What’s the trilemma or impossible trinity in health care?

#GPFUQ 112 What’s the trilemma or impossible trinity in health care? Good health care should be easy access to high quality at low cost. The reality seems to be that that we can only achieve two of these three at any one time

#GPFUQ 113 How do you ration primary care? Make people wait or make people pay.

#GPFUQ 114   Are most problems in primary care trivial or self-limiting?  Yes they are. Good GPs know that patients may present with a simple illness but often have an underlying worry about their health that needs to be identified and addressed. You can use the opportunity that trivial and self-limiting illnesses give you to build your relationship and advising patients on healthy lifestyles and opportunistic health screening opportunities

 

#GPFUQ 115 Why do patients present their bruises to GPs? Are many patients just bruised? Yes, the equivalent of mental or physical bruising are common in general practice (see 

#GPFUQ 114). Patients need to share their worries. Inevitably in a risk averse society greater specialists are called upon to relieve smaller worries.

 

#GPFUQ 116 Is it difficult  to manage self limiting illnesses? Trivial and self-limiting illnesses are not difficult problems to manage. But it can be difficult to manage the patients that have the illnesses.

#GPFUQ 117 How accessible should a GP be? Should GPs provide their routine service  ‘everywhere all the time?’ The gap between medical professional working hours and other services working hours seems to be widening. While shops and other services have extended their hours, doctors moved from their traditional very long hours of work (e.g. junior doctors hours, and GP on call hours) to reduced but more concentrated hours of work. It seems that the trend is for longer opening hours and it’s probably a ‘when’ rather than an ‘if’ as to whether GP surgeries are open 7 days a week at least for routine care problems. Suggestions for action

·               Offer greater access to services (with both shorter waiting times for urgent needs and better continuity of care for non-urgent needs) by redesigning the working week to provide longer opening hours including evening and weekends, with easier phone and personal access etc

·               Collaborate with OOH providers and/or other practices to run appointments for routine care OOH

·               Organize changes that are likely meet the needs of the practice population

·               Work shifts so that opening hours can be extended

·               Coordinate the care better among healthcare system (specialty care, hospitals, home health care, and community services and support). 

·               Start up multidisciplinary consultations (in GP offices)

·               Do more adult prevention out of the office by using tools like Interactive Voice Response notification

·               Document handovers from acute sector e.g. adding discharge summary information including prescriptions to the electronic health record, and/or contacting the patient at home to ensure that ‘all is well and they know what to do next’.

·               Work together with other practices to have a bigger and more robust chronic disease service.

·               Commit to quality care and quality improvement using evidence-based medicine to guide shared decision-making with patients and families

·               Ensure all patients with a long term condition have some kind of self management plan

·               Focus on designing systems of care that reliably get all aspects of care done for all patients (e.g. all or none bundles of care)

·               Have an efficient and successful chronic condition management programme where each member of the team plays their part and IT helps to ensure that patients do not have to make unnecessary visits for check ups.

·               Provide patient held records e.g. asthma self management plans

·               Give screening questionnaires to relatives or carers to complete at their leisure at home e.g. Dementia screening MMSE

·               Employ a 'doctors assistant' - to act as receptionist and be clinically trained to triage

·               Employ a prescription clerk who not only issues prescriptions, but monitors diary entries and actions them (e.g. blood forms, arranging chronic disease appointments etc)

·               Develop secondary care services e.g. dermatology and rheumatology to reduce waiting times and improve local care for these conditions

·               Allowing patients to read their notes before coming into surgery, so they can ask better questions about their treatment

When was the golden age of general practice?

#GPFUQ 106 When was the golden age of general practice? The golden age is now, it’s always now. Make the most of it.

#GPFUQ 107 What makes a practice a happy place? All happy practices are happy for the same reason; every unhappy practice is unhappy in its own way. Find out what’s wrong and fix it.

#GPFUQ 108   Is it possible to know and remember all the published evidence and guidelines? No, the only hope is electronic prompts to guide you in the right direction at the time you need it ‘Just in time guidance’.

#GPFUQ 109 Is it less work for a GP if you know the patient? No but it feels like less work. Increase continuity in the practice- use the least number of people that can do the work well.

Suggestions for action

·               GPs should have personal lists or allocate a 'regular long term doctor' for selected patients

·               Preserve what is left of continuity of care even when this involves a new technology such as e-mail consultations

·               Have own doctors available for telephone consultations each day ideally with direct access via telephone system so its not required to speak to a receptionist. This acts as good triage system - patients can be booked into same day slots if necessary, can often be dealt with on phone and are  often better dealt with by own doctor rather than the duty doctor.

·               stop other people dealing with results when they don't know the patient

·               have an efficient and successful chronic condition management programme where each member of the team plays their part and IT helps to ensure that patients do not have to make unnecessary visits for check ups.

·               24/7 care – The care card’. An ID badge (like staff wear) given to ‘at risk’ patients and/or attached to their personal alarms like a baggage label  to share information between primary care & secondary care and facilitate better communication to provide the best appropriate care for patients. Care card has patient password, ambulance control phone number to access special notes on an online clinical record service and a feedback phone number to report any problems that arise with the service.

#GPFUQ 110 What are the major flaws with the process of GP revalidation?

The problems include

1. The theoretical basis for revalidation. In a nutshell science dictates that you never prove anything is true (eg that a GP is competent) only that something isn't true (eg that a GP isn't competent). All the requirements and evidence are that we ask appraisees to collect information to demonstrate they are competent. We should be looking for evidence of their incompetence.   

2. The evidence base for the GMC requirements for revalidation. These have no strong link with the incompetent performance of doctors

3. Changes in the rules. Explaining to appraisees why the advice you gave them last year to plan their appraisal year is now wrong for when you have to assess what they did in that year 

4. The difference in interpretation of the requirements by the different medical specialities, different areas in the UK and different individual appraisers. There is increasing awareness and challenges by appraisees of this lack of quality assurance.

#GPFUQ 111. Are examinations of a GP’s competency fair tests? No examinations can ever be an infallible test of complex competencies and predictor of an individuals performance. Its unlikely that there will ever be a fair test of the examination process itself. The questions are usually whether its good enough, (what’s its sensitivity), to find the competent (or incompetent) GPs and whether its unfairness, (whats its specificity) is acceptable?  What’s to be done? There must always be a quality improvement and assurance process of examinations that invites and responds constructively to criticism of the structure, process and outcome of the exam. 

Who’s the most important person in the NHS?

#GPFUQ 97 Who’s the most important person in the NHS? The patient in front of you

#GPFUQ 98 Why do we need a primary care- secondary care system? In a good health care system there should be good access, high quality and low cost. The primary care- secondary care system seems the best way to achieve this ideal. A good system is when a patient can easily see their GP, and the GP can give all the needed appropriate care to most of the patients. The few patients who have more potentially serious problems are identified by the GP and referred to the appropriate specialist who then does all the necessary tests. For example a GP may see 100 patients with a headache and knows that 96% are likely to be self-limiting and don’t need referral. The GP may identify 4% who he is worried about and refers them to a specialist. That’s a 4% referral rate. When the specialist sees this 4% of patient he expects them to have a more serious problem and will usually exhaustively test them to make sure they don’t have a serious illness. A bad system is when the GP over investigates or refers too many of the patients or when the specialist fails to investigate his patients enough. If a GP is risk averse he will refer more patients to a specialist. It only needs GPs to refer 5% rather than 4% of patients to increase hospital workload and costs by 25%. If there aren’t enough GPs then patients will end up getting poorer access to more expensive services and lower quality over-medicalised care.  

#GPFUQ 99 How many GPs do we need? The UK consensus is that for a balanced primary care – secondary system of health care we need 50% GP and 50% the other specialties. NHS workforce planning has allowed this to fall to <40% and is currently funding training of 40% GP and 60% hospital specialties. Following a 3 year training scheme there will be a shortage of GPs and following a 6-7 year training scheme for other specialities there may be a shortage of jobs for these other specialists.

#GPFUQ 100 How much work is there in primary care? There are >300m consultations each year in UK primary care (90% of all NHS contacts) and 20m contact per years in A&E. Each day there are 150,000 GP contacts, 5,000 Hospital outpatient and A&E contacts and 600 hospital admissions. Even a marginal shift from primary care to secondary care will overwhelm secondary care.

#GPFUQ 101 Can GPs increase patients self treatment and reduce the need for medical involvement. If GPs don’t do the work – will GPs lose their special relationship with their patients? General Practice can be like being a good parent it involves not just quality time but also routine stuff so being a good GP means being available for the minor worries, coughs and travellers' diarrhoea as well as for major physical and psychological pathology. By dealing with the former GPs can build the relationships they need to be able to help with the latter. However many minor ailments could be self managed. IMS Health survey Dec 2007 shows 57m GP consultations annually involve minor ailments, (51.4m involve MA alone), 18% GP workload is for MA, 50% MA consultations are for 16-59yr olds, costs to NHS £2b pa (80% are for GP time), averages 1hour/day for every GP http://www.pagb.co.uk/information/research.html#tns

Suggestions for action  

·               GPs should develop a strategy for promotion of self-treatment of minor ailments, and a triage process. Setting up self-treatment facilities and advice.

·               RCGP should script Video and podcasts for use on the practice website and in the waiting room that tell patients how to look after minor ailments. Use the same RCGP script in different practices but with the local GPs as the ‘actors’ to promote local interest and validity. The video and podcast are accompanied by a printed handout on the management of minor ailments. You can have video added to video broadcasts in waiting room

·               Set up an ‘Avoid the queue, self manage your illness’ area in the practice to advise on initial best management for the following conditions which are the commonest minor ailments back pain, dermatitis, heartburn and indigestion, nasal congestion, constipation, migraine, cough, acne, sprains and strains, headache, earache, psoriasis, conjunctivitis, sore throat, diarrhoea, haemorrhoids, cystitis, hay fever, warts, nail infections, colds.

·               Produce an evidence-based handout on How to manage your minor ailment for each of the common minor ailment conditions.

·               Identify patients who have presented with minor ailments from the consultation records of the electronic health record and after the consultation mail the patient the information sheet How to manage your minor ailment for the relevant conditions- invite patients to return feedback sheet to enter into a prize draw

·               Gain greater value from previously under-utilised sources. This may include: enabling patients, carers and communities to manage and improve their own health and/or contribute to the process of healthcare; empowering members of the healthcare team whose contribution is at present limited owing to lack of training for example; and/or removing barriers that are standing in the way of obtaining full value from all members of the healthcare team eg ‘practice to the limit of the licence’

·               Triaging, consulting and prescribing for common benign conditions without red flags e.g cold, sore throat, UTIs in women, acne minor skin problems etc. Transfer most care of minor illnesses to triage by others and taught self care

·               Getting experienced staff to deliver some of doctors duties, i.e writing prescription for minor illness

·               Use local newspaper adverts about management of minor ailments

·               Provide more information for patients to record and track their symptoms and signs eg A one page leaflet to record and track symptoms of pain

·               The RCGP should publish a template for best practice

#GPFUQ 102 How do you become an expert? An expert is someone who has made a lot of mistakes. You will miss every common treatable problem once in your professional lifetime. Disasters happen as a chain of small mistakes. Try to learn from the mistakes of others, you won't have time to make them all yourself.

#GPFUQ 103 What the difference between experience and making mistakes. Experience reminds you and makes you recognise a mistake when you make it again. It’s inevitable that you will make mistakes – that fuels learning. It you keep making the same mistake – that’s incompetence.  Success gives you a habit, failure gives you learning

#GPFUQ 104  Are most problems in primary care trivial or self limiting?  Yes Trivial and self limiting illnesses are not difficult problems. Good GPs know that patients may present with a simple illness but often have an underlying worry about their health that needs to be identified and addressed. You can use the opportunity that trivial and self limiting illnesses give you to build your relationship and advising patients on healthy lifestyles and opportunistic health screening opportunities 

#GPFUQ 105  How difficult can it be to manage self limiting illnesses?  It’s easy to manage self limiting illnesses. It can be difficult to manage the patients that have the illnesses.

What should GPs do for their patients?

#GPFUQ  89 What should GPs do for their patients? You should never do for others, what they can do for themselves. 

#GPFUQ 90 How can todays GPs survive a 40 year career

Not Waving but Drowning. Nobody heard him, the dead man,
But still he lay moaning:
I was much further out than you thought
 And not waving but drowning.

Poor chap, he always loved larking
And now he's dead
It must have been too cold for him his heart gave way,
They said.

Oh, no no no, it was too cold always
(Still the dead one lay moaning)
I was much too far out all my life And not waving but drowning. Stevie Smith

Every career in general practice changes.How can any GP hope to survive a 40 year career with increased  demand, for care, extra expectations of GP expertise, more external regulation of quality, against a background of difficult changes and austerity. GPs need to develop an informed plan for a long, progressive and mostly enjoyable career in general practice..

All the world's a stage, And all the men and women merely players; They have their exits and their entrances, And one man in his time plays many parts etc . Shakespeare

#GPFUQ 91 Whats a GP personal development plan? Identify what you want to achieve and your learning or development needs, prioritise them, match those needs with opportunities to learn, check it worked. GPs need to do this as part of NHS appraisal. The most important parts of a PDP are not what you what are going to do in the next 12 months anyway, it’s the longer term planning you need for a 30-40 year career. You may not be able to think in terms of 30-40 years but you can make a plan with milestones for the next 5-10 years. You can make changes to your plan as you progress in your career and as opportunities arise.

#GPFUQ 92 How can GPs manage the demands of  the ‘Get a note from your doctor’ culture GANFYD,

This includes sick certificates (or fit notes) for employment, social control certificates for school and housing issues, sick notes for students and school children (so they don't lose their bursary for one day), certifying long term sickness absence without knowing any of the workplace adjustments achievable, filling in review forms for multidisciplinary panel meetings, dealing with some agencies problems / agendas regarding shedding responsibilities for care – e.g. the home care is concerned but the relatives are absent, completing paperwork for other government agencies, and housing forms

Suggestions for action

·               Have a rubber stamp made or automatic letter – e.g. I am unable to answer this request for a ‘note from your doctor’ in a meaningful or informative way

·               Provide instruction and facilities for patients to self write sick notes or other notes and ask patient to complete the sick or fit note ready for signing by their GP. In many of these circumstances there are no objective symptoms and signs of illness for a GP to document or certify, a doctor has to rely on the patients report of how they feel or felt. Whenever possible the patient should complete the text of the relevant certificate and a doctor can sign the certificate to attest the reasonableness of the text. No appointment to see the doctor would usually be necessary, or a telephone or email consultation might be sufficient.

·               Always charge a fee for certificates that are not part of NHS GP work.

#GPFUQ 93 Why is it sometimes important for a GP to pretend to have the memory of a goldfish? So as not to get upset over a long career when the endless circle of changes  brings back old ways of working as new bright ideas again and again.

#GPFUQ 94 Consultations – How difficult is it for GPs to schedule more efficient and effective patient consultations ‘how to get better time for consulting with patients’

Patients will always want time to discuss their problems. The appointments system (including face to face, telephone and e-mail consultations) must meet their expectations. The best appointment processes seem to manage the first contact with patient better, avoiding any user-unfriendly barriers, allow the patient to get through to someone who knows them, and provide open access scheduling so that everyone who wants an appointment that day will be seen that day. GPs should use telephone consultations more and structured e-consultation to make the process more efficient and effective and ‘stopping the ping pong of emails and with patients’.

Practices who triage all calls seem to manage their workload better ‘telephone triage of same day requests works well (done by GP's with personal lists)’ ‘our telephone triage service saves time’

Suggestions for action

·               You must know how many appointment you really need and always have enough appointments to meet demand – ‘it reduces stress for patient and staff’.

·               The appointment booking systems must have enough capacity both in terms of the number and types of appointments and be easy to use. This will ‘reduce the amount of time spent coping directly or indirectly with the consequences of poor systems’.  You may need to change appointment system to reflect the local demographics.

·               If you can’t provide enough appointments to meet demand, you must change your way of working eg more triage, more telephone and e-consultations, more delegation and skill mixing.

·               Have a health professional sift the booked appointments in advance and plan what else needs to be done before or at the appointment eg pre-consultation checks (BP, weight, urine) by a Health care assistant. Clinical prompts and pop ups on the GP computer system do the same as long as they work.

·               Protect routine work from the demands of urgent work. Provide a dedicated duty doctor +/- nurse practitioner: this protects others clinicians from fluctuating and urgent demands. They also have time to deal with patients more thoroughly and appropriately, rather than rushing urgent work alongside routine clinics

·               Have fewer face to face consultations, more phone and email consultations if medically appropriate

·               Provide a mix of appointment times - short/medium/long

·               Provide longer appointments. 10-12 minute appointments may be the current standard appointments but 15-20 minute appointments seem needed so that fewer patients are more thoroughly reviewed with as many problems as possible dealt with in each consultation ‘you can get done in 15 minutes almost as much as in 2 x10 minute appointments and the patient doesn't have to take 2 half days off work and you don't spend several minutes each consultation saying hello, goodbye and trying to remember what was going on’. ‘Longer appointment times might allow more problems to be fully resolved in one visit’.

·               Vulnerable people eg learning disabilities and patients with complex need more time - target them for 20min appointments.

·               Arrange for multiple chronic pathology patients to be seen for half-1hr appointments once or twice a year for co-coordinated management planning.

·               Have telephone triage of same day appointment requests

·               Follow up of patients with phone calls rather than repeat appointments

·               Provide Online booking

·               Use SMS text to communicate with patients

·               E-consultations - The best process seems to provide a structured email consultation route ie one that patient can access via a web page but ensure that patient uses a structured process in the consultation. This avoids patient writing a letter and clinician having to ping pong emails backwards and forwards - see HHC example xx

·               The RCGP should publish a template for best practice

#GPFUQ 95 when does a GP need to do a visit to a home or residential care home? Some patients do need a home visit. But compared to face to face consultation in the practice, home visiting limits the resources available to the GP, and can also be a less efficient use of a GPs time so has to be managed effectively. Is a GP visit adding value, or would some other action be better?

Suggestions for Actions

·               Identify the truly housebound patients, and make sure their status is clearly visible in the electronic health record

·               Set up alternative transport arrangements for patients who could be seen in the practice e.g. set up a patient volunteer transport service, make an arrangement with a local taxi firm

·               Try to have personal lists or one doctor for the practice per care home

·               Have nurses visit the housebound and residential care homes

·               Provide a weekly "ward round" visit to a local nursing home to provide better care of all the patients and decrease unnecessary acute admissions to hospital.

·               Have regular pre-emptive meetings to discuss the best care of the housebound and residential care homes

·               Avoid pastoral home visits, routine and repeat home visits

#GPFUQ 96  What is NHS idle chatter?  We should be discussing the ideas and ways for improving the NHS, not the events,  nor the people who run the NHS.

Do GPs need to have a certificate of competence in everything they do?

#GPFUQ 81 Do GPs need to have a certificate of competence in everything they do? No – GMC accreditation means that you are certificated as competent to know if you need a certificate of competence in anything extra

#GPFUQ 82 How much retraining do GPs need to do to keep them competent in procedures? Is obligatory re-training needed or are we re-teaching grandmothers to suck eggs? A bureaucracy of training and accreditation has developed that is not linked with personal learning needs or effective learning e.g. how many cervical smears or IUCD coil fits do you really need to do each year to remain competent?  Training should be directly linked to an assessment of your learning needs and produce effective learning. We should stop obligatory retraining on things we remain competent at and keep it for those things we may not be competent in because we don't do very often but do need to know. The RCGP should research, and give continually improving guidance on best practice on accreditation and reaccredidation of procedural medicine.

#GPFUQ 83 Why are there so many part-time and non-partner GPs giving full time and GP partners advice? There is a new career choice in GP – the non-practicing GP. This is someone who is not a partner in a practice, and does not do more than 2 days of clinical work each week as a GP. In the past  it was difficult for GPs to get paid for not working as a GP. There were a few academic GPs who were usually benign but also lacked any power. The new non-practicing GP career choice is to be an uber GP either as an academic, a manager, educator or appraiser GP. Most remain benign but some of these non-practicing uber GPs seem bureaucrats who set difficult standards for others to attain and may have little tolerance for contrary ideas or opinions (see #GPFUQ 84).

#GPFUQ 84 What is dogmatic General Practice? One where the GPs increase their effort after they lose sight of the goal or can't change their mind. The dogmatic GP displays selected strict standards and little tolerance for contrary ideas or opinions.

#GPFUQ 85 What s the difference between your GP vision and your GP mission. A mission statement gives your purpose, basically why your GP service exists, what it does and for whom. It’s a guide that spells out what your organisation is all about. The mission should focus on the here and now. A vision statement outlines the goals and aspirations for the future. It’s a mental picture of a specific target and should be as a source of inspiration

#GPFUQ 86 How do you become a GP leader? It’s easiest if you are surrounded by followers. It also helps if they want to follow you. They are more likely to follow you if you have charisma, power or money. None of these will make you an effective leader. If you don’t have charisma power or money then you have to build a history of success in what you do.

 I was in a group of Britons having political lectures at an election time in the US. We were outraged because it seemed that the candidates needed millions of dollars to have any chance of success. The Americans dismissed our cynicism with ‘what sort of leader would he/she be if he/she couldn’t raise a million dollars?’

As a leader you become responsible for producing the culture (what we do) and climate (how it feels). If you are a good leader you can increase your followers willingness to make extra efforts (their free and discretionary effort) for you. The main types of leadership are: Coercive – do as I say, Visionary – come with me, Affiliative - People come first, Democratic - what do you think, Pacesetting - do as I do now, Coaching - Try this. The least effective for most situations are the coercive and pacesetting though these may be essential in emergency situations

#GPFUQ 87 What sort of GP team do you need? The team that allows you be the best sort of doctor you want to be. All teams have a weakest link. Removing the weakest link may just move the problem to the next weakest link. You need to decide just how strong each link must be and stick to that standard.

#GPFUQ 88 Why don’t care pathways and plans seem to help improve care.

More extended teams cause more complications with communications. Responsibility for patients and liaising with others becomes a problem. The care of many patients with complex conditions or co morbidities involves many people. In general practice all staff accessing and using the same electronic health record makes care more efficient ‘everyone knows what everyone else is doing’ and the care is usually coordinated by one member of the team. A more formal multidisciplinary approach is needed.

Suggestions for action

·               Multidisciplinary team (MDT) working – institute regular review of problematic patients with MDT.

·               Introduce case management, selecting case by case the best profession for the particular patient. For a minority the GP will be / remain case manager; for the majority it will be other professions.

·               Use fax/email in a timely manner so that MDT meetings with other healthcare workers can be used well and avoid the whole team listening to "detail" or "catching up" about specific cases rather than real learning points or improving service

·               Inform patient and the MDT of MDT care plans

·               Engage experienced nurses to do more case management.

·               Integrate care managers work near the patient  – don’t let them do care management from a distant office

·               Make sure there is a designated social worker attached to the practice to improve collaboration with the social services to increase quality for patients

·               Redesign clinical pathways with secondary care colleagues to make the simplest possible pathway for patients

·               Review management of patients who get their "care" from hospital services, and institute case management in primary care

·               Increase the use of voluntary groups e.g. Parkinson's society

·               Have some effective method to hand over information from the practice to Out of Hours care and vice versa.

What's the second rule of three in general practice?

#GPFUQ 73 What’s the GP-patient communication formula? Effective communication with a patient is proportional to your understanding and respect of that patient.

#GPFUQ 74  What’s the formula for a patient following a recommended treatment? A patient’s adherence to a recommended treatment is equal to the patient’s preference plus the treatment’s relevance multiplied by its perceived effectiveness divided by the sum of the effort required to adher and the adverse side effects

#GPFUQ 75  What’s the 4+2 formula for successful GP management. The GP management includes the four essentials - good strategy, execution, culture and structure plus at least two of the secondary management practices- good talent, innovation, leadership and partnerships.

#GPFUQ 76 What’s the formula  for living with bureaucracy? If a problem is impossible to solve, you have to handle it where it lies.

Any large organization has arcane practices that need to be challenged. The NHS and the rest of the bureaucracy asks us for lots of meaningless information, and often refuses to process our requests unless all the information is supplied. Much of the requested information is of no practical use other than to establish who we are, what we say we’ve done, and that we are compliant. The aim is to reduce the  micromanagement of work that results in more time spent on  paperwork and less time for clinical work. It's best to work with the NHS and others to reduce unnecessary bureaucracy. Agree a ‘can do’, ‘no blame’, ‘have patience’ approach to improvement and stopping requests for unnecessary information. Always question non-evidence based work e.g. work related to unvalued target chasing

#GPFUQ 77   What’s the first rule of three in general practice? A patient (and the GP) are only likely to remember three things from any consultation. Decide what are the most important three things to remember in each consultation.

#GPFUQ 78  What's the second rule of three (or the three strikes rule) in general practice? If a patient returns three times with the same problem and you haven’t been able to solve it then you should refer the patient to someone else to help solve the problem e.g. refer to a specialist.  

#GPFUQ 79  What's the third rule of three  in general practice? Heaven in general practice is 3 patients in a row one with diabetes, one with depression one with asthma. Hell is 3 patients in a row with the same problem depression, or diabetes or asthma 

#GPFUQ 80 How long is the attention span of a GP? It varies throughout a career. It may start at about 20-30min but after a  lifetime of dealing with problems in 10-15 minutes slots  it becomes about 10-15 minutes.