Professionalism In Anaesthesia, Intensive Care And Pain Medicine

The IntensivistAn intensivist, the majority of whom in Ireland are alsoanaesthetists, is the doctor responsible for the care ofthe critically ill patient in the acute hospital setting. Theintensivist leads the multi-disciplinary team of doctors, nursesand allied health professionals in the care of the critically illpatients admitted under their care to the Intensive Care Unit.They also provide a consultation service for their colleaguesthroughout the hospital and in the Emergency Department.They provide complex therapies to these patients. Honestand open communication with patients and their families isan essential component of their competencies. They mustalso be cognisant of limits of therapy and end of life careof their patients. Their practice also encompasses the issueof organ donation in cases where brain death has occurred,where empathy and sensitivity are essential.The Pain Medicine SpecialistConsultants in pain medicine, the majority of whom arealso anaesthestists, function in the traditional consultantled model. Consultants in Pain Medicine have their ownoutpatients, theatre operating lists and admission rights.Consultants in Pain Medicine diagnose, manage and follow uppatients with chronic painful conditions as well as caring forthose at the end of their lives, frequently in conjunction withoncology and palliative care services.Medications used to treat chronic painful conditions need tobe carefully monitored and most medications have significantside effect profiles. Thus much of pain medicine treatmentis theatre based interventional techniques which requires aspecific skill set.There are also recognized complications and the potentialfor permanent disability after neurodestructive techniqueswhich focus attention on the decision to perform thesetechniques and the core issue of patient consent. Thisdemands effective communication skills both with the patientand their families.Patient advocacy is a core part of the Consultant in PainMedicine’s function. The Faculty of Pain Medicine hasestablished links with patient advocacy groups such asCOLLEGE OF ANAESTHETISTS OF IRELAND, 2018Chronic Pain Ireland and the Irish Patients Association.Research and education is a crucial part of Pain Medicineas there is a growing understanding of the mechanisms ofpain chronicity in vivo and a number of new immune basedtherapies about to enter clinical use.The Consultant in Pain Medicine must demonstrate a highdegree of partnership and collaboration to allow them to workwith other medical and surgical specialties and healthcareprofessionals. They must also have specific communicationskills to achieve consent from patients and surgical skillsto perform complex interventions such as rhizotomy andneuromodulatory techniques as well as compassion forpatients when cure is unlikely.“The Consultant in Pain Medicine mustdemonstrate a high degree of partnershipand collaboration to allow them to work withother medical and surgical specialties andhealthcare professionals.”09

The Anaesthetic DepartmentAnaesthesia is different to most hospital specialities inthat it does not operate with an independent clinicalunit lead by a consultant as its fundamental component.Instead, the majority of anaesthetists practice within adepartment, which essentially functions as an anaestheticteam. In most cases a designated head of anaesthesiaservices will be responsible for co-ordinating the activitiesin which the department is engaged, and usually serve as afocal point for communication with other clinical teams, andthe organisation’s administrative service. In some instances,the department will have a clinical director with definedbureaucratic responsibilities. While it is incumbent upon theindividual anaesthetist to perform and behave according toprofessional standards, how a department is structured, andthe atmosphere that pervades it, are particularly influentialdeterminants of an anaesthetist’s conduct.occasions for departmental learning. The aim should be toencourage all members to participate in a compassionate,no-blame manner focused on harm reduction and theimprovement of patient safety. Thirdly, a culture of respect encourages openness,and allows members of an anaesthetic departmentto have challenging discussions. Diversity of opinionand dissensus can be healthy, and critical analyses ofperformance and goals are drivers of success. Civility indiscourse encourages both the delivery and acceptanceof feedback as a mechanism of effective learning. In arespectful environment, feedback will be more frequent,specific, focused on behaviours rather than personalities,and more likely to be beneficial. Fourthly, departmental culture is a key determinant ofwhether individuals will be able to come forward and toseek help when needed. Like many doctors, anaesthetistshave higher than average rates of mental health andsubstance abuse problems. Physical health issues mayalso impact upon an anaesthetist’s capacity to performcomplex technical tasks. Historically, there has been atendency for departments to tacitly ignore such problems,and for individuals to mask them. A highly functioningdepartment will encourage its members to seek helpwhen needed, and be supportive of anaesthetistsin difficulty. It is part of the professional duty of alldoctors to acknowledge any health issues that impairtheir performance, and to seek appropriate advice andtreatment. When an anaesthetist discloses health issues tothe department, they should be treated compassionatelyand non-judgmentally, and the information consideredconfidential. If an anaesthetist appears to have impairedjudgement or performance, and refuses to acknowledgethis, it must be remembered that patient welfare remainsthe overriding consideration. Members of the departmentshould consult with the relevant institutional structuresand follow appropriate guidance. Finally, a department with a positive supportive culture willchallenge, and be intolerant of unprofessional behaviours:of rudeness, discrimination, bullying or harassment.Acceptance of these behaviours creates a dysfunctionalenvironment that negatively impacts on departmentalperformance and is particularly harmful to those on thereceiving end. CAI regards bullying, discrimination andharassment to be completely unacceptable, and expectsanaesthetic departments to foster an environment free ofthese behaviours.In medical practice, effective team working reducesmedical error and increases patient safety, and also leads toimproved staff outcomes by reducing stress and improvingjob satisfaction. The culture of an individual anaestheticdepartment creates a set of (generally unacknowledged)rules, beliefs and attitudes that governs that department’sperception of professionalism. This impacts upon howanaesthetists see their role within the hospital, and regardtheir obligations in respect of learning, teaching, anddelivering a service. The departmental culture influences howits members interact and communicate with each other, withtrainees, with other clinical teams, and with patients, and isa central factor in determining patient safety and outcomes.A department that fosters collegiality, civility and collectivefunctioning, and overtly values training, reflective practice andgood patient outcomes will thrive and maintain high-qualitycare. The converse results in a corrosive atmosphere thatleads to low morale, diminished motivation, decreased jobsatisfaction, and disengagement by consultants and trainees.Professionalism in anaesthesia demands that individualpractitioners strive to cultivate and promote a cohesive andeffective departmental team.An environment in which all team members are shownrespect and courtesy is likely to have particular benefits. Firstly, it allows for better communication, particularlybetween trainees and consultants. A steeply hierarchicalrelationship leads to hesitancy in communication, withthe possibility of insufficient information transfer and aconsequent increased risk of error, adverse event andpatient harm. Flattening the hierarchy allows all teammembers to have the confidence to speak up, andverbalise uncertainties. Secondly, anaesthetists are more likely to come forwardand discuss mistakes, near misses and adverse outcomesin a supportive culture that regards such events as10PROFESSIONALISM IN ANAESTHESIA, INTENSIVE CARE AND PAIN MEDICINE

The Intensive Care UnitIntensive Care Medicine is an area where the majority ofconsultants in Ireland currently come from a backgroundin anaesthesia. However, in line with international practicean increasing number of trainees from other disciplines areentering this career path. The principles outlined abovepertain to all practitioners. The Intensive Care Unit is relianton strong leadership and team work. It can be an areaof high stress due to the complexity of patients presentingfor admission, resource constraints and the need for staffto deal with difficult decisions in a vulnerable patient population.Intensive Care doctors must work with all specialties in thehospital and good communication and listening skills areessential. The three pillars of professionalism outlined beloware essential to safe practice in Intensive Care Medicine.“The Intensive Care Unit is reliant on strongleadership and team work. It can be an areaof high stress due to the complexity of patientspresenting for admission, resource constraintsand the need for staff to deal with difficultdecisions in a vulnerable patient population.”The Pain Medicine TeamThe Pain Medicine team is led by the Consultant in painmedicine and includes nurses trained and credentialedin Pain Medicine at the CNM or CNS level with clinicalpsychologists and physiotherapists as the core teammembers. Doctors training in pain medicine work in hospitalsrecognised for training in pain medicine alongside otherhealthcare professionals in training who are part of the PainMedicine team. There is a close working relationship with otherspecialties including rheumatology, neurology, orthopaedicsurgery, spine surgery, oncology and palliative care. A stronglink exists between the general practice specialists and PainMedicine. The three pillars of professionalism outlined areessential to safe practice in Pain Medicine.COLLEGE OF ANAESTHETISTS OF IRELAND, 2018“Doctors training in pain medicine workin hospitals recognised for training inpain medicine alongside other healthcareprofessionals in training who are part of thePain Medicine team.”11

PARTNERSHIPPRACTICEPERFORMANCE12PROFESSIONALISM IN ANAESTHESIA, INTENSIVE CARE AND PAIN MEDICINE

The Three Pillarsof Professionalism:PARTNERSHIP,PRACTICE ANDPERFORMANCEProfessionalism in anaesthesia, intensive care and pain medicine isessential to the wellbeing of patients. An anaesthetist, intensivistor pain medicine specialist who performs effectively as part of aclinical team can make a significant difference to the patient’s experiencein terms of preoperative anxiety, post-operative pain, recovery fromsurgery and survival of life threatening emergencies and critical illness.The Medical Council deploys the Pillars of Professionalism as a schematicto indicate ways in which the application of particular principles andvalues underpin good care. These principles and values are identifiedunder three headings – Partnership, Practice and Performance.COLLEGE OF ANAESTHETISTS OF IRELAND, 201813

1. PartnershipGood care depends on doctors workingin collaboration with patients, and otherprofessionals. The Medical Council identifypartnership as relying on:1. Trust(a) It is generally stated that the relationship between patientsand doctors lies at the heart of medical practice, andthat trust is a fundamental element of this relationship.Patients are more likely trust their doctor if they perceivethem to be competent, caring, honest and fair. Yet, inany relationship trust takes time to develop. In contrastto physicians or surgeons, who usually have a long-termrelationship with patients, anaesthetists frequently have avery short period of time within which to interact, provideinformation, and establish a relationship with the patient.Contemporary health service delivery entails increasingnumbers of day of surgery admissions, and so in manyinstances the anaesthetist may not meet the patientuntil shortly before the procedure. Thus, there is a challengefor anaesthetists in meeting their regulatory and legalobligations within a complex and pressured environmentthat often prioritises efficiency over other concerns.14It is here that the College of Anaesthetists (and individualdepartments) has a significant role to play, as it creates theconditions that allow the public to trust in the specialityof anaesthesia prior to any meeting between individualpatient and anaesthetist. Such public confidence issustained through rigorous training and assessment standards assuringcompetence a clear statement of professional values public engagement including the visible provision ofrelevant information aimed at advising and reassuringpatientsHowever, this does not obviate the need for the individualanaesthetist to engage professionally and sympatheticallywith the patient, provide meaningful information, answerquestions, and reassure where possible.(b) Trust between anaesthetists and their colleagues isalso essential for good professional practice. Integrity,mutual respect, effective communication and sharedaims are important ingredients in delivering good patientcare.PROFESSIONALISM IN ANAESTHESIA, INTENSIVE CARE AND PAIN MEDICINE

Intensive Care and Pain Medicine3. Good CommunicationThe principles outlined above equally apply to doctorspractising in Intensive Care and Pain Medicine, where theelement of continuity of care over a longer period of timecomes into play and more often than not a professionalrelationship with the patient’s family members andadvocates. Intensivists and Pain Medicine consultants mustfrequently interact with a wider range of other specialistsand healthcare workers, so mutual respect, trust and effectivecommunication are essential.Effective communication is central to patient choice,autonomy, safety and outcome. It is also the key tool doctorshave in order to protect themselves from future complaints.Excellence at communication is a core element of medicalprofessionalism.2. Working Together Anaesthetists, intensivists and pain medicine consultantswork in a multidisciplinary environment and interact witha variety of healthcare specialties. Developing, and beinga part of, a highly-functioning clinical team is an importantpart of professional identity, and is essential to theoptimisation of patient outcomes. Patients expect this (notunreasonably), and generally anticipate that the healthcareteam providing their operative, or intensive, treatment willcollaborate to deliver safe and effective care. However, teamwork is complicated, and the healthcareprofessionals with whom anaesthetists and intensivistsengage may have a plurality of knowledge, skills,experiences, attitudes and views. Disagreementsoccasionally arise, both about patient-centred mattersand organisational issues.Resolution of divergences of opinion are best achievedthrough respectful dialogue that is focused on factsrather than emotion. Anaesthetists and intensivists arefrequently well placed to have an objective perspectiveof matters relating to the care of individual patients,and indeed may have a particular role in safeguardingpatients’ welfare.1 Any disagreement should be resolvedwith patient outcome, wellbeing and safety as theprimary objectives. “It is generally stated that the relationshipbetween patients and doctors lies at the heart ofmedical practice, and that trust is a fundamentalelement of this relationship. Patients are morelikely trust their doctor if they perceive them tobe competent, caring, honest and fair.”1.(a) Anaesthetist-patient communication: Listen to patients. Provide honest and relevant information. Explain and advise on choice of technique wherepertinent. Seek questions from patients, and respond to them in acomprehensive and comprehensible manner. Clearly document all of the discussion.(b) Anaesthetist-operating theatre team communication:How communication takes place between healthcarepersonnel in the theatre environment is a key factor in anumber of functions: Building and maintenance of team relationships andstructures. Co-ordination of team tasks and performance. Exchange of important clinical information.Effective communication between theatre staff is critical tothe delivery of high-quality outcomes, especially in a complexsetting. Conversely, communication deficiencies can leadto inadvertent error, and the risk of patient morbidity ormortality.(c) Anaesthetist-anaesthetist communication: Within the operating theatre or the intensive care unit,handover of patients from one anaesthetist to another isa common occurrence. Handover marks the transfer of clinical and legalresponsibility for the patient from one professional to theother. The anaesthetist handing over should effectively transmitall relevant knowledge of the patient’s perioperative care,and plans in respect of ongoing or future care, to thereceiving anaesthetist.Communication issues for intensivists and pain medicinespecialists can be broadly divided intoSee The Lourdes Hospital Inquiry: Report of Judge Maureen Harding-Clark (2006) pp336-7COLLEGE OF ANAESTHETISTS OF IRELAND, 201815

(a) Intensivist to Intensive Care Nurse/ Pain MedicineSpecialist to Pain Medicine CNM/CNS(d) Intensivist/ Pain Medicine Specialist to PatientTwo-way communication with a critically ill patient in theintensive care setting may be difficult, but every effort tocommunicate with the patient who is often undergoingdifficult treatments in an alien and challengingenvironment. Even heavily sedated patients can hearand recall conversations, so conversation at the bedsideshould always be respectful of this. In Pain Medicine therecan be recognised complication to treatment and thepotential for permanent disability after neurodestructivetechniques which focus attention on the decision toperform these techniques and the core issue of patientconsent. This demands effective communication skillsboth with the patient and their families.The intensive care nurse is a highly skilled member of theteam and is providing one on one care to their patient andregular communications to the family. Their importancein the intensive care team cannot be overstated. Theintensivist must give clear instruction, verbal and writtenon the care plan for the patient. The intensivist shouldalso seek the input of the nursing staff to their decisionmaking in care of the patient.(b) Intensivist/ Pain Medicine Specialist to Primary TeamThe intensivist / pain medicine specialist mustcommunicate with the primary team on a regular basis.This avoids misunderstandings and reduces the potentialfor conflict. If a referral is deemed not for admissionto intensive care this should be communicated to theteam and documented in the medical record, withany recommendations on future care or review. In PainMedicine, good communication between the primary careteam and the hospital based doctor regarding diagnosis,treatment and medication management in particular isessential.(e) Intensivist/ Pain Medicine Specialist to Family andPatient AdvocatesMore often than not the intensivist is communicatingwith the patient’s family, next of kin or advocate, to keepthem informed of the patient’s condition and plannedtreatments. Admissions to the intensive care are oftenemergent and it may not be clear whether the patienthas indicated with whom information may be shared. Theintensivist must respect the sometimes difficult balancebetween the patient’s right to confidentiality and theneed to communicate to others on critical issues while inintensive care.(c) Intensivist/ Pain Medicine Specialist toMulti-disciplinary TeamThe complex nature of intensive care is such that inputfrom many health care professionals is required to enablea successful outcome for the patient – for exampleradiology, laboratory medicine, microbiology, pharmacy,allied health professionals, psychological medicineand many other medical specialties. The intensivistmust co-ordinate the care of the patient and communicatewith all of these healthcare providers, ensuring safe,evidence based care always in the patient’s best interest,even if that involves with-holding or withdrawingtherapies.The Pain Medicine team is led by the Consultant in painmedicine and includes nurses trained and credentialedin Pain Medicine at the CNM or CNS level with clinicalpsychologists and MSK physiotherapists as the coreteam members. Do

self-care and that of colleagues is a fundamental principle of professionalism. We are dedicated to on-going education, life-long learning, to maintain our knowledge and skills at the highest level. As specialties of Anaesthesia, Intensive Care and Pain Medicine, we are committed to the three pillars of professionalism: