If you are in a pickle with an aspect of your practice population care (immunisation, cervical screening, CVRAs), Jo Scott-Jones, clinical director, suggests reviewing, judging and and acting on a "set piece" response.
An update from Dr Jo Scott-Jones, clinical director.
One of our practices had pretty dreadful DAR statistics. Like most practices, they had dropped over the height of the COVID-19 period and never recovered, in fact they were getting worse.
They held a 'set piece' practice meeting, outlined below, where the whole team went over the issues with a fine tooth comb, understanding the current way they were each doing things, and thinking about how they might improve.
This revealed two key issues.
Solving these two problems has lifted the practice's DAR statistics from less than 20 per cent to over 80 per cent over the past 3 months.
If you are in the same pickle with some aspect of your practice population care (immunisation, cervical screening, CVRAs) consider allowing a few key staff to take a few hours to see, judge and act on a "set piece" response.
Sport teams prepare their 'set pieces' with repeated practice and trying out new and varied strategies to try and outwit the opposition.
In football (soccer), the corner and the free kick. In rugby, the scrum and line out, for example.
In theatre and film 'set pieces' are elaborate sequences where one action builds on another leading to an ultimate climax, the care chase scene, that bit in Star Wars where they blow up the Death Star (sorry, spoiler alert!).
In general practice our 'set pieces' are the consultations we can prepare and strategise for. NZ Health Surveys tell us that most people go to the GP for either a check up, or for management of short term illnesses, followed by management of longer term conditions, such as cardiovascular disease, respiratory and musculoskeletal conditions, and for issues like contraception, immunisation, and mental health conditions.
Australian health surveys suggest that around 40 per cent of a GP's time is taken up with managing one of 23 different disorders, including hypertension, asthma, URTIs, sprains, back pain, osteoarthritis, depression, skin rashes, heart failure, gynaecological issues, and heart failure.
What you consider a set piece may vary according to your practice style and population, but the lifestyle change consultation, telling bad news, admitting to an error of judgement or omission, and the common clinical situations, the respiratory tract infection, hypertension, asthma, arthralgia, the contraception consultation, back pain, and the off work certificate might be good starting places.
For most patients this may be the first and only time they come to talk to a GP about an issue, but for you as a GP these consultations can be the bread and butter of your day, or should I say the carrots and quinoa in these more enlightened and healthier eating times.
One of the joys of general practice is that every person's cold is different, the way it is effecting them, the consequences, their fears ideas and expectations. Drawing these out and addressing them in the consultation is one of the things that separates health professionals from computer generated diagnostic tools. (Check out WebMD symptom checker for an idea of where the future may take us if we don't see the value in these "simple" consultations.)
However, even though every consultation is different, there is great value in preparing your 'set pieces' to help you to use the patient-centred method, and to enable everything to be fitted into the fifteen minutes allotted.
Frameworks really help, but whenever you are applying a template, be aware that "the opposition" (if we can call the patient such) may have a different plan in mind, and be prepared to adapt.
1. "What's going on?"
2. "How do we test our ideas?"
3. "What are we going to do now?".
4. "How will we know if things are getting better?"
What's going on?
I like John Murtagh's framework for considering "what is going on?" he suggests first to think "probability" - what is the most likely diagnosis? He then reminds us to consider the pitfalls that we often miss, (drug and alcohol misuse for example) and the things that should not be missed - could this be a tumour or a manifestation of HIV?
He then describes what he calls "the common masquerades" - conditions that have lots of symptoms and can present in a number of ways, he lists depression, diabetes, drugs, anaemia, thyroid function, spjnal dysfunction, and UTI. We also need to think if the patient is trying to tell us something.
How do we test our ideas?
and
What are we going to do now?
Proving the diagnosis usually means tests, but often a trial of therapy, or applying tincture of time and seeing how things develop is the ideal course of action and can be part of addressing "what are we going to do now?" Remember that patients sometimes just want to be heard, to share the burdens of life and know that someone else is not concerned about the funny looking lump on the side of their foot.
How will we know if things get better?
Planning with the patient "how will we know if things get better?" Roger Neighbour describes in terms of "safety netting", answering the "what if questions" - "if the lump gets bigger we should see each other again, if it stays the same we should relax unless it is causing you some functional problem, if it shrinks and goes away I would be surprised and would like to have another chat with you about it..."
Although you still meet the odd doctor who thinks that medicines alone make people better, in my experience it is unusual to be able to say with certainty "take this course of tablets and it will all be better by next week."
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