In a recent copy of Guidelines in Practice Phil Hammond reflected on whether clinicians should be more "robotic" in their approach to clinical care.(1) Lord Darzi is apparently very keen on robot-assisted surgery as their accuracy has huge benefits in delicate work, such as prostate surgery where such precision can minimise the risk of incontinence and impotence. In primary care, the use of robots seems less likely although I suppose it could be argued that the new reception system at my GP surgery, where I am now required to "sign in" by pressing buttons on a screen, is an example of a machine replacing a human.
The widespread introduction of robots into primary care is an unlikely scenario, but the argument that a systematic approach offers clinical benefits has weight. In his book Complications (a brilliant reflection on the challenge of delivering clinical care which ought to be read by anyone who goes anywhere near a patient), Atul Gawande describes a Canadian "hernia factory" that only carries out hernia repairs.(2) The resulting care is superb in that the procedure takes half the average time, costs half the average cost and has only a 1% recurrence rate. The other surprising factor is that the clinicians are happy to abandon the clinical variety of general surgical practice for the satisfaction in pursuing excellence.
Are there any useful lessons here for primary care nursing? One of the challenges for primary care is the huge variety of clinical challenges that present. An essential skill for the primary care clinician is sifting out those that can be managed well in the primary care setting and those that need referring for more specialist care. However, even among those conditions that are generally viewed as appropriate for management in primary care, there are areas of specialty. Examples that spring to mind include asthma, travel medicine, leg ulceration and diabetes. Consequently, it is quite usual to find in GP practices' different clinicians choosing to develop advanced skills in different clinical areas. This system appears to work well for both clinicians and patients, but there are potential flaws in this approach.
Many GP practices are relatively small but the development of expertise requires extensive deliberate practice, which in turn requires a reasonable number of patients with the required condition.(3) It is quite possible that despite the best intentions of their GPs and primary care nurses, patients are getting suboptimal care simply because these clinicians do not see enough patients to develop an adequate level of expertise. A further problem is that of recognising whether our own level of skill and knowledge is adequate. Is the patient failing to improve because we do not have sufficient knowledge and skills or is the problem intractable, even in the hands of an expert?
I can't offer any robust solutions to this situation but would suggest that one possible solution is to bring in expertise from outside when we identify a gap in our knowledge and skills. This requires us to be honest about our own strengths and weaknesses. We can't all be expert at everything but we owe it to our patients to enable them to receive the best care possible.
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