First do no harm: dropping in on members of the team, encouraging and thanking them

‘First Do No Harm’ is a series of 12 brief monthly articles with internet footnotes about harming and healing in general practice. Each instalment is based on one of the 12 RCGP competency domains, this month’s being:

8. Working with colleagues and in teams: working effectively with other professionals to ensure patient care, including the sharing of information with colleagues.¹

‘When left to its processes, each intervention system will maximise its potential to make iatrogenic errors’.²

INTRODUCTION

The healthcare systems that are most equitable, high-quality, holistic, and cost-effective are those based on primary care. Primary care is the point of entry to the healthcare system for members of a family, community, geographical area, or list and provides care that is long-term, comprehensive, coordinated, and focused on people rather than on diseases.^3,4 Optimal management of individual diseases may require shared-care with specialists³ but referring patients with functional problems undermines their self-efficacy, medicalises, disrupts the clinician’s therapeutic relationship with them,⁵ and risks diffusion or abnegation of responsibility through the ‘collusion of anonymity’.⁶

HARMING

Allowing structure (of service) to impede process (of care).⁵ Raising expectations that can’t be met. Undermining other professionals and second-guessing their actions: ‘your doctor should have arranged a scan’. Applying ever-increasing doses of a favourite therapy.² Working in professional isolation.⁷

HEALING

Designing and navigating structure (of service) to facilitate process (of care).¹ Working with the possible. Cooperating with and supporting other professionals: ‘your doctor has done a good job’. Encouraging cultural change from within rather than depending on checklists imposed from without.⁸

ATTITUDE

Being committed to the health of both the patient and the practice.

KNOWLEDGE

General practice requires organisational and personal continuity of care. Patients value the reassurance of a continuing relationship with a usual doctor.⁹ Members of the team retain autonomy while communicating face-to-face across professional boundaries,¹⁰ putting the needs of patients before personal gratification and the needs of the organisation.¹¹ Team-work prevents isolation and personal care prevents anonymity.¹² Incompetence is often compounded by the individual’s failure to recognise it in themselves:¹³isolation and lack of insight are risk factors for poor performance.⁷ GPs faced with clinical questions are unlikely to find, or understand,¹⁴ answers in the research literature; they’re more likely to depend on advice from colleagues.^15,16

SKILLS

When referring or delegating being prepared to surrender authority: not ‘the nurse will heal that ulcer with silver dressings’ but ‘the nurse will help with that ulcer’; not ‘your doctor will do a blood test’ but ‘your doctor will see you and take things from there’.⁵ Learning from and teaching peers; seeking and acting on feedback from colleagues, from other practices if necessary.⁷ Dropping in on members of the team, encouraging and thanking them. Complimenting and complementing colleagues. Aiming for high challenge and high support.¹⁷

Supplementary information

The internet footnotes accompanying this article can be found at: http://www.darmipc.net/first-do-no-harm-footnotes.html