CGCOM

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