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Working in isolated environments - case study

Ramesh was excited about learning new skills on his rural placement, but working in an isolated environment brought its own issues.

Ramesh is a fourth year graduate entry medical student doing his first clinical placement in a rural area. His placement is at a GP practice in a small town alongside Dr Alison MacCallan, who is the only GP in the town and the surrounding area. Ramesh sits in on Dr MacCallan’s consultations and also joins her for home visits and emergency out-of-hours GP work.

During these consultations Ramesh met Ewan, one of the doctor’s regular patients. Ewan has a chronic condition and several co-morbidities, and takes a lot of long-term medication to manage his health.

One day, Ewan contacted the surgery about some acute symptoms and Dr MacCallan decided she needed to do an urgent home visit. Ramesh accompanied her. During the visit, Dr MacCallan asked Ramesh to help her with a diagnostic procedure. Ramesh had observed this procedure in clinical placements, but had not done it himself.

He thought he should know it as a fourth year student, and felt bad no one else was around to help. He was also worried Ewan would think he is not competent enough.

What should Ramesh do?

  1. 1. Carry out the procedure to help Dr MacCallan – as there is no one else around he can only do his best.
  2. 2. Tell Dr MacCallan he can’t help her as he has never done the procedure before.
  3. 3. Tell Dr MacCallan he has observed, but not done, the procedure and ask if she and Ewan would still be comfortable for him to try.

What did Ramesh do?

Ramesh was honest with Dr MacCallan and said he'd seen the procedure twice, but not performed it himself. He said he could try and do his best with her supervision, and asked if she and Ewan were happy with this. Dr MacCallan reassured him and continued with the procedure herself. She asked Ramesh to call an ambulance as Ewan needed to be transferred to hospital. Once Ewan was admitted and stable, she arranged for Ramesh to practise the procedure at the surgery.

The next day, another patient of the surgery, Donald, met Ramesh on the street and asked him if Ewan was ok. He said they'd been neighbours and friends for years. He had seen Dr MacCallan and Ramesh go into Ewan’s house and was worried about Ewan’s health. Ramesh was not sure what to say and he didn’t know if Ewan had given consent[4] for any details of his condition to be shared.

What should Ramesh do?

  1. 1. Tell Donald that Ewan is in hospital but he believes he will make a good recovery in a few days – Donald is only asking out of concern after all.
  2. 2. Tell Donald he cannot share any details because Ewan has not consented to it.
  3. 3. Ask Donald to speak to Dr MacCallan, as Ewan is her patient.

Support from Dr MacCallan

Ramesh felt there was nothing he could tell Donald without breaching confidentiality[5]. He told Donald he was sorry, but he couldn't share any details with him. Donald was not happy with Ramesh’s response and kept pushing him to give an answer. Ramesh felt uncomfortable and couldn't think of anything to say. He rushed away telling Donald he had to be at the surgery.

Ramesh spoke to Dr MacCallan about Donald. Dr MacCallan said it was a difficult situation and agreed he had done the right thing not sharing any information about Ewan’s condition[6].

Dr MacCallan didn’t recall Ewan mentioning Donald at any point. She checked Ewan’s records to ensure he hadn’t given permission to share health information with Donald. Dr MacCallan told Ramesh no information could be disclosed to Donald under these circumstances.

Dr MacCallan also told Ramesh although this was primarily about patient confidentiality, it was worth considering whether he (or any other medical student who was not qualified) could give an accurate picture of Ewan’s situation.

Ramesh returned to his medical school at the end of the placement. He shared his experiences with other fourth years[1], in a session designed to debrief about their rural placements.

What to take away

  • Acting within competence. Medical students must recognise the limits of their competence[2] and ask for help when necessary. Students should clearly explain their level of competence to anyone who supervises them on a placement[3], so they are not asked to do anything they are not trained to do.
  • Asking for help. If students are not sure they are able to carry out a procedure competently, they should ask for help from a more experienced colleague. Students should only attempt practical procedures if they are trained to do so, and only under appropriate supervision.
  • Maintaining patient confidentiality. All patients have a right to expect their doctors will hold information about them in confidence. Confidentiality is central to trust between doctors and patients. Medical students must be clear about what information a patient has agreed can be shared with friends and family before discussing their care

References to the guidance

Achieving good medical practice: guidance for medical students

Domain 1: Knowledge, skills and performance

  1. 1. Practical tip #1: What is reflection?
  2. 2. Apply knowledge and experience to practice (paragraphs 6-11)
  3. 3. Practical tip #2: Bring professional on placements
  4. 4. Practical tip #3: Consent – things to remember

Domain 3: Communication, partnership and teamwork

  1. 5. Maintaining patient confidentiality (paragraphs 56-59)
  2. 6. Practical tip #8: How does confidentiality apply to my placements?

Other guidance

You can find more information about when and how you can disclose personal information about patients – with their consent, where the law requires it and in the public interest – in our guidance, Confidentiality:

  1. 7. Principles (paragraphs 6-11)
  2. 8. Protecting information (paragraphs 12-16)
  3. 9. Sharing information with a patient's partner, carers, relatives or friends (paragraphs 64-66)