Monday, 2 April 2012

Continuous Professional Development

Close up of purple flowers on our rosemary bush
Rosemary flowering in the garden, March 2012
The lecture last week was one of a weekly series held in a side room off one of 'my' wards, covering aspects of elderly medicine. Following a recent incident, one of my favourite doctors suggested that it would good if I gave one of the lectures about re-feeding syndrome, which is a potentially fatal condition that may arise when someone who has had little or no dietary intake for more than five days starts to eat (or is fed). At the time I was less twitchy about my workload, and conscious of the need for evidence of CPD (continuous professional development), so I agreed.

Every two years, all professionals regulated by the HPC (Health Professions Council) are required to re-register. To ensure that professional standards are maintained, 5% of the registrants, selected at random, are required to submit a portfolio of evidence to demonstrate that they are engaging in CPD and keeping up with the latest developments in their particular field. CPD might consist of attending a professional meeting or a training course, a written piece of reflection on a particular case or condition, or researching an aspect of practice, and as in this case, delivering a lecture about it. If a Dietitian is unable to produce a satisfactory portfolio then registration may be withheld, meaning that he or she is no longer allowed to practise as a Dietitian. Loss of job and livelihood ensues.

The week before my lecture I thought it would be useful to see the room and hear someone else talk, to judge the kind of thing that might be expected. In a tiny room with space for no more than about fifteen chairs squashed together we were offered supermarket sandwiches, crisps, fruit and chocolate by a rep (I would have written 'lunch' but thought you might imagine something more lavish). The first part of the lecture (which is all I could stay for) was about admissions to hospital and mortality of stroke patients in the local area compared with a different local area, an English region and England as a whole. It was mostly attended by doctors, from the most junior Foundation Year trainees up to the senior consultants. The senior consultants asked many detailed searching questions, and I am now thoroughly apprehensive. But it was nice to mix with the doctors off-ward, where it is possible to converse on a social level - two lanes out of three have been closed on a main route into the hospital; that part of our journeys, normally less than 5 minutes, took 45 minutes. We talked quite a bit about how late each of us had been that morning.

Clinical Supervision is an opportunity for us three newly-qualified and newly-appointed Dietitians to have some scheduled time with a more senior colleague, and can also be used as evidence of CPD. In my first supervision we talked about the generalities of the job and about specific patients, where there is some ambiguity about the treatment, the patient or our role.

For example, one of the main things we all seem to experience is how much we should contribute to the overall holistic care of the patient. For example, patients who have the capacity to make their own decisions are entitled to make decisions that we think are unwise, and we have to deal with the consequences. A patient for whom swallowing has been deemed 'unsafe' (i.e. food or fluid is at risk of entering the lungs rather than the oesophagus), may refuse to have a tube placed, in which case the lead consultant usually allows the staff to offer food and drink on the basis that this is better than allowing the patient to starve.

In this situation, the Speech and Language Therapists will not advise on the 'safest' texture of food or thickening of drink, on the basis that their professional opinion is that the patient should not be eating or drinking anything. The lead consultant generally rules that the patient should then be offered thickened fluids and a puree diet, because these will probably cause the fewest problems. The patient's nutritional requirements will almost certainly not be met without supplements, but should Dietitians similarly withdraw from the situation, or continue to recommend nutritional supplements that may cause harm if taken?

The consensus in the Clinical Supervision meeting was that we should recommend that supplements are offered, since it is in the patient's best interests to have a sufficient dietary intake, and if the patient has capacity and chooses an unsafe route of ingestion, then that is their right. Our discussion also concluded that we should challenge the consultant's ruling on puree diet and thickened fluids, because this form of intake is generally unpalatable and limiting, and if a patient chooses to eat unsafely rather than be tube-fed safely, they might as well be offered an unsafe appetising menu, rather than gloop which is also unsafe.

In future Clinical Supervision meetings we hope to invite experts to talk about various aspects of practice, such as how much we should know about diabetes on the wards, and what might influence our choice of feed regimen. I'm hoping we'll also plan some more evenings out, because last week's night out was great. I had two drinks (double my usual intake) and reached home well after normal bedtime.

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