Following direct observation of Dr Alina, you provide her with feedback and inform her that there are some aspects of her consulting that could be improved. You noted that with every consultation:
- there was poor structure to the consultation (ie moving back and forth between history and management very frequently)
- she conducted minimal physical examination
- she was hesitant in the formulation of her management plan (as if she wasn’t sure what to do)
- the management plan was delivered in a disorganised fashion and the patient appeared confused about what to do.
Dr Alina acknowledges that she is having difficulty. She says that more often than not she is unsure whether she has made the right diagnosis and consequently she goes back to check information. She also says that her patients interrupt her by asking questions and she loses track of what she is doing because she is compelled to respond to them.
How can you assist Dr Alina to improve?
You tell her that from your observation, she might have more surety as to the diagnosis if she takes a better history and conducts an appropriate physical examination; consequently, the required management will be much clearer. Patient questions can generally be left to the end of the consultation. This will assist with maintaining her focus and the flow, and it will probably be easier to answer questions at the end when she has a better sense of the problems at hand.
In consultation with Dr Alina, you prepare a learning plan that will address the concerns and strengthen her skills.
What should be included in the learning plan?
It is important that all issues are itemised on the plan, including how they will be addressed, what resources will be required and the expected outcomes. It is also important to specify a time frame for the plan and what form of assessment will be conducted, upon its completion, to determine whether the outcomes have been achieved. Other important elements to include in the plan are what her supervisor’s role will be (if her supervisor is able and willing to assist), and whether Dr Alina might benefit from the assistance of a medical educator and/or mentor (and what their roles will entail).
Learning plans should be realistic and any constraints should be taken into consideration (refer to the RACGP Practice Experience Program (PEP): Remediator guide, which provides information with respect to remedial assistance that is available to GPs enrolled in the PEP).
Dr Alina should also spend some time sitting in on her supervisor’s or other GPs’ consultations so she may gain a better understanding of what competent experienced general practice is and what she should be aiming for.
As agreed, you return to conduct direct observation of her consulting and to determine what progress has been made. You are pleased to see that her consulting has improved considerably and is now of an acceptable standard. You encourage her accordingly.
You return six months later to conduct direct observation of her consulting. You observe a significant deterioration in her skills. In fact, all the original concerns have reappeared.
What might account for this?
Dr Alina’s skills may have regressed because of one or a combination of the following:
- a heavy workload resulting in shorter consultation times (and the learnt skills are not maintained because they haven’t become habit)
- not seeing any value in adhering to the learnt skills (‘it takes too long’)
- something may be happening in her personal life that has caused her to be distracted from doing her job properly (eg personal illness, family issues, financial problems).
How might you address this situation?
You inform Dr Alina that her consulting skills have regressed significantly and that they are now much as they were the very first time that you conducted direct observation. You ask her what the reasons for this might be.
Dr Alina says that she has had some health issues over the last few months. She has been diagnosed with diabetes and she has been feeling very tired because she has been finding it very difficult to manage her blood sugar levels. In addition, she has had one cold after another and, consequently, has had to take frequent days off work. She says that even though she may not be ‘doing it by the book’ as you want her to, she doesn’t think that there is anything wrong with her consulting because her patients are happy with her.
How do you respond to her?
You say to Dr Alina that even though her patients might say they are or appear to be happy with her, she has certain obligations towards them, as set out in the Medical Board document, Good medical practice: A code of conduct for doctors in Australia. This document sets out the principles that characterise good medical practice and it explicitly states the standards of care and professional conduct that are expected of doctors by their professional peers and the community. Failure to adhere to these principles (ie failure to do the right thing by her patients) may well result in an adverse event and/or a complaint about her to AHPRA. In order to be more explicit, you say to Dr Alina that her haphazard style of clinical work will result in poor outcomes for her patients because she is exposing herself to excessive risk by missing information, failing to identify serious conditions and failing to safety net or follow up her patients.
You also remind her that it is every doctor’s responsibility to attend to self-care and to ensure their safety to practise. This means that her personal health issues, family and other responsibilities have to be managed so that, as best as possible, they are not impacting negatively on her clinical capability and consequently compromising patient care. If there is potential for patient safety to be compromised, then time off to address those issues should be seriously considered.
As you are leaving, the practice manager takes you aside and says that Dr Alina has been taking a lot of time off and that this has been very disruptive to the running of the practice. She wonders whether Dr Alina has actually been ill because she has never produced a sickness certificate. She confides to you that she thinks that Dr Alina is lazy and asks you what the best thing to do with her is.
How do you respond to the practice manager?
It is not for you to comment on whether Dr Alina is or isn’t lazy and it is paramount that all parties maintain confidentiality in such situations. As for her taking frequent time off work and the matter of sickness certificates, that is an employment issue for the practice manager and the practice principle to address.