Why don’t GPs know and do everything?

#GPFUQ 121  Why don’t GPs know and do everything? Every week there is a media report that complains ‘GPs need to be better trained at what they need to do’. GP knowledge about specific but different conditions is deemed inadequate and an extra training programme recommended as the answer to most problems. This is the ‘why can’t a generalist be more like a specialist’ story. The story fails to accept that it’s impossible to train all GPs in everything or ever have enough specialists to see everyone, and it ignores the benefits of a duel system of primary care generalists and secondary care specialists (see #GPFUQ 98). General Practice can either be considered very easy because GPs don’t need to have a depth of knowledge about anything or very difficult because GPs need to know something about everything.  A patient kept agitating to be referred to a specific super specialist. On arrival at the super specialist clinic the specialist said to the patient ‘I just hope you’ve got what I treat! Each specialist deals just with only a very narrow area.  Someone (usually the GP) needs to have an broad overview and co-ordinate the care of the patient.  There can never be a defence for bad general practice but good general practice is not about knowing everything its about providing easy access to good quality advice and treatments at lower costs than all the alternatives.

#GPFUQ 122 If GPs don’t do the work – how will it get done? Nothing is impossible as long as you don’t have to do everything yourself. Delegation is not abdication. Many simple tasks can safely be done by others.

Practices are different in their organisation and how and to whom jobs will be delegated will vary according to circumstances.

Suggestions for action

Restructure the primary care team to enable patients first point of contact with practitioners to be the most appropriately trained to provide care. For example with minor musculoskeletal problems – get patients to book in to see a physiotherapist directly for anything that could be handled by physical therapy first.

Use administrative staff to sweat the interface with hospitals. For example arranging admissions to hospital ‘trying to admit someone to hospital’, chasing up hospital regarding appointments, results, clinic letters etc, Phone call tag – ‘repeated phone calls to get hold of people who can’t get hold of you’. Get your staff to arrange telephone appointments at specific times through direct phone lines

Stop doing things individually. Stop treating patients individually if its not needed. Consider more group sessions for education of new hypertensives, musculoskeletal problems, contraceptives.

Review and notify patients of routine investigation results automatically via online access to their records or email.

Stop routine follow ups, especially monitoring of stable patients

#GPFUQ 123 How can GPs cope with the overload of information? The information highway is too busy. There are too many unsorted, unsolicited and uninformative emails, guidelines and protocols that arrive each week. Too much information leads to fatigue and the emails being ignored.

Suggestions 

·               Practices should return unsolicited or unstructured medical email to the sender and ask for improvements (see below)

·               Non-urgent information should be sent ‘batched’ in a weekly or monthly email. The email should be structured with an informative title about its purpose, the intended audience followed by a one-line summary of each item with a hyperlink to more detailed information. The author of the document should be contactable, there should be an ability to give feedback about the information and to subscribe and unsubscribe from circulation lists

·               Practices have these waves of guidelines and protocols coming from different local and national NHS organisations and each practice needs to keep up to date by loading on its intranet. Instead a local centre (eg a CCG based webpage) could keep all these up to date and reduce the work for practices. All the healthcare and other organisations should load important information on their own websites so that GPs can link to relevant information rather than have to load a complete set of document on a practices intranet

·               Stop the constant changing of NHS websites addresses so that the weblinks get out of date.

·               Stop the invention of the wheel in each practice. For example if the Chief Medical officer writes a letter describing who should be offered a flu jab - they should include the appropriate READ or SNOWMED CT codes searchers for each GP clinical system

·               The RCGP should publish a template for best practice for the dissemination of information to practices

Why you shouldn't have a career in general practice?

#GPFUQ 120 Why you shouldn't have a career in general practice? This FUQ is meant for medical students and junior doctors contemplating a career in general practice.

You need to be aware of some of the hazards and you should not be a GP if you don't like most of the following

Talking to people and getting to know them and their families
Being an expert about the local community
Having and maintaining a broad medical expertise
Having an overview of everything - the whole experience of life
Coping with anything that comes through your door
Working in the messy real world
Solving problems
Managing risk
Having special interests in your career like teaching, research, or an area of clinical medicine
Not losing your skills unless you want to
Being responsible and in charge - both for your patients and your own business
Thinking globally about improving health care but acting locally for the benefit of your patients

Being able to find work and and then work flexibly almost anywhere in the world

Being able to quickly change and improve your working conditions
Being one of the most trusted professionals in society

How do you know what you don’t know?

#GPFUQ 119. How do you know what you don’t know?

You won’t but you can assess your learning needs. To be able to discover all your learning needs have to try to address the St Augustine, Johari, Rumsfeld question. How can you ever know what you don’t know?  The different types of needs assessments include:

Gap or discrepancy analysis. This formal method involves comparing performance with stated intended competencies- by self-assessment, peer assessment, or objective testing -and planning education accordingly.

Reflection on action and reflection in action Reflection on action is an aspect of experiential learning and involves thinking back to some performance, with or without triggers (such as videotape or audiotape), and identifying what was done well and what could have been done better. The latter category indicates learning needs. Reflection in action involves thinking about actual performance at the time that it occurs and requires some means of recording identified strengths and weaknesses at the time.

Self-assessment by diaries, journals, log books, weekly reviews. This is an extension of reflection that involves keeping a diary or other account of experiences. However usually these tend to be written nearer the time of their review than the time of the activity being recorded.

Peer review - this involves doctors assessing each other's practice and giving feedback and perhaps advice about possible education, training, or organisational strategies to improve performance. The main types of peer review are internal, external, informal, multidisciplinary, and physician assessment. The last of these is the most formal, involving rating forms completed by nominated colleagues, and shows encouraging levels of validity, reliability, and acceptability.

Observation in more formal settings doctors can be observed performing specific tasks that can be rated by an observer, either according to known criteria or more informally. The results are discussed, and learning needs are identified. The observer can be a peer, a senior, or a disinterested person if the ratings are sufficiently objective or overlap with the observer's area of expertise (such as communication skills or management).

Critical incident review and significant event auditing Although this may be used to identify the competencies of a profession or for quality assurance, it can also be used on an individual basis to identify learning needs. The method involves individuals identifying and recording, say, one incident each week in which they feel they should have performed better, analysing the incident by its setting, exactly what occurred, and the outcome and why it was ineffective.

Practice review. A routine review of notes, charts, prescribing, letters, requests, etc, can identify learning needs, especially if the format of looking at what is satisfactory and what leaves room for improvement is followed.

Will a Personal Development Plan keep making you a better doctor?

#GPFUQ 118. Will a Personal Development Plan keep making you a better doctor? Probably not. PDPs were designed to reinforce adult type self-directed learning where the learner identifies their own educational needs, formulates a plan to address those needs, reflects on the learning achieved or confirmed, and identifies further needs. But PDPs are being used differently now. Annual PDPs are a requirement for NHS appraisal and GMC revalidation. What went wrong? The process of the learner identifying ‘important learning needs’ has disappeared and been replaced with a bureaucracy of documentation. Arguably a means to an end has become an end in itself.

The main aim of a PDP is to ‘identify and address your learning needs’

1. The General Medical Council says: PDP will help you identify and address your needs and those of others. It will also help employers identify, coordinate and resource the learning and development needs for all staff.

2. The Royal College of GPs says: PDP consists of a number of ‘SMART’ (Specific, Measurable, Achievable, Realistic and Time-bound) objectives,  although some may, of necessity, be less measurable and time-bound than others.

The PDP must contain the following key elements for each objective:

• a statement of the development need

• an explanation of how the development need will be addressed (the action to be taken and the resources required); objectives are more likely to be achieved if consideration is given to several ways of meeting them

• the date by which the objective will be achieved

• the intended outcome(s) from the objective.

3. The British Medical Association says: PDP should contain a list of personal objectives with an indication of the period of time in which items should be completed and how completion should be recognised. The PDP represents the main developmental output for the doctor.

4. BMJ Learning says: PDP is a demonstration of your personal responsibility for continuous improvement in your professional roles

5. The NHS revalidation Support Team says: PDP is an agreement, between the appraisee and appraiser, on the learning and development needs of the appraisee, identified at the appraisal interview, with an outcome-based learning plan for the subsequent year.

6 The Higher Education Authority (HEA) says: PDP is 'a structured and supported process undertaken by an individual to reflect upon their own learning, performance and/or achievement and to plan for their personal, educational and career development'.

7. Wikipedia says: PDP is the process of creating an action plan based on awareness, values, reflection, goal-setting and planning for personal development within the context of a career, education, relationship or for self-improvement.

A review of the history of PDPs in the UK doesn’t reveal any evidence base (in terms any better outcome such as learning and career development) for writing a PDP once a year. Personal Learning plans (PLP) developed in Higher Education in the 1970’s from the idea of having learning pathways agreed between the learner and the institution. In the 1980s PLPs were used to develop key skills in undergraduates and then spread to encourage more flexibility and autonomy in learning. The Higher education institutions used them to integrate new curriculum demands like communication, problem solving, teamwork and personal development. They asked their learners to identify ways in which they could develop these skills, identify their needs and find ways to develop and demonstrate them.  Around the same time the phrase `the reflective practitioner' was coined by Schon (1983) and the notion of reflection in professional life became a key feature in professional development. PLPs are consistent with new 1980’s educational approaches like `deep' learning’ and ‘adult learning’. In the 1990s, work-based appraisal systems spread along with the need to demonstrate continuing professional development to maintain membership of professional bodies like accounting and banking. Personal learning targets set by the learner were used as evidence in portfolio-based learning and assessment.

In medicine in response to concerns about the quality assurance of doctors performance, the GMC set a target that all doctors should undergo a process of regular appraisal, and be involved in a process of periodic revalidation. In 2002 Personal Development Plans PDPs became part of compulsory annual NHS appraisals and would be a requirement for GMC revalidation. After ten years of delays GMC revalidation finally started in 2012.

This completed the transformation of Personal Learning Plans from a short-term, learner-centred, reflective tool based on identified learning needs to the Personal Development Plan that is a never-ending cycle of mandatory, directed documentation used to address any appraisal-driven whim. How can this make better doctors?

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.