To visit, or not to visit? That is the question.
As a GP, the thought of visits either makes you gooey inside, indifferent to another job still to do, or infuriated at yet ANOTHER job to do.
I must admit I sit in the middle road. While I find visits important particularly with the housebound population, I do tend to find most are unwarranted or could easily have been dealt with in some other format than me traipsing across a given landscape. Additionally as most OOH clinicians will attest to, the abilities and resources you have within a practice far outweigh that which you may carry in a car (unless you work for Hankmed- Royal Pains reference).
To look at visits, I think it is important to look at how a patient gets a visit. In most places this will be requested by the patient or by a representative of the patient (parent, carer, nurse etc). This request is invariably placed onto a list, either directly as a visits list (book or electronic) or a triage list to be dealt with by a clinician (see Appointments = Nightmare). The other way that visits appear is by a review visit. This is when a GP requests or plans to do a repeat visit. Normally this is for the housebound or care home population. In essence this can be the only method for true continuity of care in the housebound, but raises the frustrating issue of acute demand versus holistic chronic care.
Anyway a patient is on the list. Hurdle one is over.
Then comes decision time. Visits are normally distributed throughout the working clinicians on that particular day (GPs, NPs, community matrons etc). Sometimes patients will request a particular clinician and while most places will make every effort for this to happen, reality shows us that in some cases it cannot (clinician not working that day or already has umpteen visits).
Most places will discuss who deals with each individual visit. In an ideal way it would be nice for clinicians to meet up in a communal area, vent/discuss the morning surgery and then divvy up the visits. While I know of a few places where this occurs, reality again shows us that most practices just assign clinicians to a visit or 2 etc and then just crack on with the work. At this point it is up to the individual clinician how that visit request is then handled, which we will come back to.
Another method is the triage list. Here all patients requesting or needing a visit are placed on a single list for a single clinician to deal with. The outcome can be either allocation by that clinician or even in some cases, that clinician will have to deal with all the visits themselves (not having a standard clinic). This is an interesting method as it can work effectively, or be a complete nightmare (one colleague once had 19 visits in a morning to do on his lonesome). It also raises the nasty consequences of allocating visits. While we would all want to work in a supportive, cohesive environment. Occasionally idiosyncrasies, of personalities and discord can lead to inappropriate allocating of visits (newbie’s getting the hard ones, salaried/partner workload divide, territorial ownership of patients and even requesting lots of reviews from either previous on-calls or so that will have enough visits already so that no acute visits are allocated). In my view the worst however is when requests are refused, so that following days then become more stretched as visits were refused on earlier days. While this will always happen based upon clinical assessment, I am sure most of us know instances where this is the norm with particular systems or clinicians, and not the one-off.
I mentioned we would come back to how a clinician may handle a visit request. There are effectively three ways. Number one, which is highly inadvisable, is just ignoring it (I have seen this done before….very unsettling). Number two is to jump in your car, on your bike or yes even walk over to the visit, and see the patient. Number three, is to call the patient first. As mentioned at the start most visits are not always necessary, and particularly if there is no triage before hand, it could be something that simply is dealt with over Alexander Graham Bell’s famous invention.
In a practice where lots of visits are requested, or where workforce is a bit short, it can be very effective to try using telephone triage to assess all visits. Firstly it helps to get rid of the dross. In this circumstance, the dross tends to be:
- Any person requesting the visit under the age of 65 with no significant health conditions.
- Children (they are portable and always better assessed in a practice than at home).
- My personal peeve- because they can’t get to the practice (circumstance over health, see below).
Now I will be the first to admit that in medicine there are exceptions to every rule. However asking for a visit because your car is stuck, or because it is raining too hard outside would not endeavour a GP to visit the patient.
Once rid of the dross, you can then manage the patient’s needs. This can sometimes be a simple collection of information, tweak of medications, organising a social referral etc. However by ringing it also allows you to get a flavour of the visit, more so than the one line comment of: squits, vomiting, breathless, or my personal favourite – requested by home. With the flavour (preferably chocolate or cherry….yum!) you can be prepared, i.e. will you need to possibly take any medications with you (later post) or check you have specific things like stool sample bottles, peak flow meter etc.
If a visit is needed, I also use the call as a way of confirming where the patient resides. Locums for example may not know the area like the back of their hand, and therefore sometimes finding a residence can be interesting, even with a sat nav. My personal intense peeve of visits is residences which have names instead of numbers. While this may appear classy or quirky; to me as a visiting GP it means you are harder to find, means more time wasted, more petrol burnt, and generally a more frustrated GP, just to showcase a sense of pomp and uniqueness. (If you have a house with a name and not a number, do not call me for a visit, or better yet, you’re barred).
Once discussed though, at least you can know what kind of visit you are heading off to (trying to solve the conundrum), so all that is left now is to pack the bag, grab the sheet and head off on the visit/s. What you do when you get there…….well that is another conundrum.