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Medical education podcast for General Practitioners, from the Irish College of GPs.
Email podcast@icgp.ie with feedback and suggestions for future episodes. We read everything we receive!
This episode was recorded in quarter four twenty twenty five. The information provided in this podcast is for educational and informational purposes only. The views and opinions expressed by hosts and their guests are their own and do not necessarily reflect those of the Irish College of GPs. By listening to this podcast, you acknowledge that no party is liable for any direct or indirect consequences resulting from the use of the information provided. More information can be found in the show notes or at irishcollegeofgps.ie.
David:One and a half million people are seen every year in A and E, but interestingly in out of hours GP co ops up and down the country, some two to 3,000,000 consultations take place every year.
John:Hello and a very warm welcome to the GP Podcast from the Irish College of GPs with me, doctor John Maher. Today, I'll be joined by doctor David McConaughey to discuss an approach to working in the out of hour setting. Here's David.
David:My name is David McConaughey. I am the Irish College GP's Clinical Lead for Prevention. I'm part of the Integrated Care Team for Chronic Disease at the HSE. I'm a GP in Salons County Gildare and also medical director of TLC DOC, an out of ours GP co op in Dublin.
John:During our discussion today, David shares numerous clinical pearls of potential use to GP registrars, newly qualified GPs, recent arrivals to Ireland, as well as seasoned vets, for want of a better phrase, in general practice. And I hope you'll find the episode of value to you. Topics covered by David will include the importance of the out of hours service in the broader Irish health care context, tips for newcomers to the out of hour service, and a broad approach to providing health care in this setting, tips for managing difficult requests during the consultation, how to appropriately manage requests for things like illness certs and medications of potential misuse, how to manage house calls and palliative care patients. And as usual, we'll provide some useful resources that you can access from your phone or from your doctor's bag in the out of error setting. And you'll find links to these resources mentioned today in the show notes where you'll also find a complete transcript of the show.
John:David began today by reflecting on his own experience as a doctor in the out of era setting over his career in the last twenty plus years.
David:Yeah. So at the moment, whilst I'm medical director of TLCDoc and also part of KDOC at Kildare Co op. I've had quite varied antivirus experience. Obviously as a hospital doctor I did call, which all doctors have done. And then as a medical SHOI sometimes would cover a group of GPs out of ours, so it would be myself, Doctor.
David:Zviag, a defibrillator, a Vauxhall Nova and I would look after a town road for twenty four or thirty six hours over the weekend when I was a hospital doctor. I then worked in Australia where I did some remote general practice and I would be on call 20 fourseven for eight days at a time. And then when I came back to Ireland then I did occasionally the odd shift in deputising service as well around Dublin, which was a fantastic learning experience. And now I'm privileged to be part of a co op as well, which I think out of all the iterations of out of hours care that I've been through, think the co ops offer the highest quality and safest care for patients whilst being fantastic value from money to the exchequer and quite fair to GPs as well.
John:Could you just set the scene here for how the out of air service sits in the framework of provision of primary care in Ireland in terms of numbers and stats, please?
David:So we know that every year in Ireland, 29,000,000 GP and GP nurse consultations take place in ours. One and a half million people are seen every year in A and E. But interestingly, in out of ours GP co ops up and down the country, some two to 3,000,000 consultations take place every year.
John:So we're looking at significant numbers that don't make their way to the emergency department out of hours. So it's a really important, bulwark, you might say, against overwhelming the emergency department and tertiary care services. Is that fair?
David:Yes indeed and our statistics from TLC doc would say that our referral onward rate to secondary care, in this case accident and emergency, is under ten percent and even a number of years ago we had some very good stats when there was a respiratory and influenza outbreak over a Christmas New Year period. Our onward referral rate to A and E at this extremely busy time when daytime general practice was closed over a holiday period, largely our referral rate onto A and E was around six percent, which is very impressive considering that the volumes of acutely unwell people that were being seen.
John:So again, a really invaluable service for the community and for our hospital colleagues. In terms of newcomers to the out of our service, whether that's registrars or perhaps people who have practiced medicine abroad and aren't accustomed to the Irish system and they're seeing it through the the eyes of the the out of era service in the first instance. I guess it's important to start with that idea that the out of air service is not the daytime service but in a different building. It's it's quite a different approach in some ways, isn't it, in terms of how to keep yourself and your patients safe?
David:That's right. And when I sit down with registered colleagues, I'm a GP trainer as well, my own registrar, or doctors joining our group, I often think that being well prepared is half the battle. So with my registrar I will talk in advance about Out of Hours, about the differences. So you're in a different environment, you have different computer software, you generally don't know very much about the patient, You're relying on them to tell you their background, their medicines. And so we always talk about just taking a careful history, slowing the consultation down, and also preparation for the shift, turning up perhaps ten-fifteen minutes earlier, making sure that you're fed and watered, you're not tired or emotional and perhaps if you've had a busy day in practice, you know, make sure that you sit down, have a bite to eat and compose yourself before you start into the consultation.
David:Things that we tend to work on with registrars that get them to slow the consultation down, introduce yourself to the patient, I think that's really important. It's highly unlikely that they've met you before and then ask them important questions. Things that we really need to know when a patient sits in front of us in an out of our setting is that are they allergic to any medicines? Have they any significant past medical history? What current medications, if any, are they taking?
David:And then to ask them then to slowly and clearly explain the main reason that they're there in front of you in the co op and their ideas, concerns, their expectations. So taking time to gather that information carefully before then going on to examine, work out a diagnosis and map out a treatment plan.
John:I found in my own practice, David, I never regretted having a smile and a warm welcome for a patient in whatever setting I find myself. It can really work in your favor in terms of getting the patient on-site and willing to open up to whatever questions you need to ask them.
David:Yeah, think that's important. Think the warm welcome, a smile, introducing yourself. I often, you know, devours introduce myself as Doctor. David McConaughey and then it gives the patient the opportunity if they want they can call you David, Doctor. David, Doctor.
David:McConaughey, whatever they feel most comfortable with. And again, that's important to put people at ease and set the scene before you go into the nuts and bolts of a consultation.
John:And you mentioned that it is important to note as well that you are somewhat limited in the out of area setting in terms of the your access to the patient details. The threshold, I guess, for who needs referral onwards should be appropriately low, given that it as I said from the outset, this is not daytime practice, and the the landscape is a little different.
David:Yes, again, as I mentioned earlier, referral rates from Irish GP co ops into secondary care are low. I suppose we need as well, because of the limited information you have and not knowing the patient as well, Again, I would always talk to colleagues about, you know, if pulmonary embolism, myocardial infarction, unstable angina, enter your diagnosis thoughts, then this patient needs to be seen in secondary care. Fortunately these are rare enough sort of presentations but I think the potential for missing something is somewhat higher when it's a strange patient in a different environment. And in those kinds of situations if you feel that they're part of the thoughts, you know, that patient is better seen in A and E to get where there's ability of radiology, laboratory, etc. To get to the diagnosis.
John:And on that point, David, you mentioned turning up a little bit early, you know, on your shift to get yourself oriented. And, you know, whenever I find myself in the out of hours, I like to introduce myself to whatever other doctors and nurses are about the house as it were. Part of it is that you don't know if an emergency is going to come your way and having a colleague down the hall can be very, very helpful in terms of an extra pair of hands.
David:Oh indeed again and I always tell my registrar to you know, to go around introduce themselves to nurses, drivers, administration staff and the other doctors on because as you rightly say, you don't know, what's going to come through the door and it's much easy to ask for help if you've introduced yourself to somebody, there as well and for them also for you. The colleague up the corridor might have an interest in rash, an unusual presentation and that might be of use as well to show another colleague as well and it's nice, it's one of those times where there's a bit of collaborative working as well and that can be very enjoyable and educational also.
John:Yeah. It's a really good way of looking at it, isn't it? That, you know, given that you have to do a hundred and twenty hours per year as a registrar, you can see it as a burden on your on your free time, but you can also potentially see it as a real opportunity to to see some things in the out of hours because oftentimes numerous people will come through the door. Oftentimes the presentations can be acute. So things like rashes, see quite a volume of interesting and relevant spot diagnoses just by being attuned to it and being open to colleagues showing you some interesting cases as they go.
David:That's correct. Again, you can, by seeing high volume patients often with acute illness, you build up skills and pattern recognition, you can quickly hone your skills and what a truly unwell person looks like, which is very useful. Also for doctors in training as well, one of your exit exams is the clinical skills assessment. And I often found as a registrar that when I was out of ours I would read up on a consultation model and then here we have in front of me in the out of ours call up a brand new patient, a case I've never seen before, fit my consultation model and to that presentation and it upskilled me then for examinations down the line and again I'd encourage registrars if they're listening to this to maybe consider that go and read about Roger Nabors consultation model and use the five strands of that on their next ten out of hours consultations. And again, it's a bit like riding a bicycle with the practice, it becomes effortless and intuitive.
John:And you mentioned, I suppose there's a few different competing interests potentially in the consultation room because you talk about slowing things down to take your time, to make sure you capture the information. You also mentioned the idea that in the out of hours, it can be quite a high volume, and the importance of having a consultation concept or structure, if you like, such as Roger Naber. So does your consultation style change somewhat in the out of era setting or do you have advice about an approach that can be useful for people new to the service?
David:Yeah, think then what I always try to do is put the patient at ease. Early on I explained, unfortunately, don't have any background on you here, unlike your own GPU has computer software with all your important details on. So firstly, are you allergic to any medicine? What regular medicines do you take, if any? Do you have any serious health problems in the past?
David:And then I say, you know, thanks very much for telling me all that. Now take your time and tell me what led to you attending us here today. And then I let the patient talk and I try my best not to interrupt them, let them tell their story. Most people, if you don't interrupt them, will talk for about a minute and a half to two minutes, but in that period, you could have gleaned all the information that you need to know about that illness, that reason for presentation. And you might actually find that you don't have to ask very many questions before you proceed on then to examination, working out a diagnosis, developing a plan and handling that plan over.
David:I also, when a patient is departing, I take some time to explain the diagnosis, explain the treatment plan and put a plan in place for the eventuality if something goes wrong. Again, Roger Niebors safety netting, you know, to answer the question what do we do if things go wrong or things don't go to the plan that we thought would happen. And sometimes I'll write this down on a piece of paper, perhaps just three pieces of information and hand over them And then before they depart, I always make sure that either the patient or their carer or parent, have I explained everything well enough to you, do you understand the plan, is there anything else you want to ask me or tell me before you go so that they leave confident of what you've told them and up to speed and that you also know going that they understood your plan. And again, this will hopefully lead to better healthcare outcomes.
John:So that sounds really a reasonable approach, David. And I guess the hazard here is it's all well and good to execute everything really effectively and competently. But if you don't reflect in your notes, you're leaving the door open to problems down the line potentially, and maybe more so in the out of error service, again, given the the the hazards that we've already outlined.
David:John, that's correct. Writing up good notes is very important, because firstly, well, notes are a legal obligation on practitioners, but they're also important information because you're handing the care of this patient on to their own GP the next day, the next week, and it'd be important if the patient sits down in front of their GP that the GP has a good idea about what the reason was that they were at the co op and what the treatment plan was. That's also unfortunately if you're going to be complained about it statistically speaking more likely out of ours, mainly and the reasons for this are multifactorial, but the patient is seeing a different doctor with access to limited information in an out of our setting and they're more likely to be acutely unwell. So that unfortunately is the case. Again, when I'm talking to colleagues about writing up notes out of ours, I like a model called what I call the SOAP If model.
David:So S is for subjective, what the patient told you, objective is what you found on examination, A is for assessment, your working diagnosis, I is for the information that you pass to them, F is for the follow-up and P is for the plan, the plan of action, the medicine you prescribed, the undertakings that you've asked them to do in relation to their illness. And I think if you can remember the SOPATH and make it your regular note out of ours, this will when you're busy become you'll revert to type and do this process and it means that when a GP is under pressure they will still write good quality notes that will aid ongoing care and also if a question was made about the care they deliver to help them defend it. Unfortunately, have to deal with the odd complaint as medical a director of a co op, and I'm grateful that my colleagues write good notes, you know, where they outline that examinations took place, what they found, observations were done, you know, and that a plan was handed over and a working diagnosis. And it does make these complaints or questions about care much more easy to defend.
John:I suppose we're lucky in the sense that there are so many online resources available to patients now and we can give them a bit of a steer around what are the more reputable sites. And one very important site again, I guess for the out of our service for clinicians is antibioticprescribing. Ie.
David:Correct. Because of the nature of out of ours, we see more acutely unwell people and therefore the antibiotic prescribing rates are higher out of ours. But this is, I feel, justified and we have some good international data, some studies from The Netherlands that show that antibiotic prescribing is higher out of ours but justified. And again, Outeridge colleagues and Irish GPs are very good at this, to prescribe antibiotics appropriately with reference to antibioticprescribing. Ie, a fantastic useful resource where it will help you out on in various scenarios, conditions, and also regarding dosage, what to do in particular allergies.
David:So it's a fantastic resource and thankfully widely available whether it's on your desktop, in the consultation or on your smartphone.
John:So thanks, David. So that's, you know, reflects the importance of antibiotic prescribing. Ie and where we sit in with our international peers in terms of our prescribing patterns. And while we're on that topic, another potentially thorny issue that springs to mind in the out of era setting is patients who are potentially seeking particular medications and thinking about the controlled drugs, opiates, drugs, things like pregabalin, sleeping tablets, that kind of thing. Do you have any tips around how somebody can approach such consultations?
David:Again, think this is something that each individual out of ours co op needs to have a policy on and at TLC we discourage people from prescribing any of those classes of drug that you mentioned. But of course there may be an occasion where you have to prescribe these drugs, someone could be in, you know, have had a grief reaction or be acutely anxious and it may be entirely appropriate to prescribe benzodiazepine. I think the advice here would be a short course for enough days to get them until they can see their own GP again. Again, unfortunately these drugs that you mentioned are often abused and some individuals do see an out of ours co
John:op
David:as an opportunity to source them. So I think it goes back to the co op, having a policy around these to, a limit on what drugs can be prescribed and if they are for what duration and also similarly around six certificate duration as well.
John:The HSC medicines management program are just reminding me, they've got a very useful one page guideline on prescribing benzodiazepines. Think some of the information from that is equally relevant in the out of era service as well and some of the approaches can be more broadly applied I think to control drugs. So I might put a link to that in the show notes. And similarly, David, how about, you know, people seeking six Hertz?
David:There's an obligation on us as practitioners and from the Medical Council as well to be reasonable in sickness certification. And again, again, that our policy would be that to limit a sick certificate until they can get back to their own GP to have the certificate extended as well. This sometimes can cause friction but again, I think we have to as GPs looking after somebody else's patient out of ours, be judicious and fair about what is an adequate amount of time off but if you had someone looking from you to extend a certificate for example two weeks for a self limited illness, this wouldn't be appropriate and I think you just have to politely tell them this isn't really what we do in this co op, we have a policy against it, but I will write to your own doctor and you can contact them at the next working day opportunity and discuss that certificate at that stage with them.
John:And you mentioned both on the medication side and on the Sixth Sword side, David, the idea of policies. I think even if, you know, the particular service or center that you're operating from doesn't have clearly written policies on the wall, for example, I found it useful when I find myself in such settings to be able to say to a patient, I'm not making a judgment on you, you know, this is not personal. It's simply I am disbarred from providing you with what you're looking for, because of the policy of this organization. And it can actually diffuse situations when you're not making it about you personally choosing not to do something, but to kind of offer it up to a higher power as it were in terms of the organization and what you can and can't provide in this setting. So it can be quite a useful tool, can't it, with potentially fraught consultations like those?
David:Indeed. And again, it's just a bit of being prepared again as recurring theme in the out of hours setting, but again as an organization, most co ops have committees, medical directors and at that level it's good every now and again to say well, what's our current thinking on potential drugs of misuse, what's our thinking on sickness certificates as well, what's our thinking on antibiotic prescribing and such. And in many co ops, I know in the past we've audited antibiotic prescribing in the Iovirus setting as well. And also feedback from GPs as well, it's important that if you're listening to this, you're a GP in a co op and your co op has a particular approach to any of these topics sickness certification like that, that you feed back to the medical director any concerns that you had. And also it's important too in large organizations like co op if you witness good care or a patient compliment about care delivered by one of our co op colleagues that you share that with the medical director and it's shared on.
David:A significant event analysis doesn't always have to be about a negative thing. Often it can be good to celebrate good care, proper care, good outcome.
John:Great. Because it's easy to fall into that mode where pass compliments by, we're so busy and to focus on the negative. So it is good as you said to step back and actually enjoy the compliments if and when they do, they come your way. The next thing, David, that that springs to mind in the others in the out of our setting is, those out of our services that offer house calls. And what I'm thinking is, obviously, many of the house calls that we're asked to see are appropriate and should be actioned.
John:Sometimes if I see a triage note for a house call, sometimes the symptoms may not seem so severe to necessarily let's say warrant a house call in every case. And I'm always mindful of the fact that especially if I'm on my own or I'm overnight in center, getting into a car and going on a house call could cost me an hour or more out of the center. And then when you come back, you could be faced with you know, a barrage of patients waiting to be seen. So in terms of dealing with that caseload of of, of house calls, have you any strategies or tips to share with people starting out?
David:Yes. House calls in Irish general practice as a whole are becoming less frequent, and I've had over twenty years now of working in Irish coops. I would think that the number of house calls is actually on the decrease. But there are times when a house call has to happen, for example palliative care being an example and is really important in this case. Often from co op to co op it varies.
David:The house call decision may have been triaged by another colleague, a nursing colleague, another GP colleague, and I think if my advice would be that if you looked at the call sheet and you felt some uncertainty about whether this house call is needed, I don't think there's any issue with phoning up the patient, carer and just reestablishing the facts and see is that house call absolutely necessary. We all know, and I don't think there'd be any disagreement on this, the safest place to see a patient is in an office setting where you have some support around you, you have proper lighting, all the equipment you need. It's hard to deliver high quality care from the boot of a car, although our co ops do have lots of well stocked bags, vehicles etc, but where possible it's better to get someone in face to face. But again I would certainly feel that if I thought that the call could be managed remotely or over the phone perhaps, if that was appropriate, or to try and have a chat with the patient or carer, see could they be brought in or if it can be safely maybe postponed till the morning to daylight as well, they're all appropriate things.
David:Again, it's hard to give definitive guidance here and I think sometimes you just have to phone up, take your time and work out the situation, ask the questions that need to be and sort of make your decision from there.
John:And you mentioned the palliative care patients and what came to mind, David, was a very useful guide that was published during the COVID pandemic. You may recall, I think it was a one page A four sheet with some of the common presenting palliative symptoms and management strategies that didn't necessarily involve a syringe driver, like using the transdermal route, the PR route, that kind of thing. And I kept that in my doctor's bag. And was a really useful one, know, to refer to. So I'm gonna try and dig that out and put a link to that in the show notes too.
John:I think all these little resources, whether it's a copy of the Oxford Handbook on medical emergencies or even the emergency section in the back of the handbook, that palliative care guide, the antibiotic prescribing website, etcetera etcetera. These small little time savers that you can have at your fingertips can really save you a lot of stress on the day or on the night, isn't that it?
David:That's right, again having useful and easily accessible resources, the BNF, the Mims, as well the other resources you mentioned at the hand now and we're blessed everyone has a smartphone in their pocket, there's usually internet connection and so we can look up things easily again to the the best in the best interest of getting a good outcome.
John:And one other resource that I've come across, David, is a newer app called OLAS Medical, E O L A S, which has things like the BNF, medical calculators, NICE guidelines all there at your fingertips. So that might be one that's worth looking up as well. And again, I'll put a link to the app in the show notes. Finally, David, some mornings I might go into the the out of hours, know, let's say on a bank holiday Saturday or Sunday morning, and I pass a colleague who's just on the night shift. And you can tell they've had a rough night before you speak to them because they're they're they're wearing it on their face.
John:So overnight in the out of hours can be a challenging shift, can't it? Because, you know, again, you're expecting the unexpected, and the shifts can be a bit longer in terms of, like, you know, maybe a ten hour overnight shift, for example. Any particular advice on preparing for an overnight?
David:Again, you're doing an overnight, think the thing is being prepared in advance, so try and come to the shift as rested as possible. It's not an idea to be coming from another workplace to go straight into a red eye or an overnight shift. Try and be fed and watered, bring food with you, snacks, pace yourself overnight and try and factor in breaks into your shift where every few hours you might sit down, have a drink, a snack so that you are at the top of your game and alert. I think as well pace yourself and the temptation might be that there's a large group of people waiting and you're going to go through them quickly. But again it's this advice to maybe slow down, take your time, if you're unsure about something, ask the question again, give the patient full attention as well because we want the best outcomes at all possible.
David:I think after the shift then obviously have time off the next day, it's not a good idea to go straight from an overnight into a daytime shift and I think my advice would be that at least get home for a few hours sleep before resuming duty again. Again, always we're very grateful to our colleagues that do the red eyes and out of our shifts and to provide cover for us. But again, co ops are good, they spread this work out in my experience and that whilst there are some doctors that prefer to do red eyes and out of ours, the co op road manager should be able to manage this and make sure that they get sort of appropriate time off and they're not overloaded with this overnight work.
John:Okay. Anything else, Dave, that you wanted to mention before we wrap up today?
David:Well, again, suppose as part of our GP contract is the provision of out of services and I can't see that change anytime in the future. We're fortunate in Ireland that there's an interest in out of ours care both from the HSE that help fund it and from our colleagues who organize it, staff it and make sure that there are people on duty to see unwell patients out of ours. So we certainly should be grateful in that as a GP in practice. I'm grateful for the co ops and the the cover that they give which allows all of us to get some downtime, family time as well to focus on delivering good care to our patients. Our colleagues who we meet who have, didn't have access to co ops or they practice perhaps, so many practiced 20 fourseven.
David:The others were part of town rotors where they'd be on call every fourth night, every fourth weekend, for example. They certainly had challenging times whereas the co ops are albeit it's high intensity, less frequency work, but still very important in the whole scheme of things for the health service.
John:Okay, I think that's very well put David and I think it's a good point to wrap up today as well. So thanks for your time and for your expertise in all things, all matters out of ours And, hopefully, our listeners will, will drive a lot of value from the many pearls that you share today. So thanks for you, David. Many thanks to doctor David McConaughey for speaking to me today. And don't forget to check the show notes for chapter markers, links to resources, as well as a complete transcript of today's episode.
John:If you have any comments or feedback on today's show or indeed any suggestions for future episodes, please let us know. You can drop us a line at podcast@icgp.ie. And that's it for today. Many thanks again for listening, and until next time, take care.