Consultation skills - Surviving home visits

You have just seen your last patient of the morning, a milkman with hypertension whose readings are always up when he sees you. He is nervous and you are irritated because you cannot get him to target. Still, no matter, you have visits to be getting on with.

Undertaking home visits during GP training is, for many, a foray out of the comfort zone. Initially a new and often daunting aspect of general practice, domiciliary consultations open up a new way of working to GP trainees, and constitutes one of the cornerstones of the GP role.

Love them or loathe them, visits offer a new challenge to training GPs, and their inherent requirements ensure that preparation and adaptability should be prominent tools in the bag of the intrepid, if perhaps tentative, registrar.

Before you go
What do you know? Visits are visits for a reason, and a little pre-arrival preparation is invaluable. What have the patient's most recent attendances been about? Is today's visit the result of a telephone consultation? Time spent undertaking a little research at the surgery could yield key information and save you struggling later. Consider taking along a summary printout to help you.

Make sure you have everything you need; stethoscope, a prescription formulary, scrip pad, sample bottles, urine dipsticks, swabs, gloves, lubricant, otoscope/ophthalmoscope, forms, headed paper - the list could go on. What about the sphygmomanometer? Is there room in the bag?

Think: do I need the back pain advice book? If you find out that your patient is a young man with a lumbar injury who cannot get up, then you probably will. If you are going to see a palliative patient, consider taking the guidelines for end-of-life care instead.

Is your patient well known to one of the partners? Do not be afraid to ask their advice before you leave.

Lastly, do not set out without giving some thought to logistics - do you need a map or GPS? What about your mobile? Do you have the numbers for your surgery, the ambulance booking service, the local hospital or GP liaison service saved? Your clinical supervisor's number may also come in handy if you need reassurance.

While you are there
Remember, it may be unfamiliar ground, but it is still a consultation. If anything, the patient's confidence is higher when you enter their home.

However, the patient and/or their family may be nervous. Having the doctor visit is a big deal to most people.

Try to be prompt and offer the same level of service as you would in the surgery - extend courtesies and respect their home yet ensure professionalism runs through proceedings. Is there adequate privacy for examination? Where is the nearest sink, so you might wash your hands? Astutely take stock of your surroundings - do not be nosy, but if squalor is prevalent, it might be important to note this.

When considering management, think about whether a prescription will suffice and, if so, have you considered how the patient will collect their medication? This needs addressing in your shared management plan. Often a friend or relative can collect it; however, offering to liaise with the pharmacy or district nurse may be appropriate.

When considering admission, co-ordinating this back at the surgery might be an option, but potential unforeseen urgency should mean you are prepared and able to manage this while visiting. Local admission policies vary, but organising the ambulance, discussing with the local resident medical officer, admitting senior house officer or bed manager, and writing the accompanying letter are all necessary tasks.

Might admission be prevented? Timely discussion with social care or the local intermediate care team might offer a solution that allows the patient to stay at home.

After the visit
Back at the surgery, it is important to document everything promptly and thoroughly. Recording basic observations is good practice. Notes should be clear, stating that the consultation was domiciliary and not in the surgery.

If the visit was undertaken on your way home your first priority in the morning is documentation. Do not forget to replenish your bag - the chances are you will be visiting again soon.

Different visits offer different challenges. Inner city or rural hamlet, high-rise flat to care home - good preparation will ensure a feeling of readiness, at least in some small part.

Visits will always be necessary, and GP trainees will continue stepping into the unknown to develop their skills. So next time you are visiting and your soft-soled approach to the front door is greeted by a cacophony of angry barking dogs, spare a thought for the milkman and consider what your systolic might be doing.

• Dr Reeves is a GP ST2 in Warwickshire

Reflect on this article and add notes to your CPD Organiser on MIMS Learning