Caroline McCarthy is a GP in Co Kildare, Ireland and a clinical lecturer at RCSI, University of Medicine and Health Sciences.
“…that space where the needs of our patients and the extent of our training and experience intersect..” Dr John Wootton1
Recently I had the pleasant experience of supervising our trainee site her first intrauterine device. Remembering my first procedures (for example the chest drain as a respiratory SHO or lumbar puncture as an intern or even the first rectal examination as a medical student), I reflected on how it takes courage to override the natural instinct not to stick a needle into the intervertebral space or to dissect the intercostal space or even to insert a gloved finger into the rectum. Clinical courage is a term that has emerged in the field of rural general practice, particularly in Canada and Australia where isolated practitioners may find themselves in situations where the needs of their patients are at odds with their own training and experience.1 In the case of a doctor in training the patient’s needs can often be met by another more experienced clinician. But as Atul Gawande explores in the first chapter of his book, Complications, doctors must learn by doing and in order to train future generations of doctors, patients must be involved in this learning curve.2
Despite this need for courage to progress in our training, I sometimes feel our profession has developed a sort of learned helplessness that is aggravated by a litigious, risk averse and guideline driven culture.
Despite this need for courage to progress in our training, I sometimes feel our profession has developed a sort of learned helplessness that is aggravated by a litigious, risk averse and guideline driven culture. I am often struck by the paradox of referring patients out of a sense of it being something I ought to do, rather than something I feel is necessary. (For example the slightly odd looking seborrhoeic keratosis thrown at you as the patient leaves the consultation room or the young mother who stopped breastfeeding her toddler a few weeks ago and has a rubbery little breast lump.) There is something quietly disturbing about referring patients when I know it isn’t truly necessary, when others with more urgent needs remain stuck on waiting lists (for example the child with multiple complex needs awaiting specialist assessment and community supports). Deprescribing is another example, where we may be reluctant to “rock the boat”3 even when we identify medicines that may carry more risk than benefit. It can be hard to go against the grain in these situations and sometimes easier (but ultimately soul-destroying) to just sit in this helplessness.
Feeling proud of our trainee and her courage, I decided to share with her a related story of a time when I had to show some courage. I was working in a practice where my predecessor had inserted intrauterine devices for many years. It was coming up on the then 5 year lifetime of these devices. Although I had learned the skill during my GP training, over the years I had gradually stopped inserting them in most part due to it not being required of me where I was working.
Although I had learned the skill during my GP training, over the years I had gradually stopped inserting them in most part due to it not being required of me where I was working.
Although horror stories from specialist colleagues of perforations and other bad outcomes appearing in the emergency department did not help. I know the perception of the prevalence of these bad outcomes was skewed, but fear isn’t rationale. In my new practice, it was a service very much required and I couldn’t find anyone willing to take on these public patients. At the time, the fee for such cases was small, difficult to claim, and often delayed—making it more hassle than it was worth for many GPs to provide the service for patients who were not their own This has thankfully changed with the recent introduction of a new state funded contraceptive scheme. COVID didn’t help matters and as each lockdown lifted, more and more patients were presenting needing their coils changed. The routine gynaecology wait-time was more than a year. Slowly it dawned on me that this was ludicrous. This was a simple, safe and straightforward procedure with which I had experience. I set about with a methodical plan to ensure I was adhering to professional standards and delivering safe care. I visited a colleague to watch her insertions, viewed relevant educational material, got advice from colleagues on where to source the best single use instruments, discussed within the practice my plan and most importantly explained to my patients that I was relearning the procedure. I kept a detailed log for that year and noticed the failed insertions getting less frequent, and my confidence slowly increasing. Now, in a new practice, training our trainee and acting as the “go-to” for more complex insertions, I feel proud of when I showed clinical courage in the face of my patients’ needs.
References
- Konkin J, Grave L, Cockburn E, Couper I, Stewart RA, Campbell D, et al. Exploration of rural physicians’ lived experience of practisingoutside their usual scope of practice to provide access to essential medical care (clinical courage): an international phenomenological study. BMJ open. 2020;10(8):e037705.
- Gawander A. Complications: A Surgeon’s Notes on an Imperfect Science. New York: Metropolitan Books; 2002.
- Sinnott C, Mercer SW, Payne RA, Duerden M, Bradley CP, Byrne M. Improving medication management in multimorbidity: development of the MultimorbiditY COllaborativeMedication Review And DEcision Making (MY COMRADE) intervention using the Behaviour Change Wheel. Implementation Science. 2015;10(1):132.
Featured Photo by MARIOLA GROBELSKA on Unsplash
