LWP update 3: revalidation and limited licensure.

In this series, key recommendations by the RCVS Legislation Working Party (LWP) are explored by those directly involved in making them. Here, former RCVS council member Amanda Boag discusses proposals for revalidating vets and limited licensure.

Cardiotoxicity and cancer: prudential judgment in medical practice / Cardiotoxicidad y cáncer: el juicio prudencial en la práctica médica

ABSTRACT The objective of this paper is to propose a conceptual tool for consideration by medical professionals and cardiologists, based on the concept of prudential judgment or Aristotelian phronesis to confront the problems of cardiotoxicity resulting from cancer treatments. We start by analyzing the case of a young female patient who received two types of therapies: the first with anthracyclines (adriamycin), which produces type I damage, as stated in the consensus of 2014; and the second treatment, one month later, with trastuzumab, an agent that produces type II damage not dependent on dose. In this case, the patient manifested acute cardiac insufficiency, with a decrease of LVEF to 28% on the echocardiogram and to 27% on magnetic resonance imaging. Reports have indicated that treatment with beta blockers and the suspension or decrease of the dose limits damage, but during preclinical stages. Awareness and early attention to subclinical damage have thus become extremely relevant to substantiate treatments based not only on clinical evidence but also on the ability of medical professionals to rely on prudential judgment--which moves away from the medical practices that are developed on a daily basis in order to influence and reduce the cases of irreversible heart failure known as cardiotoxicity.(AU)

RESUMEN Este trabajo tiene como objetivo proponer el juicio prudencial o phrónesis aristotélica como herramienta conceptual para la deliberación de los profesionales de la medicina y cardiólogos para afrontar la problemática que implica la cardiotoxicidad como resultado de los tratamientos contra el cáncer. Partimos desde el análisis de caso de una paciente joven que recibió dos tipos de terapias: la primera con antraciclinas (adriamicina) que produce daño por el mecanismo tipo I, propuesto en el consenso del 2014, y un mes después con trastuzumab, agente que produce daño tipo II no dependiente de dosis. En este caso la paciente presentó insuficiencia cardiaca aguda, con disminución de la FEVI a 28% por ecocardiograma y de 27% por resonancia magnética cardiaca. Se ha reportado que el tratamiento con betabloqueadores y la suspensión o disminución de la dosis limita el daño cuando se encuentra en etapas preclínicas. Por ello el pensamiento y el abordaje temprano en búsqueda de daño subclínico ha tomado extrema relevancia para fundamentar los tratamientos no solo desde la evidencia clínica, sino también en el juicio prudencial que dejan las prácticas médicas desarrolladas día a día para impactar y reducir estos casos de falla cardiaca irreversible conocidos como cardiotoxicidad.(AU)

Community and family nurse: Present keys, future challenges. / Enfermería Familiar y Comunitaria: claves de presente, retos de futuro.

It is the mission of the Community and Family Nurse through an integral and holistic approach to accompany people from cradle to death in developing their health potential, and promote different family, work and social environments to facilitate this development. Throughout history, various international, European and national organizations have regulated the figure of the Community and Family Nurse, and now their functions, powers and professional performance are fully regulated. The Community and Family Nurse can respond to the needs of a changing population and take on new responsibilities in management and research. Their extensive basic and advanced skills gathered under a rigorous training programme, benefit the health system, the nursing profession, citizenry and its communities. Many challenges remain for the Health Departments of each Autonomous Region to make it possible for this specialty to develop its full potential for improving care.

Constitutional Regulation of Speech (and False Beliefs) in Health Care.

False beliefs in medicine can be regulated by constitutional doctrines of false speech and professional speech, whereby government can restrict professionals' false beliefs or impose its own false beliefs on professionals. In our allegedly "post truth" society, such regulations and their foundations can have an important influence on health care practice.

La gestión de los servicios de fisioterapia de Atención Primaria: un techo de cristal para los fisioterapeutas / The management of Primary Care physiotherapy services: A glass ceiling for physiotherapists

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Do the public think medical regulation keep them safe?

OBJECTIVE: To assess public knowledge and expectations of the ways to assess doctors' competence to ensure patient safety. DESIGN SETTING AND PARTICIPANTS: Telephone survey of a random sample of 1000 non-institutionalized Hong Kong residents. MEASURES AND RESULTS: Only 5% of public were correct that doctors are not required to periodically be assessed, and 9% were correct that the doctors are not required to update knowledge and skills for renewing their license. These results echo international studies showing a low public knowledge of medical regulation. The public overwhelmingly felt a periodic assessment (92%) and requirements for continuous medical education (91%) were important processes for assuring doctors' competence. A high proportion of the public felt that lay representation in the Medical Council was insufficient. CONCLUSION: There is a significant gap between public expectations and understanding of the existing medical regulation and the actual policies and practices. Despite a lack of public knowledge, the public thought it important to have an ongoing structured monitoring and assessment mechanism to assure doctors' competence. The public also expects a greater involvement in the regulatory processes as members of the Medical Council. There is a need to review and enhance the current regulatory system to meet public expectation and ensure accountability for the privilege and trust granted by the State in professional self-regulation. In the context of our complex health system, a thorough understanding on the dynamic interactions between different institutions and their complementary roles in a meta-regulatory framework is required in assuring patient safety.

Financing of forensic psychiatry in view of treatment quality and threat to public safety. / Finansowanie psychiatrii sadowej a jakosc leczenia i zagrozenie bezpieczenstwa publicznego.

Stay in a psychiatric hospital of persons who committed the gravest criminal acts while in a state of insanity aims to ensure their effective treatment (therapeutic function), but above all to prevent the repetition of prohibited acts of significant harm to the community (preventive function). Forensic patients are provided with suitable medical, psychiatric, rehabilitation and resocialization care. The court imposes an indefinite detention. In view of the dual purpose of the stay in a psychiatric hospital, both therapeutic and preventive, the treatment costs generated by forensic wards are higher than those of general psychiatric wards. This prompts person from outside psychiatry, who do not understand the nature of preventive measures, to call for continuing reductions in the expenditure on forensic psychiatric care. It is, therefore, worth analyzing the possible meaning and results of the attempts to economizeforensic psychiatry, to find savings and to manipulate financing system under the pretence of economic incentive to improve treatment quality. In this paper, the authors address and discuss the above and other issues.

Police-community safety and trust.

(1)In 2017 alone, 46 states have enacted over 270 laws affecting policing. (2) At least six states have enacted laws to train the public on their rights and expectations during police interactions. (3) Police are increasingly partnering with health care professionals to more safely respond to mental health and substance use disorders.

Profesionalismo: valores y competencias en formación sanitaria especializada / Professionalism: values and competences in specialized medical training

Objetivo. Conocer la percepción de los profesionales sanitarios implicados en la docencia de la formación sanitaria especializada (tutores, residentes y colaboradores docentes) sobre los principales valores y competencias que desarrollan habitualmente en su trabajo. Métodos. Se diseñó un cuestionario para ser autocumplimentado, con 4 secciones y 51 variables (escala 1-10). Se distribuyó entre los profesionales de un hospital universitario y 9 centros de salud. Resultados. Respondieron 287 profesionales. Participación: 97% de los tutores (n=59), 38% de los residentes (n=61) y 56% de otros profesionales sanitarios (97 con faceta docente y 70 sin ella). El coeficiente alfa de Cronbach fue de 0,945. Los 3valores mejor puntuados fueron la responsabilidad por cumplir con el propio trabajo (8,7 puntos), la integridad ética (8,6 puntos) y el respeto hacia el equipo de profesionales con el que trabajan (8,3 puntos). Las 3competencias mejor puntuadas fueron la comunicación con pacientes y familiares (8,16 puntos), el liderazgo para motivarse a uno mismo (7,9 puntos) y el trabajo en equipo (7,8 puntos). Los valores recibieron, de media, 0,7 puntos más que las competencias (IC 95%: 0,5-0,9). No se observaron diferencias entre tutores y residentes, aunque sí entre médicos y enfermeras, y entre hombres y mujeres. Conclusiones. La percepción sobre los valores y las competencias es compartida por tutores, residentes y colaboradores docentes. Sobre esta percepción influyó la categoría profesional y el sexo, pero no la edad ni trabajar en el hospital o en atención primaria (AU)

Objective. To determine the perception of healthcare professionals (tutors, residents and teaching collaborators) involved in specialist medical training on the core values and skills to develop their tasks. Methods. A tailor-made questionnaire aimed at healthcare professionals in 9health care centres and a referral hospital. Questionnaire: 4 sections and 51 variables (scale 1-10). Results. A total of 287 professionals participated, which included 97% tutors (n=59), 38% residents (n=61), and 56% others (97 teaching collaborators and 70 not associated with teaching). The alfa Cronbach coefficient was 0.945. Best rated values were work compliance (8.7 points), ethics in professional practice (8.6 points), and respect for their team (8.3 points). The best rated competence was communication with patients and families (8.1 points), followed by self-motivating leadership (7.9 points), and the practical application of medical and healthcare theoretical knowledge (7.8 points). The values received, on average, 0.7 points above competences (95% CI: 0.5-0.9). There were no differences between tutors and residents, although differences were found between doctors and nurses, and between males and females. Conclusion. Most of the professionals (tutors, residents, and teaching collaborators) share the same perception of the values and competencies that influence their professional development. This perception was influenced by the professional category and gender, but not age or working in a hospital or primary health care (AU)

Impact of personal competencies and market value of type of occupation over objective employability and perceived career opportunities of young professionals / El impacto de las competencias personales y del valor de mercado de la profesión en la empleabilidad objetiva y la percepción de oportunidades de carrera en profesionales jóvenes

The research of employability shows tension in the social field of career, where variables such as market value, gender, and personal skills are important. The aim of this study was to identify the predicted weight of market value of type of occupation, sex, and career competences (self-efficacy, pro-activity, and locus of control) over objective employability and perceived opportunities for a future career and satisfaction of young professionals. In this study, 294 graduates from 27 different undergraduate degree programs participated, describing their labor situation, satisfaction with career opportunities, and their level in the studied competences. Each type of occupation has a specific market value score, according to national and international criteria. It was possible to identify that the market value of their occupations had significant effects on objective employability (p<.000, f=.48). Also, self-efficacy and locus of control were significant predictors of perceived employability opportunities (p<.000, f=.26). This predictive value of personal variables was different between males (p=.011, f=.82), and females (p<.000, f=.34), and between occupations with low market value (p=.016, f=.45), medium market value (p<.000, f=.34), and high market value (p=.006, f=.21), which allows the development of specific intervention strategies to promote equality in labor opportunities and job placement (AU)

La investigación sobre la empleabilidad permite advertir la tensión en el campo social de las carreras laborales, donde son importantes variables como el valor de mercado, el género y la habilidades personales. El objetivo de este estudio fue identificar el valor predictivo de competencias de carrera profesional (autoeficacia, proactividad y locus de control), el sexo y el valor dado por el mercado a las profesiones, tanto sobre la empleabilidad objetiva, como sobre las oportunidades percibidas de empleabilidad y desarrollo de carrera de jóvenes profesionales. Participaron 294 graduados de 27 titulaciones diferentes, quienes respondieron un cuestionario respecto de su situación laboral, satisfacción con las oportunidades de carrera y las competencias personales estudiadas. Cada profesión obtuvo un valor de mercado de acuerdo a criterios de nacionales e internacionales ampliamente usados. Fue posible identificar que el valor de mercado dado a las profesiones tiene efecto significativo sobre la empleabilidad objetiva (p<.000, f=.48). Además, autoeficacia y locus de control fueron predictores significativos de las oportunidades de empleabilidad percibidas (p<.000, f=.26). Este valor predictivo de las competencias personales fue diferente en hombres (p=.011, f=.82) y mujeres (p<.000, f=.34) y en profesiones con valor de mercado bajo (p=.016, f=.45), medio (p<.000, f=.34) y alto (p=.006, f=.21). Estos resultados permiten desarrollar estrategias de intervención específicas para promover la igualdad en las oportunidades laborales (AU)

Necesitamos más matronas / No disponible

En España hay actualmente 7073 matronas con un reparto no equitativo en el territorio. Su número se ha mantenido bajo, con un aumento que no ha permitido llegar a las necesidades previstas. La mayoría de las matronas ejercen en el ámbito público. Se accede a la formación como una especialización de enfermería, en régimen de residencia y durante dos años, tras obtener plaza mediante un examen estatal (EIR) en alguna de les 112 unidades docentes públicas de formación repartidas por las diferentes comunidades autónomas. La matrona es una profesional autónoma en la atención al embarazo y el parto fisiológicos y los procesos relacionados con la salud sexual y reproductiva, sobre los que tiene plena responsabilidad en el marco de la interdisciplinariedad (AU)

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Could legal requirements in nursing practice trigger actions that would change the rates of urinary tract infections? A case study in Brazil.

We evaluated the influence of a Brazilian resolution, published in 2013, that restricts the performing of urinary catheterization to nurses, as opposed to others from different nursing professional categories, on indicators of catheter-associated urinary tract infection in an intensive care unit. The resolution triggered actions such as the implementation of protocols and nursing staff training that led to behavior changes related to the reduction of catheter-associated urinary tract infection rates.

Research competency and specialist registration: Quo vadis ?

The requirement of 'research completion' as necessary for specialist registration with the Health Professions Council of South Africa (HPCSA) has recently been subject to legal action, with a court order potentially shifting requirements beyond those envisaged by the HPCSA. The research requirement is congruent with National Department of Health strategy in this regard, i.e. the strengthening of research as a stated priority. While the expectation of research competency is not in itself contentious, the capacity of institutions and the ability of registrars to facilitate and complete, respectively, have brought the issue into focus. Specifically, the apparent discrepancy between a court order and a regulation needs to be resolved to ensure that specialist registration is not unduly hampered, while ensuring that a potentially important contributor to a national priority is not prejudiced.

The importance of the patients deemed not guilty by reason of insanity for the psychiatric reform.

According to the Greek Penal Law if someone "because of a morbid disturbance of his mental functioning" (article 34) is acquitted of a crime or misdemeanour that the law punishes with more than 6 months imprisonment, then the court orders that this individual should be kept in a public psychiatric institution if the court reaches the conclusion that this person poses a threat to public safety.1 Individuals who have broken the law and deemed "not guilty by reason of insanity" are treated in psychiatric units of Psychiatric Hospitals according to the article 69 of the Penal Code. In Athens, in the Psychiatric Hospital of Athens and the Dromokaiteion Psychiatric Hospital, and in Thessaloniki in the Unit for "Not guilty by reason of insanity (NGRI)". The person who is deemed not guilty by reason of insanity following a crime is facing double stigmatisation and marginalisation from both the legal and the health system. He/she is usually treated initially with fear and later since there is no therapeutic aim but only the court instruction for "guardianship", with indifference. The patient who is committed by the courts in a psychiatric unit for being "NGRI" is facing a unique legal and psychiatric status.2 In this respect he/she is disadvantaged when compared to either convicted criminals or psychiatric inpatients. If the patient was not found "NGRI" (ie innocent as far as sentencing is concerned) he would have been punished with loss of liberty for a certain (specific) amount of time, and like all individuals convicted in court he/she would have the right to appeal and reduce his/her sentence in a higher court and maybe released from prison earlier for good behaviour etc. In this respect the individual found to be "NGRI" is disadvantaged when compared to a convicted felon since he/she is kept for an undefined period of time. Additionally, he/she will be allowed to leave the psychiatric unit following a subjective assessment of a judge with no psychiatric knowledge who will decide that this certain individual has "ceased to be dangerous". These problems are accentuated by the difficulties that the Greek justice system is facing. On the other side, from the psychiatric point of view, the "NGRI" patient who is an inpatient is not receiving the holistic, (bio psycho social) treatment and assessment of needs he/she requires. The psychiatric team looking after him, once the acute symptomatology is controlled is just getting used to a patient who will not be discharged in the immediate future. These patients form the "new chronic asylum psychiatric inpatients" for whom the treating psychiatrists are not allowed to discharge back into the community whilst it is unclear whether they can be transferred to supported rehabilitation units. It is a medical but also legal paradox to assign to contemporary psychiatric units aiming mainly to treat patients in the community to "keep and guard" inpatients whilst these psychiatric units should focus on care and rehabilitation of the patients (including the "NGRIs").3 Keeping patients like these in psychiatric units creates problems in the functioning of the units. These patients are "kept" in acute beds for long periods of time (5 to 6 years minimum) with patients treated voluntarily or against their will and cannot be discharged without a court's decision. The problems are obvious if one realises that the average time of hospitalisation is not exceeding 2 months for the vast majority of psychiatric patients. With the prolonged stay patients of the "article 69" (NGRIs) they not only burden the already limited resources (there is an established lack of psychiatric beds nationwide) but also this prolonged hospitalisation increases their stigmatisation and marginalisation. Thus the prolonged hospitalisation for "safety" reasons according to the court decision leads to the absence of a therapeutic aim other than maintaining the patient on the ward. Greece has agreed that there is an urgent need in developing community psychiatry services and closure/transformation of the big psychiatric hospitals (asylums). It is impossible to close hospitals where "NGRIs" are kept. The decision to move them into the community is not a medical-psychiatric but a legal one. In this respect it is imperative to establish a Forensic Psychiatric Unit for these patients. In our country as the "Psychargos" external evaluation highlighted, there are great gaps in the provision of Forensic psychiatric services.3 It must be emphasised that these gaps affect negatively psychiatric reform and social reintegration not only for the forensic psychiatric patients but for the whole of mentally ill individuals. Given that forensic Psychiatric services are developed in Athens and Thessaloniki and that training in Forensic Psychiatry has moved forward, it is imperative that the state should build upon the existing knowledge and experience and create specialist forensic units aiming to treat and rehabilitate this special and important group of patients.4 Only when the patients found "not guilty by reasons of insanity" have their own (safe for the society and them) therapeutic and rehabilitative services the aim of de-institutionalisation will be visible and realistic to implement.

[Medical negligence]. / Ärztliche Fehler.

Medical negligence is a matter of growing public interest. This review outlines various aspects of medical negligence: epidemiology, taxonomy, and the risks, causes, psychology, management and prevention of errors.

Desarrollo y mantenimiento profesional / Professional development and maintenance

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Prescripción enfermera: más barreras para cuidar a las mujeres / No disponible

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