Knowing the limits of your expertise

Scope of practice and acting within your skill set is important as a doctor, but what happens when someone takes on procedures that fall out of their usual practice yet within their expected skill set? Dr Emma Green discusses the issue.

A doctor’s duty to act within their expertise has its origins in the Hippocratic Oath, but knowing the boundaries of practice is not always as straightforward as one might anticipate. 

With the development of hybrid specialties, breast surgery – for example – can be performed by both plastic surgeons and general surgeons with breast surgery training. 

Some procedures may also fall within the purview of different specialties – for example, endo­vascular procedures may quite properly be undertaken by both vascular surgeons and radiologists. 

What matters is that the doctor concerned has undergone the necessary training and has the appropriate skills and knowledge to carry out the proposed role and that their background specialty is relevant.

In other circumstances, clinicians may have their boundary of practice limited by exposure. 

Smears, cannulation, venepuncture, breast examination and vaginal examination, for example, are considered skills that most GPs would have acquired through their training. 

However, resources and patient preferences mean that often male GPs may be less likely to perform intimate female examinations than their female counterparts. This therefore leaves the question of whether they are skilled enough to perform the procedure should the need arise. 

Safety issues

The same issues arise within private practice whereby clinicians may be required to perform procedures that are not within their regular area of practice or are only performed relatively infrequently on a small patient population. This raises the question of competence alongside important patient safety issues.

Career breaks including parental leave can also result in doctors becoming deskilled and the Covid-19 pandemic has led to concerns from some clinicians over deskilling due to operating list cancellations and deployment to other clinical areas. 

For more specific circumstances like Covid-19 and parental leave, return-to-work courses and supervised clinical practice, for example, can be used to counteract these periods of not practising, thus reducing risk. 

More generally, however, can it be considered acceptable practice to become deskilled in procedures which you may be required to perform in the future? 

And it is unacceptable to perform procedures in circumstances where limited exposure means a clinician has not performed the skill recently.

GMC guidance

The GMC guidance within Good Medical Practice states that you must keep your professional skills up to date, you must regularly take part in activities that maintain and develop your competence and performance and you must recognise and work within the limits of your competence. 

Therefore, it is important that clinicians have insight into those areas where they may be competent but out of practice or those areas where competence could be questioned.

Domain 2 of the same guidance, which addresses safety and quality, states that you must take part in systems of quality assurance and quality improvement to promote patient safety. 

This includes:

a) Taking part in regular reviews and audits of your own work and that of your team, responding constructively to the outcomes, taking steps to address any problems and carrying out further training where necessary;

b) Regularly reflecting on your standards of practice and the care you provide.

Role of appraisal and revalidation

Appraisal should cover the whole scope of practice and therefore offers an opportunity to identify areas of discordance between procedures being performed in different areas of practice

It should also identify remedial actions to ensure professional skills are up to date and that doctors are working in their area of competency. 

The Royal College of General Practitioners gives specific reval­idation advice for those whose scope of practice involves specific clinical skills – such as minor surgery, joint injections, cervical smears, intrauterine contraceptive device/intrauterine system insertions.

It says: ‘It is appropriate and necessary to maintain an ongoing log of personal outcome data and reflect on the outcomes at least once in the revalidation cycle.’

The Royal College of Surgeons of Edinburgh recommends that surgeons keep a logbook of their operating activity – whether through the surgeon’s portfolio or through a different mechanism – as part of demonstrating the scope of their work and as an adjunct to validated outcome data.

Clinicians should consult their college to get specialty-specific guidance for appraisal and also revalidation-supporting documentation to reflect their scope of practice. 

Examples of ways that doctors may be encouraged to identify or address areas where they may need to focus their practice include supervised practice, logbooks, courses and education. 

Emergency care: Good Samaritan acts

Acing within competence levels also extends to the Good Samaritan situation. Although there is no legal duty for doctors to assist in an emergency, there is an ethical and professional obligation. 

In this situation, doctors remain obliged to make the care of a patient their primary concern and should consider their own limitations, both physically and in the scope of their clinical competence. 

Limitations should be made clear to the person being assisted and doctors should still consider best interest decisions where capacity is impaired.

What should I do if faced with an unfamiliar procedure?

Doctors should be aware of warning signs which may indicate that they are unfamiliar with a procedure or may be about to stray out of their usual area of practice. 

The same gut instinct that can influence a clinical diagnosis could also be critical in getting a clinician to pause before proceeding with an unfamiliar practice. 

Re-assessing the clinical urgency of a procedure in light of potential risk-benefit to the patient may prevent a clinician from straying outside their area of training. 

For example, it may be preferable to wake a patient from anaesthetic, rather than to proceed with a risk of harm to the patient if the scope of a procedure changes intraoperatively. 

Similarly, a smear could be delayed until another colleague can supervise or undertake the procedure. 

Obtaining consent

Some clinical skills such as venepuncture may carry few adverse consequences if performed after a prolonged period and many patients, even when aware of the lack of experience, remain happy for doctors to perform the procedure. 

When obtaining patient consent for procedures, if appropriate, they should be advised of any limitations of the procedure being offered, including those identified by the clinician in terms of their scope of practice. 

Claims have arisen in the context of relative inexperience in a procedure, which on the basis of Montgomery would be valid in terms of risks the patient may consider important in their decision making. 

Patients should be given options of seeking treatment elsewhere with another provider or delaying treatment whilst they consider their options. 

Complaints, disciplinary processes and regulatory investigations could all be a consequence of a doctor acting outside of their usual scope of practice, but claims can also arise should a patient suffer harm. 

Always contact your medical defence organisation, for advice if in doubt.

Dr Emma Green (right) is a medico-­legal consultant at Medical Protection