When GP skills trump algorithms

24 July 2020

"You should try to be a little more flexible". The enduring words of Elastigirl to Mr Incredible in the opening scene of that film still makes me smile. I can empathise with Mr Incredible on many things - particularly his attempt to cram in a multitude of tasks before pressing deadlines.


Flexibility and the ability to 'roll with the punches' is one of the reasons I love general practice.

The greatest technical minds can draw up algorithms, but it will never replace our unique blend of generalist skills and knowledge of our patients' lives and values.

Similarly, clinical scoring systems always need an expert generalist to see who will benefit from them, and to identify the inevitable case which just does not quite fit into a neat pathway.

For example, this week I performed a telephone consultation with a young 32-year-old woman Tracey (not her real name) who gave a very accurate description of a small lump which had developed in her neck.

It was small (approximately 3mm in length), soft, situated in her anterior triangle and was mobile. She had no B symptoms and was otherwise well.

A computer algorithm would have accurately diagnosed an innocent lymph node and would most likely not have recommended face to face assessment.

I knew Tracey well, however, and I was aware of her personal story.

Her husband had been diagnosed with Acute Myeloid Leukaemia five months ago. While she had done well to support him through his first cycle of treatment, the second cycle had been very hard on them both, as it occurred during the COVID-19 pandemic.

He had to have inpatient treatment and she was allowed to see him once a week from behind a glass door - an impossibly difficult situation for them both.

When I explained to her over the phone what her small lump was likely to represent, I could tell from the tone of her voice that she was not happy.

"Would you like me to examine it?" I asked. She immediately jumped at the opportunity and came to see me that afternoon.

The appointment lasted only five minutes, but I might as well have given her a million pounds. She was so grateful to have been physically reassured and was able to ventilate about her experiences on how she was struggling to support her husband.

An appointment was arranged with our in-house counsellor and we addressed other issues to do with him having been made redundant the month before.

I hope you agree, having the flexibility and personal knowledge of my patient was the key and added much more than a fixed pathway or artificial intelligence model could ever provide.

Flexibility is going to be so important for all of us this winter. You have done incredible things already by offering new ways of engaging with our patients, and we all have concerns about this winter.

Our flu vaccination campaign this year is going to be the most important, and yet the most challenging of any in our history.

We have a position document to help organisers of flu clinics (601 KB PDF) and my own experience is that it will require the unique locality flexibility GPs can provide.

If you have a novel way of performing your flu clinic this year, please let us know and we can share your best practice.

Clinical scoring systems

It is vital we retain this ability to meet our patients' needs as they frequently don’t read or follow predestined dictates.

In September 2019, RCGP Council sent a clear message that while we were keen to learn more about scoring systems like the National Early Warning Score 2 and use them when appropriate, we would not be ruled by them. 

I personally disliked having to score every new depression using the tool Patient Health Questionnaire-9 (PHQ-9), but I did find that the prompt to review a patient with first case depression in two weeks was helpful and very much appreciated by my patients.

In her wonderful book 'H is for Hawk' the author Helen Macdonald recounts her own depression, caused by the loss of her father, through the eyes of a goshawk she rears and looks after.

Her goshawk is a violent, unpredictable raptor and was bought from a dealer in Belfast. When she finally accepts she needs help, her appointment with her GP whom she finds "impossibly kind" is gratifying.

She then recalls him filling in a questionnaire - which was undoubtedly a PHQ-9 - and to me, her recollection of this event jars the free flowing, supportive consult she should have experienced.

The Q-risk calculators for conditions such as primary prevention of cardiovascular disease and cancer risk are very helpful but must guide our decisions, not dictate them.

We are likely to be doing much more remote consulting in the future, so it will be important we retain the flexibility we know and value.

Importance of medical education

Thank you to everyone who has participated in the PRINCIPLE trial.

It is the largest primary care randomised controlled trial in the world and is an urgent public health badged study.

Any GP in the UK can recruit to this study. It’s easy, straightforward, takes 10-15 mins and research costs (income) per recruit are very good.

It’s entirely remote and patients complete an online consent or call the freephone trial number. Currently treatment is azithromycin versus usual care, but doxycycline is to be added as an arm and there are plans to add other potential treatments.

The General Medical Council is launching its National Training Survey this week. It is very important we feedback into this work.

Education is a vital part of what we do and will be the future of our profession, so it is important we understand what our students want and need.

As the best teachers, mentors and role models, we will benefit in the long run by attracting the brightest and the best students to our profession so read more about the survey.

There will be challenges in delivering medical education in our surgeries this September and I am very grateful to all our tutors’ commitment.

If you can continue your work in education, we would really appreciate it.

Some new tutors have come forward to help despite current challenges, which is impressive, so if you would like to know more about teaching, please get in touch and we can let you hear the experiences of some of your peers or arrange contact with the right people.

Face coverings

The advice on face coverings was updated yesterday with the NI government announcing they may become mandatory in shops and other enclosed spaces from 20 August.

We have engaged regularly with the Department of Health (DOH) and the Chief Medical Officer on clarity for primary care and face coverings for GPs and patients in face-to-face appointments.

Back in April we advised that it is best for practices to be able to risk assess their patients when they attend.

We also explained the importance of GP clinical judgement to insist surgical grade masks are used by patients in specific circumstances, such as prolonged leg ulcer dressings which can take up to 30 minutes to compete.

There is new evidence emerging that face masks do have a benefit when used by the public and we will support this message when possible.

You can read our policy document about use in practice (397 KB PDF), as well as a useful article on face coverings by Professor Trish Greenhalgh. Of note are the early paragraphs about how our understanding has changed.

Changes to Health and Social Care Northern Ireland

We have all heard about the Department of Health's plans to establish a better way for primary care to link in with our secondary care colleagues when patients need escalation of care.

These suggest establishing a specific pathway of care for patients that need to be admitted as an alternative to emergency departments - urgent care centres.

Based on feedback you have given me, I have made it clear to both the health minister, Robin Swann and Permanent Secretary, Richard Pengelly that we do not support any mandating of GPs out of their practices.

We cannot support anything that destabilises our GP practice core.

We do, however, support a system where we have clear support to help us when we are managing the clinical risks of our jobs and which can help ensure patients are treated and investigated quickly and appropriately.

Again, I am very keen to hear your views on these proposed changes so please let me know your views via email.

I’m even more keen to hear from as many of you as possible so I will be available to chat on an open Zoom meeting on the last Friday of each month from 13:00 - 13:30, namely 31 July, 28 August and 25 September.

Please come and join me for three minutes or 30 minutes - there is no structure.

I simply want to hear from you, how you are getting on in practice, what good things you are doing and what challenges you are facing.

The links to these meetings will be in your inbox soon, so share them with your colleagues and jump on at any time over the 30 minutes. It will be good to hear from you on whatever topic you chose. 

Post written by

Dr Laurence Dorman, Chair of RCGP Northern Ireland

Dr Laurence Dorman took office in November 2019 after three years as Deputy Chair of Policy for RCGPNI. A GP principal in Mourne Family Surgery, Kilkeel, Co Down, since 2007, he is the fourth generation of GPs in his family. He was also, until recently, the Chair of Newry and District GP Federation. 

Laurence has particular interests in new ways of working in primary care, cancer care, and inspiring the next generation of GPs. He set up the successful Dear Colleague initiative to improve the interface between primary and secondary care and has been a strategic advocate for interface and communication since September 2017.

During his time as Chair, he wants to support College members to ensure that the future of GP services is protected, supported and sustainable.

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