Clinical practice - don't get out of your depth

While it's good to face new challenges in your day to day practice, the MDU's Dr Caroline Fryar explains why it is important not to get out of your depth, especially while in GP training.

Discuss with your trainer if you feel you are being asked to work beyond your competency level
Discuss with your trainer if you feel you are being asked to work beyond your competency level

A recent survey of nearly 6,000 GP trainees by the GMC, found that half (50%) said they had felt ‘forced to cope with clinical problems beyond your competence or experience’ at some stage in their current post. Of these, one in five said this occurred daily, weekly or monthly. The rest said it had happened, but only 'rarely'.1

There are a number of scenarios where GP trainees (and recently qualified GPs) might be asked to work beyond their competency levels. For example, you might be asked to take part in out-of-hours shifts, perform minor surgery such as the removal of skin lesions or to represent the practice at MDT meetings.  There are a number of issues to consider before accepting.

Seek advice

Firstly, if you are a GP trainee, you may wish to discuss what you've been asked to do with your trainer and seek their feedback. It might also be wise to check whether your deanery has a policy on the issue. For example, some have policies on gaining competency in working out of hours.  It may be wise to seek external advice concerning any contractual implications and it is also important to check that your indemnity arrangements will extend to cover any additional level of responsibility.

Secondly, if you are asked to undertake an additional role, you should bear in mind the GMC’s advice that in providing care, you must "recognise and work within the limits of your competence." (Good Medical Practice, 2013, paragraph 14).The GMC also advises doctors responsible for training that they must "make sure that all staff you manage have appropriate supervision" (paragraph 40).

Your level of expertise

If asked to act up, you must firstly consider whether or not you are competent to undertake the extra responsibilities and tasks the role entails. If you feel that you are not competent or sufficiently experienced to take on the work, you should not agree to do so and should explain why.  You can consider what extra training needs you might have in order to prepare you for a similar role in the future.  

If you were to agree to perform a task that was beyond your level of competence and expertise, you may be putting patient safety at risk and you may have difficulty justifying your actions if later asked to do so. In such cases, the GMC states that ‘if patients are at risk because of inadequate premises, equipment or other resources, policies or systems, you should put the matter right if that is possible. You must raise your concern in line with our guidance and your workplace policy. You should also make a record of the steps you have taken.’  (paragraph 25b) In practice, this would mean discussing the situation with your educational supervisor or deanery in the first instance.

Emergencies

Exceptionally, you may be asked to act up in an emergency situation where there is no one more senior who can assist, such as if an injured patient comes into the surgery or because of staff illness, such as a pandemic, you are asked to take on additional roles. In these emergency situations, you may have no choice but to step in, although the GMC says when doing so you should take account of your own safety, your competence and the availability of other options for care. (paragraph 26)

Summary

In summary, when asked to take on a new role, GP trainees must carefully consider what they are being asked to do, whether they are competent to undertake it, and what alternative arrangements can be made if they are not. As always, patient safety must be the first priority.

Case study

Three weeks into his GPST3 post a doctor was asked to go on a home visit to see a terminally ill patient.  His trainer was away and the GP supervising him that day felt it would be good experience.  The doctor did not wish to appear unwilling to do visits so agreed to attend.  He reviewed the patient’s notes before leaving the practice and noted the patient had been diagnosed with terminal lung cancer.  He had been seen four days earlier by one of the other GP partners, who had increased his analgesia.  

On arrival at the patient’s home the doctor found the patient was struggling to breathe with lots of secretions.  The patient’s family wished for him to be kept comfortable and stated that the doctor must do something straight away to relieve the patient’s distress.  Having had little palliative care experience, the GP trainee felt out of his depth and was unsure what to prescribe or who to contact.  Fortunately, the palliative care nurse arrived and the doctor discussed the options with him and agreed the best course of action with the patient and his family was to admit the patient to a hospice.    

After the patient died the family wrote to the practice to complain about a number of aspects of the treatment, including sending a GP trainee out who clearly did not know what to do.  The practice apologised to the family, explaining that, after discussing the case at a significant event meeting, they had changed their policy for visiting terminally ill patients.  The GP trainee accepted that he could have avoided the situation by speaking up about his inexperience at the outset.  

 

Dr Fryar is an MDU medico-legal adviser

Reference

1 GMC National Training Survey 2013 

Resource

Good Medical Practice, 2013

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