Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario

Pre-deployment you had concerns about a colleague struggling with his mental health after multiple tours of duty. His performance is erratic. One day he seems fine and the next he is making preventable errors. His surgical skills are desperately needed. What can you do?

• List the Issues that arise from the scenario

His surgical skills are in desperate need so it might be in medically best interests to still do surgery on patients. His performance is compromised so actually it might not in patient’s best interests to continue to let him do surgery.

The issue of confidentiality. On one hand you want to protect his right to confidentiality: the idea that other people do not have the right to know about private or personal matters. However, if maintaining confidentiality puts others or yourself at risk, then this confidentiality should be breached.

The issue of what is best mental health wise for the doctor. It might be difficult for him to take time admit knowing that he could of used that time to help patients. But equally, if he was allowed to do surgery and in the event of grave error, he could suffer moral injury for his mistakes.

• Identify Critical Information required and Assumptions to be made

Step 2 – ANALYSE

Patient: What are the views of the Patient? (and ‘patient group’)? How do 4 principles of : Autonomy, Beneficence, Non-maleficence and Justice apply? Other perspectives?

Beneficence: If his surgical skills are safe, then it might be in patient’s best interests to receive care.

Non-maleficence: If his surgical skills are unsafe, then it would be doing patients more harm to allow him to practice.

Autonomy: Patients have a right to make an informed decision. This includes being told about the risks and benefits to treatment. If the surgeon’s skills are deemed to be appropriate, then the risk of error is something that should still be communicated to patients.

Justice: If you evaluated this surgeon’s performance and took into account the number of people he could treat and extent to which he could improve their quality of life if he was allowed to operate, and then considered if he wasn’t allowed to operate how many people would suffer due to lack of availability of his calibar of medical skill, is the right decision in terms of good versus harm being made?

Clinical: What are the clinical diagnosis, prognosis, treatment options? Is this scenario covered by professional regulation or guidance? What are the views of individual members of the clinical team? Other perspectives?

As a colleague you need to do what you think is in the best interests for the patient. You should evaluate his risk to medical performance and question the evidence behind this.

As a friend, you should check that even if his performance is deemed to be of still appropriate standard, if there was enough evidence to show that this surgeon is struggling with his mental health, then you should check with him that he is managing okay.

As a team leader, you also need to think the effects that his performance compromise will have on workload of the team, and therefore care of other patients.

If it is deemed that his surgical skills are not safe for him to continue practice on patients for the time being, consider what the alternative treatment options are for patients. Can they be managed with some antibiotics, painkillers and wound dressing?

Legal: Is scenario covered by IHL, Geneva Conventions, military law, other law? Other perspectives?

‘Ethical Principles of Healthcare in times of armed conflict and other emergencies’.

Health-care personnel shall at all times act in accordance with relevant international and national law, ethical principles of healthcare and their conscience.

A physician shall deal honestly with patients and colleagues. and report to the appropriate authorities those physicians who practice unethically or incompetently or who engage in fraud or deception

A physician shall seek appropriate care and attention if he/she suffers from mental or physical illness.

Societal/Military: Is there a military necessity? Is this scenario covered by military regulation or military perspective? Is this scenario covered by public health or societal ethics? Other perspectives?

The GMC expects that if care falls below appropriate standards, then you have a responsibility as a colleague to flag to this to the colleague in question and also to seniors.

Step 3 – FUSE

· Summarise conclusions

· Insert citations to key reference sources for your analysis

· Determine the exact Decision(s) to be made

The risk of harm/benefit to patients must be weighed.

The determine risk, evidence and examples of surgeon’s compromise to performance must be determined. The severity should be considered in terms of consequence to patient health and outcome. Risk can also be relative so consider other treatment options for patient. Consider whether risks still meet appropriate standards of care for patients.

If this balance of benefit/harm is still seen medically as what could be in patient’s best interests, then this must be communicated to patients as part of informed consent.

If not, then treatment should be withheld.

If risk to patient means that care falls below appropriate level of standard, confidentiality should be breached and concern should be flagged to seniors.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

Risk to patient safety must be determined. If risk to patient safety falls below appropriate standards of care, then this concern should be flagged to seniors and surgical treatment withheld. If risk to benefit balance is still deemed as what could be in patient’s best interests, then this must be communicated to patients as part of informed consent.

Reviewed and formatted by: Yvonne Zhou MBBS Year 3 King’s College London Dec 2024

General Medical Council (UK). Good Medical Practice. Domain 2: Safety and quality. Respond to risks to safety. At: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-2----safety-and-quality?#paragraph-28 accessed 11 Jun 2020.

General Medical Council (UK). Working with colleagues. At: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/leadership-and-management-for-all-doctors/working-with-colleagues? accessed 11 Jun 2020

Deciding Whether To Refer a Colleague to a Physician Health Program. Boyd J. AMA J Ethics. 2015;888-893. doi: 10.1001/journalofethics.2015.17.10.spec1-1510.