SCA toolkit: Clinical management

The commonest cause of failure during GP consultations is an inability to manage conditions according to up-to-date guidelines and evidence-base. This is likely to be a knowledge problem.

In addition, without proper planning it can be difficult to manage time well. This leads to the management part of the consultation being rushed and/or not patient-centred. A failure to discover patient specific information such as psychosocial impact or ICE may further compound the problem.

The trainee therefore needs to be able to:

• Have sufficient knowledge to offer to the patient effective and safe management strategies
• Involve the patient so that the final management plan is patient centred (see also toolkit sections ‘Shares and uses ICE in plan’, ‘Negotiates and uses psychosocial information in the plan’)
• Consult in such a way that there is sufficient time to allow the necessary discussion between patient and doctor. (see also toolkit section ‘Supports in decision-making’)

One problem relating to management plans within audio consultations is that the patient may not understand the management plan and may therefore embark on an incorrect or even dangerous treatment programme. It is therefore important to offer information in additional forms, such as a text message, or a link to an appropriate website. There is also more need to formally check that the patient has understood the information you have presented to them.

Activity 1

Carry out a needs assessment of your management knowledge gaps. Do this by looking at the GP Super-condensed topic guides in the GP Curriculum section on the RCGP website.

Activity 2

Make sure you address your knowledge gaps in the area of clinical management.

• Use resources such as NICE, clinical knowledge summaries, guidelines and patient.info.
• Focussed revision is essential here to avoid spending too much time reading and not enough time applying your knowledge to patient management.
• You must internalise the management of common GP conditions to improve recall of the facts needed to form safe plans.

Activity 3

Develop this routine. Whenever you see a patient where you are not sure how to manage the problem - write this down. Then afterwards (as soon as possible) read up on the management of this condition and write down what you have learnt.

If possible, try to discuss what you have learnt with your trainer or other colleagues. This method is sometimes called PUNS (Patient Unmet Needs) leading to DENS (Doctors Educational Needs), to describe how a patient need should focus your revision and learning. Many trainers will encourage this approach to help you consolidate the knowledge more effectively.

Activity 4

Check that you are seeing the right sort of patient cases, based on the needs assessment you have done. Speak to your trainer and/or senior receptionist to make sure you get the right clinical exposure for your needs. If all else fails, get your trainer to role play the types of cases you need to see.

Activity 5

Review a series of your consultations with your trainer - how often is your suggested management plan different from the one suggested by your trainer? Discuss why this is? Possible reasons to consider (apart from insufficient knowledge) include:

• Wrong diagnosis (so wrong management)
• Lack of time leading to either no management plan or a rushed management plan
• No consideration of simple management options such as - time, rest - reassurance - regular review etc.

Activity 6

Now address the problem areas identified and review new consultations with your trainer. Is the gap between your management plans and those of your trainer becoming less marked?

Activity 7

Keep on top of gaps in your knowledge. You can do this by:

• Reading and summarising all new relevant guidelines from NICE and SIGN
• Presenting new guidelines to colleagues in the practice
• Making sure you follow up any gaps in your knowledge that emerge from consultations (see (3) above) - ‘PUNs and DENs’
• After each surgery discuss your management plan from one of the consultations with a colleague in the practice - let your colleague choose which consultation you will discuss
• Try a “What if...?” analysis. This involves using a case which you think you have managed well but add another layer of difficulty. Examples include:
• o “What if the patient refuses the treatment that you offer...?”
• o “What if the patient has other medication that may interact with the medication you are suggesting...?”
• o “What if the patient wants a solution to their problem very quickly...?”

Audio activity 1

Review a series of your audio consultations, focussing just on the part of the consultation where you talk to the patient about management. As well as being able to offer an up-to-date, appropriate management plan, you have the extra challenge of making sure the patient has understood and accepted the plan. For each of the consultations you review, how confident are you that the patient will follow the treatment plan you suggest? What verbal cues might help you here?

Exercise 1

Consider why there are gaps in your knowledge? Are there some areas that you consistently avoid (if so, then you must address these first so start reading or using the FourteenFish GP Revision Library)? Are there some areas that you feel you know well, but actually don’t? Are there some areas that you just find difficult? Discuss with your trainer.

Patients in UK general practice, particularly elderly patients, will often present with multiple health problems. One in four adults in the UK have two or more medical conditions and one in three adults admitted to hospital have five or more medical conditions. Similarly, elderly patients often take multiple medications over 2 million adults in the UK take seven or more prescribed medications.

When multi-morbidities and polypharmacy are not considered, this leads to unsatisfactory health care, adverse drug reactions and poor health outcomes. In practical terms, it is important to be able to:

• Be aware that treatment for an existing health problem may be causing the current presentation
• Be aware that an existing health problem may limit the range of treatment options for a current health problem. Example ­ the presence of renal failure may restrict diuretic use in the treatment of heart failure
• Be aware of prescribing decisions and how prescribing for one condition may affect another condition. Example ­ prescribing a beta blocker for angina may worsen a patient’s asthma, prescribing an anti-inflammatory may worsen a patient’s heart failure
• Be aware how common side effects of prescribed medication may cause side effects in particular patient populations. Example: prescribing amitriptyline for chronic pain may cause confusion and drowsiness in an elderly population
• Be aware that prescribing can affect social function. For example, changing a patient’s diabetes medication can affect restriction on their driving
• Be aware of allergies and previous drug reactions
• Be aware if the particular problem of prescribing for patients with dementia. Ill-judged prescribing may worsen dementia. A patient with cognitive impairment may also misunderstand prescribing information, and this determines how information is presented to the patient.

Audio consultations allow you to concentrate on the patient’s past medical history and focus on the patient’s list of existing medication and allergies ­ this can be difficult if you are interacting with the patient in a face-to-face consultation. But the reduction of visual cues from the patient may make it harder for you to appreciate patient concerns about proposed medication or worry about pre-existing conditions. As for all audio consultations, it is important to summarise and to check that the patient is happy with a new management plan.

Activity 1

Get into the habit of quickly reading and memorising the medication that a patient is taking. Don’t just read this information passively ­ as you read, think ‘How might this medication cause problems with any possible management plans that I might suggest?’

Activity 2

Get into the habit of quickly reading and memorising the past medical history of the patient. Don’t just read this information passively ­ as you read, think ‘How might these medical conditions cause problems with any possible management plans that I might suggest?’ Consider how an existing medical condition might also influence other aspects of management such as imaging and referral.

Activity 3

Get into the habit of quickly checking any allergies that may affect a patient. Don’t just read this information passively ­ as you read, think ‘How might these allergies cause problems with any possible management plans t that I might suggest?’

Activity 4

Get into the habit of thinking about the whole patient ­ not just about the particular problem that the patient is consulting about today.

Given the patient’s lifestyle and expectations, is it is necessary to prescribe a particular medication? Would stopping an existing medication actually improve the patient’s overall well-being? Is the patient happy to be prescribed additional medication?

Given the patient’s existing medical conditions, do they have any expectations about imaging and/or referral? Or do the conditions limit the feasibility of various management options? Or perhaps the existing medical condition changes the time frame of referral for example, to urgent from non-urgent.

Activity 5

Review a series of five video consultations with elderly patients. For each consultation, ask yourself:

• Did I actively consider the possibility that existing medication was contributing towards the presenting problem?
• Did I actively think about allergies?
• When I initiated a management plan, did I actively consider the impact on existing medication and existing medical conditions?
• Did I involve the patient in the decision to start/stop medication?
• Did I involve the patient in decisions to refer or other management options?

Audio activity 1

Repeat the exercises above with audio consultations ­ is there any difference in how you think about co-morbidity for face to face, video, and audio consultations.

If there is a difference, why do you think this is the case? What can you do about this?

Exercise 1

Think about the way that co-morbidities might affect the way that you present information to the patient. Particular issues might include:

• Dementia or other forms of cognitive impairment
• Anxiety
• Low mood or impaired motivation

Safety netting and follow up are important for patient safety and concordance. Bad or no safety netting/follow up can be dangerous for the patient or cause inappropriate anxiety. So, you need to be able to:

• Develop a safety net for the patient that is SMART (Specific, Measurable, Achievable, Relevant and Timely)
• Offer appropriate follow up to the patient, which is dependent on the nature of the condition

It is even more vital to ensure that the patient understands the follow-up and safety net plan. It is therefore important to offer information in additional forms, such as a text message, or a link to an appropriate internet site. There is also a greater need to formally check that the patient has understood the information you have presented to them, as you will not be able to check as easily as a face-to-face consultation.

Activity 1

Review a series of consultations to see how often you actually discuss safety netting and follow up with the patient? In the cases where you do discuss safety netting/follow up, would this allow the patient to come back for review at the appropriate time (not too late, not too early)

Activity 2

Use your patients! Ask them if they feel confident about the follow-up and safety netting plans you discuss with them? Get them to repeat to you when they would come back - have they understood your explanation? If not, do this again and again check back with the patient.

Activity 3

Continue practising these skills - continue to ask your patients about their confidence in, and understanding of, your suggestions.

Activity 4

Follow up in a GP setting must be appropriate to the condition and adapted to the patient’s situation and context. Discuss with your trainer different kinds of follow up such as telephone or face to face review. How important is the timing of the follow-up? Watch or listen to your trainer and write down how they manage follow up.

Audio activity 1

Listen to four or five of your audio consultations, focussing just on the part of the consultation where you talk to the patient about follow-up and safety-netting. How sure are you that the patient understands and will follow the agreed plan? In how many of the consultations do you check that the patient has understood the plan? What could you do differently?
 

Exercise 1

What do you think is the purpose of a good follow up and safety netting plan? Are there some consultations where it is more important, even crucial to offer follow up and safety netting? Discuss your reflection with your trainer to gain more insight.