Probity and professionalism: Republic of Ireland

• Just over 1% of registered medical practitioners received a complaint to the Medical Council in 2022, according to its annual report, and a surprisingly high number of these complaints relate to professionalism and probity.
• Therefore, avoiding complaints that could impact on your ability to practise requires more than just good clinical skills and medical knowledge. The standards and behaviours that make up professionalism are just as important.
• A doctor's primary responsibility is to act in the best interests of patients, without being influenced by personal considerations.

Professionalism and probity pitfalls

The following areas of concern are taken from the Medical Council's published analysis of the complaints it receives (appendix C of its annual report), as well as the MDU's experience of assisting doctors respond to complaints.

Treating patients with dignity

This is largely about respect for the patient, both as an individual and for their choices. It is unusual for doctors to undermine the dignity of patients, and in our experience it is usually inadvertent when it does occur.

• Do: as part of your professional competence activity, consider whether patient feedback could help identify traits you might be unaware of but that could create the appearance of a negative attitude.
• Do: take part in equality and diversity training and reflect on how it might impact on your doctor-patient relationships.
• Don't: allow personal judgements to cloud professional ones when treating patients.

Intimate examinations

Complaints relating to inappropriate intimate examinations can often have their roots in communication failure (see below). Explaining carefully to patients why an intimate examination is needed, and what it will involve should help minimise subsequent misunderstanding. Dignity is vital, and patients should have privacy to undress and remain covered as much as the examination allows.

Chaperones help provide reassurance to patients as well as support for the doctor. Always offer a chaperone for an intimate examination and note who they are in the clinical record. This can be helpful if a complaint is made later.

• Do: ensure you have informed consent from your patient before beginning an intimate examination.
• Do: ensure your surgery or clinic has ready access to a chaperone where these examinations are likely to be carried out.
• Do: keep discussion with the patient during an intimate examination professional. Broadly speaking it should be to explain what you are doing and to check the patient is not experiencing pain or discomfort.
• Don't: discuss the patient's sexual history during an intimate examination. Where this is clinically necessary, it should be when they are clothed and after you have explained why the information will help.
• Don't: carry out an intimate examination on an anaesthetised patient unless you sought prior consent to do so.

Communication

This is consistently the single biggest factor reported in complaints to the Medical Council. It's also something the MDU recognises as one of the key factors in how complaints can arise.

Medicine typically involves explaining technical concepts and often may require sharing information that is distressing to the patient, such as test results revealing a poor outcome. Add in to the mix the range of emotions that might surface and it's easy to see how even the most skilled communicator might occasionally struggle.

• Do: actively work on your communication skills and consider further training as part of your CPD plan.
• Do: seek feedback on your communication style and effectiveness, if possible.
• Do: reflect on how you deliver bad news - is there room for improvement?
• Do: reflect on how you deal with challenging situations and how professionally you respond.
• Don't: assume you will never need to improve your communication skills.

Fees

Many situations relating to disputes about fees arise from perceived conflicts of interest.

• Do: be open with patients about any financial interest you may have in a clinic, medical device or treatment you are proposing.
• Do: be candid about any professional relationship you may have with pharmaceutical companies, such as sponsorship or payments for services.
• Do: set out clearly to patients any fees you charge and ensure these are understood and agreed.
• Don't: accept gifts or inducements that may be seen to influence your clinical decisions.

Referrals

There are a significant number of Medical Council complaints about referrals each year. It is easy to forget to refer a patient, so it's helpful to have robust systems in place to minimise the chances of it happening.

However, other complaints about referral are more to do with the ethical responsibilities involved in the process than the effects of a delay.

• Do: ensure the patient understands to whom a referral will be made, and why; how long it may take to be seen and what to do if their condition worsens in the meantime.
• Do: refer to a doctor who has the appropriate skills and specialism that the patient requires. This may be straightforward most of the time, but could require further enquiries for less common clinical conditions.
• Do: respond politely and constructively if a patient requests a second opinion; in most circumstances it will be reasonable to arrange this for them.
• Don't: pay a fee to the doctor to whom you refer (or accept a fee from them for making the referral) - the Medical Council will view this as unacceptable (Medical Council Guide, paragraph 54).

Duty of candour (open disclosure)

Things can and will go wrong in clinical practice, and it is important to respond professionally and appropriately when they do. When something does go wrong and the patient suffers harm, it is important they are told as soon as practicable. In particular:

1. tell the patient what happened, which could include explaining how the particular set of circumstances arose
2. apologise
3. explain what will happen next (usually an investigation with a focus on learning lessons and reducing future occurrences).

• Do: if you are in a leadership or trainer role, encourage a culture of openness, candour and learning within your teams.
• Don't: be afraid to call out behaviour that suppresses candour and learning.
• Don't: withhold an apology because you believe it will be an admission of liability - this is not the case. An apology provided in an open disclosure meeting with the patient will not be treated as a legal admission and prejudice any subsequent claim for compensation.

Dishonesty

Dishonesty is an important finding in complaints made to the Medical Council and may increase the likelihood of a sanction being imposed (including, for serious cases, erasure from the register - see Law Society of Ireland v Herlihy [2017] IEHC 122). There are several circumstances that can give rise to a finding of dishonest conduct, including allegations of plagiarism, falsification of CVs, and falsification of clinical records, as well as convictions, such as for fraud.

However, it is important to stress that findings of dishonesty against doctors by the Medical Council are uncommon. But it is important to highlight that some of the allegations, such as plagiarism or an exaggerated CV, are often inadvertent and due to inadequate checks or attention to detail.

• Do: check carefully any document that goes out under your name to ensure it is accurate - it's your responsibility to make sure it is.
• Do: ensure you attribute quotations fully and accurately in academic writing.
• Do: where it is necessary to amend clinical records, add an additional note, making it clear when it was made, why it is being added non-contemporaneously and set out clearly what additional information is required.
• Do: when allegations of dishonesty are made, ensure you get prompt professional advice before making a formal response.
• Don't: attempt to hide or minimise an error you make, even if it could lead to criticism.

Social media

For many doctors and patients, social media is part of their everyday life. But professional boundaries can quickly blur, and paragraph 20 of the Medical Council Guide sets out the expectations of the professional regulator. Key points from the Medical Council guidance are as follows.

1. Keep personal and professional use of social media separate.
2. Be aware that confidentiality cannot be guaranteed, regardless of privacy settings applied.
3. Avoid communicating with patients through personal social networking sites.
4. If you give clinical advice online, you should always identify yourself by name.
5. You must not publish information about, or images of, individual patients from which those patents might be identified or identifiable on publicly available platforms.
6. Keep in mind that personal posts may reflect poorly on you professionally, even if you have used conservative privacy settings on your social media account.

• Do: make sure your comments on social media are professional and not derogatory
• Do: assume anything you post will always be visible, somehow, to someone, regardless of your privacy settings
• Do: keep patient confidentiality first and foremost in your mind. Even if information about a patient is anonymised, there might be enough circumstantial evidence (such as an exceptionally rare disease) that could allow an individual to be identified.
• Don't: post when you are angry, upset or tired.
• Don't: make comments about employers or colleagues. Even positive ones can be misinterpreted.

Prescribing for yourself or those close to you

It can be tempting to circumvent care pathways by prescribing for yourself or those close to you. There are good clinical and ethical reasons why this is rarely, if ever, a safe or proper course of action.

The Medical Council's Guide makes clear that doctors have an ethical obligation to look after their health and wellbeing (paragraph 12). It says you should not treat or prescribe for yourself, you must not prescribe controlled drugs for yourself, you should have a GP (who is not a person with whom you have a close family or personal relationship), and you should make sure you are vaccinated against common infectious diseases.

The guidance also makes clear that the same principle of not treating or prescribing for yourself applies to family members or others with whom "you have a close personal relationship," except where this might be necessary in an emergency.

Part of the ethical responsibility to look after your own health and wellbeing is to avoid the risk of illness impairing your professional judgement and impacting the care of patients. In practical terms this means you must seek appropriate medical advice and follow it.

Sometimes your health may be impaired to the extent that there is a risk to patients, and the Medical Council could become involved to ensure you are safe to practise. It is important you let your medical defence organisation know of any correspondence you get from the Medical Council.

If, in an urgent situation, you do prescribe for yourself, make a contemporaneous record of what you did. It may be helpful to then share that information with your GP. Similarly, if you treat a family member because of an emergency you may wish to share the information with their GP, unless they object.

Some health problems arise from chronic stress or burnout, and being aware of the warning signs may help stop problems escalating. If you are eligible, consider using the counselling offered as part of the HSE's Employee Assistance Programme. A further source of support is the Practitioner Health Matters Programme, which welcomes direct contact from doctors.

• Do: register with a GP and seek their advice if you become ill; if you are a GP, wherever possible register in a different practice to your own - many GPs are particularly skilled in consulting with their professional colleagues and are part of the ICGP Health in Practice programme.
• Do: recognise the warning signs that could suggest there is a problem brewing, such as avoidance behaviour, using alcohol as a way to cope with stress, worsening sleep patterns and poor concentration with irritability.
• Don't: prescribe for yourself or those close to you, even if the illness is one which you are competent to treat, unless you have to offer assistance in an emergency.
• Don't: assume your professional performance will be unaffected by ill-health. It may require the objective assessment of an occupational physician.

This page was correct at publication on 08/01/2024. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.