Dr Marika Davies, a medicolegal adviser at Medical Protection, discusses the best ways to handle your CSA consultations
Doctors are working under more pressure than ever, and on a busy day, it is understandable that a GP can feel frustrated when a patient presents with a seemingly trivial complaint.
During a CSA, you will be tasked with simulating real-life consultations and may face requests which you feel are unimportant. The aim of the CSA is to test your ability to gather information, apply clinical understanding and deliver patient-centred care appropriately in a standardised context. Each candidate is allocated a consulting room and has 13 ten minute consultations.
Concerns about inappropriate use of primary care resources were raised in a survey by Resilient GP, an online support group for doctors in general practice.1 Nearly 200 examples of requests that GPs thought were an inappropriate use of their time and skills were published online, including:
“I have had a mouth ulcer for two days”
“I have had a runny nose for the last half hour”
“I have a scratch on my arm”
“My baby’s snot is too green”.
It may seem easy to be dismissive of a patient who presents with something seemingly unimportant, and it is undoubtedly tempting to rush such consultations. In doing so however, doctors risk missing a potentially more serious diagnosis, a loss of trust in the doctor-patient relationship, or even attracting a complaint.
There is clearly a fine balance between being an approachable GP, always willing to listen to the concerns of your patients, and the risk of consultations being used inappropriately when time and resources in primary care are under increasing pressure. So what is the best way to handle consultations about seemingly small matters during your CSA?
1. Maintain professionalism
No matter how trivial a query from a patient, doctors are well practised at maintaining professionalism, and know how important it is to avoid the temptation to be condescending or patronising. If a patient feels belittled or rushed, even if their problem has been dealt with appropriately, it could lead to a complaint. Dr Nik Kendrew, a GP in Kent, says, “It’s all about how you deal with it, and making sure patients feel listened to.” If concerns are not addressed, and a doctor is dismissive, patients may be reluctant to present in the future with something that could be more serious.
2. Rule out a serious medical condition
The risk of not carrying out a full assessment is that a more serious diagnosis may be missed. It can be very frustrating for GPs when they are so busy, but going through a quick checklist to rule out anything of concern does not take very long. Conditions evolve – something may seem trivial to start with, such as a nosebleed, or indigestion, but it is important to bear in mind what else it might be.
3. Explore any underlying issues
When dealing with minor symptoms, Dr Kendrew suggests taking a step back to look at the underlying problem. “These patients are genuinely worried,” he says. “If they are coming in repeatedly with lots of trivial things you need to think ‘why are they doing that?” he says. Exploring with a patient why they are concerned about a seemingly trivial condition, such as a short history of a sore throat, can be helpful, for example, there may have been a death in the family from throat cancer. A pattern of insignificant complaints might also be a presentation of an underlying anxiety disorder.
4. Reassure the patient
Once anything serious has been ruled out, give the patient a clear explanation and reassure them. Safety netting is an essential tool, and it is helpful to ensure the patient understands the parameters in which they should come back if something changes.
Dr Kendrew tries to empower patients to take the initiative, and to know if it is something serious in the future. “It might not be that problem, it might be something else, and what you don’t want to do is to make them scared of coming to their GP because they are going to be laughed at or belittled. It’s a really fine line, because equally you don’t want to encourage somebody turning up unnecessarily.”
Educating patients is key to ensuring they use healthcare services appropriately. Once the problem has been dealt with, it is reasonable to politely point out to the patient if it has been an inappropriate use of the service, explain the reasons why and tell them where else they can obtain advice and treatment.
Dr Kendrew thinks some patients have lost the confidence to know what is and isn’t serious, or when to see the doctor. “We should be educating the public about health, not just to stop the trivial things coming in, but to teach people about red flags, so these symptoms aren’t sidelined,” he says. “It’s about educating the right people to access services in the right way.”
1. Resilient GP Inappropriate demands to GPs
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