Abstract
Managing medical complexity
The Workplace-based Assessment (WPBA) component of the Membership of the RCGP (MRCGP) exam is designed to test GP trainees’ abilities, knowledge and skills necessary for professional practice in 13 key areas derived from the core RCGP curriculum statement ‘Being a GP’.
In this two-part series, Dr Hana Patel discusses how to manage medical complexity, particularly looking at aspects of care beyond the acute problem, including the management of co-morbidity, uncertainty, risk and health promotion.
What capabilities should I demonstrate towards the end of my training programme
‘Simultaneously manages the patient’s health problems, both acute and chronic. Is able to manage uncertainty including that experienced by the patient’.
In the descriptors for ‘competent’ for managing medical complexity, the RCGP states this as:
Communicates risk effectively to patients and involves them in its management to the appropriate degree Recognises the inevitable conflicts that arise when managing patients with multiple problems and takes steps to adjust care appropriately Consistently encourages improvement and rehabilitation and, where appropriate, recovery Encourages the patient to participate in appropriate health promotion and disease prevention strategies
Managing uncertainty is a challenge for all clinicians in primary care at any point in their career, and it is not uncommon to find it difficult suggesting a way forward for patients when we are dealing with a condition or presentation that is unfamiliar to us.
In the hospital setting, clinicians are used to following pathways and protocols on management of specific medical conditions. In general practice, the wide variety of medical conditions seen, and the varied presentations of disease, can be difficult to assimilate and hence it can be difficult to generate our own management plans. This has to take into consideration not only the most up-to-date medical knowledge and management for each medical condition, but also incorporate our individual consultation style in dealing with each medical condition.
How should I tackle ‘managing uncertainty’?
Common reactions to uncertainty for any clinician tend to include ordering further investigations or referral of patients. However, the RCGP suggests limiting investigations and using targeted management. Other tactics include the use of safety netting. Safety netting incorporates the safety of both the patient and clinician, avoids unnecessary referrals and helps adopt a ‘watch and wait’ strategy when the diagnosis is uncertain. However, this strategy should come with a clear follow-up plan so that patients understand the possible causes of their symptoms, how to look after themselves and what to do if symptoms persist. This is good safety netting. Research suggests that patients are more likely to follow advice if they are involved in developing the follow-up plan. They need to understand why they are receiving this advice, what actions are required and by whom.
Some clinicians use their colleagues or supervisors to help develop patient advice and management plans. This may include help developing a more comprehensive list of differential diagnoses. GP registrars usually have an element of autonomy when seeing patients and use this to arrange sooner follow-up appointments rather than over referring or requesting investigations.
It can be difficult for GP registrars to manage their learning needs and unknown learning needs during this process. Exposing our ignorance to patients may make us feel uncomfortable. However, it can be liberating and help the safety-netting process if we share our uncertainty with patients and use time to learn how the condition or disease evolves or progresses.
