1. Get advice. If you don’t know what to do try not to be disheartened. Sometimes no one knows what to do but a problem shared is a problem halved. Use your GP supervisor as your first port of call and if they are not around, ask another GP whose opinion you trust. Still no good? Maybe the admitting doctor in the emergency department can help for acute issues, the pathology lab for results or the radiographer for scans. There is a much higher chance you will find a solution to the problem if you ask for help.
2. Use second opinions. When your opinion and the patient’s opinion diverge dramatically, or you come to an impasse, consider bringing in a second opinion. Start firstly with your supervisor. If the second opinion is different from your own, reflect upon it and take stock. Maybe your colleague had a differing view to avoid conflict; maybe your decision was clouded. Having the option of a second opinion can be tremendous at conflict resolution. Who could argue with, ‘I’m sorry, but what you are asking me to do is outside of my normal practice. But would you like another opinion on this? I could sit you back in the waiting room and see if one of my colleagues is free to discuss this with you.” This eases the situation; sure you aren’t doing what they want but you are compromising. Compromise is important. Failure to compromise and to be flexible will lead to problems.
3. Escalate. If you realise later that you should have done something, escalate it.If you realise later that you should have done something, escalate it. Speak to your supervisor and come up with a sensible plan on how to resolve the situation. Call your patient and explain your thinking. Share the task of decision making with them. Believe me they will thank you for it. ‘The doctor carried on thinking and worrying about me after I left’ – said the very satisfied patient.
4. Share your decision making. Share it with the patient. Ease the burden of being right or wrong. Present the facts, the evidence, and the guidelines to the patient, and then help them choose. Think of your role as a consultant. The patient wanted to know the options, give them to them, and let them decide. Use the information the patient gives you to find a solution and be wary of the question ‘What would you do doc?’ Your life circumstances and the patient’s are totally separate. What you would do is irrelevant and may influence a patient unfairly, especially if they are indecisive.
5. Refer when appropriate and don’t be frightened to do so. If you are unsure talk to your supervisor for guidance on whether what you are about to do is appropriate. Don’t worry about being criticised by the doctors in the emergency department or clinic. If you feel a referral is justified have the confidence to do it. With urgent referrals try to frame the clinical situation in terms of the worst-case scenario. Can you exclude it? No? Then make sure you act upon it. If you don’t it could hang over you, increasing your anxiety and stress. Try to work on the following rule; are you strongly considering an action? Does the action reflect the safest option? Then do that. This comes with practice and this approach stops you sitting at home, dreading the fact you didn’t send someone to the hospital or a clinic.
6. Try to make your practice evidence based. Try not to head off down rabbit holes with your patients. If they want to have their urine checked for rhubarb, or wish to try an experimental treatment that is not indicated for their problem, try to work out why they want it. Explore their ideas, concerns and expectations about what they are asking for. It can be easy to be pressured into ordering tests and prescribing medications when you do not feel comfortable doing so. Try to follow the guidelines where possible and if you choose to diverge from the guidance document clearly why and consider what a group of your peers would do in a similar case. Sometimes choosing not to follow the guidelines will be the right thing to do. Try and reflect on these decisions with your supervisor. Ideally you would do so before you commence a treatment or make a referral. If you are doing something contrary to your colleagues, consider why and question your actions.
7. Offer patient centred care. Try not to put up a wall of opposition to patient requests simply because their views differ from your own. If the patient makes a reasonable request try to fulfil it where possible. For example, a patient asks for a head scan but has no red flags and they have not hit their head. However, they have had headaches for a long time and they are worried about what is going on. Explain why a head scan may not be helpful, the risks associated with having a scan and your reasoning to advise against it. If they take on board your opposition and still wish to proceed, it may be best to offer it regardless. Where patient’s requests are reasonable but not met, the likelihood is that they will be fulfilled elsewhere. Remember that delays will only end up impairing your future relationship with the patient. Try to be mindful of the time and effort they have expended in seeing you.
8. Assess your own performance. Reflection is a word everyone is sick of hearing but it helps and we grow because of it. Are you referring too much, ordering too many tests, not ordering enough? Be scientific, audit your work and compare it to your colleagues.
9. Understand why your patients feel the way they do. Why do they want the thing they want or expect the things they expect. This may help your reassurance, or direct them to the test or treatment that will help them. If your patient wants a chest x-ray but they want it to rule out breast cancer, knowing this will help you direct them instead to a mammogram, ultrasound or breast referral. Not knowing their concern may result in an unnecessary and unhelpful test, or reassurance which fails to comfort them.
10. Do not assume why your patients have come to see you. You may incorrectly assume that a patient presenting with a simple URTI will want antibiotics. If you make assumptions it is likely you will head off on conversational tangents, only for your patient to stop you and say ‘I don’t actually want antibiotics, but would you mind if I had a sick note please.’ If you can find this out early you save wasting time and the consultation tends to run smoother.
11. Use time as a diagnostic tool. It is not possible to give all of your patients the correct diagnosis and treatment on their first presentation. With time the clinical picture may change to help guide your assessment. You can help your patient by explaining this process to them. Make sure you acknowledge that waiting will help you choose the correct path. Do not be in a rush while you are still learning. You do not have to be as good as your supervisor on the first day. This will come with time.
Would you like to write for TeachMeGP?
We are always looking for new authors on a whole host of topics which affect our patients. So if you would like to submit a piece for consideration, we would love to read it. You can send all submissions to email@example.com
Teach Me GP is not intended to be an alternative to seeing your own GP. It is intended to be used alongside your GP consultation as a learning aid. The advice provided within is as accurate and as comprehensive as possible. However, it is only general advice and should not be used as a substitute for consulting your own doctor.