Doctors' Visits to Clinics

Prof. Ian Couper (Wits University)

What is the Role of the Doctor Visiting Primary Health Care Clinics?


1.The Issue

Doctors visiting primary health care clinics in districts do not have clearly defined roles. In some districts doctors are specifically employed for this task. In many other districts, doctors from the local district hospital go out to clinics to perform this task. Usually the former system provides a more regular service while the latter assists integration and continuity of care. However, regardless of the system, the exact tasks these doctors are meant to perform are not clearly defined. In addition there is a wide variation of expectations from these visits in terms of - the health service requirements, what the doctors perceive their role to be, and what they do when visiting clinics.

2.Roles as they are currently seen

Currently a clinic visit is seen by many doctors as being entirely a clinical function. On any day, a doctor will see a set number of patients that have been booked for him or her and then leaves the clinic without getting involved further.

In some instances doctors take on wider roles and responsibilities relating to issues such as drug supply, sharing of information, teaching, organisational issues and even clinic management.

From the nurses side there is often an expectation that doctors should be part of the primary health care team. There is a hope that doctors would be supportive of primary health care nurses in their roles of patient care through teaching and through working together co-operatively. Some nurses also expect doctors to be further involved in issues relating to administration and management.

From a district management point of view there is often not a clear understanding of what the doctors role should be. Some districts have included doctors on district or sub-district management teams and thus expect doctors to be involved in a broader range of activities.

These different perceptions of roles and responsibilities make it difficult for doctors to perform their roles effectively. The purpose of this article is to suggest a more defined role for doctors during their visits to clinics.

3. Structure of visits


The frequency of visits will obviously depend on the type of clinic, its location and the type of health service provided. The principle used in some provinces is that a health centre should have a doctor on site every day, a residential or fixed clinic should have a doctor visit once per week, and mobile clinics or clinics that are not fixed could have a doctor involved from time to time, possibly once a month.

In order for this to happen, it is necessary for any irregularities with the availability of transport to be sorted out. It is vital that the district/sub-district management play an active role in attending to any lack of transport, as it is often a limiting factor. Ways of doing this can include subsidising doctors to use their own cars or arranging for a team of health workers to visit the clinics together.

Where possible, it is useful to link doctors visits with drug deliveries. In so doing, emergency and critical drugs which might be out of stock can be supplied when doctors visit the clinics. It is a good idea for doctors to bring a box or a bag with medicines that are not on the EDL list to clinic visits. Alternatively they could keep a cupboard at the clinic, where these medicines can be stored for dispensing their clinic visits.

From an organisational point of view, doctors visits can also be used for the dissemination of information. For instance, circulars or memos that need to go out to clinics from the hospital can be given to the doctor, depending on alternative methods of communication. In other words, if there is a regular visit by a clinic supervisor who does this, then the doctor does not need to, but where the doctor is the main link to the hospital then s/he should be taking on that responsibility. Similarly the doctor can take laboratory results out to the clinics.

4. The Scope of Responsibility of the Doctor

a.Clinical role

The key responsibility of the doctor will remain clinical care. More complicated medical cases, which nurses find difficult to deal with, can be referred to the doctor who can then give advice on treatment, make decisions and help solve problems. Ideally this process should involve the presence of at least one of the nurses who refer patients to the doctor. Whatever s/he learns by being present should be fed back to colleagues to broaden the knowledge base. A book for doctors referrals can be maintained and comments noted in this by the doctor or nurse for feedback. The advantages of this clinical role include:

* Ongoing development of good clinical care by the clinic team.
* Increased effectiveness of decentralisation of services, by reducing the patient consultations which might otherwise occur in the hospital.
* Better management and follow up of patients with long term chronic illnesses, which are often the bulk of the load for the clinic doctor.
* Patients are assisted with a number of other issues such as medical legal work, filling in forms for disability grants, care dependency grants,
completion of medical certificates etc.

Nurses have mentioned that when a doctor is involved in the clinic, this often gives patients confidence in the services provided. The doctors support of clinic staff encourages patients to value the staff in the clinic.

In the case of for non-emergency patients, the doctor can also assist with decision making about patient referral to the hospital (whether this should be for admission or for specialist opinion). Here it is important that a referral system is in place that allows doctors who refer patients from clinics to by-pass the hospital out-patients department and admit them into the wards or alternatively direct patients directly to specialist care where this is needed.

b. Broader role

There are a number of other areas where it is useful for doctors to be involved. It is important that these are negotiated with the other members of the clinic team. In this way there is a shared vision for the doctors role and team work is developed. There should never be an assumption from the doctor that s/he is required to fulfil all these roles. Importantly, the doctor should not attempt to take on the job of supervising nurses, which remains the responsibility of the community nursing supervisors, unless this role has been specifically delegated.

Some of these broader roles include the following:

* Ongoing training of primary care nursing staff. In order to do this effectively, it is suggested that specified time is set aside for teaching nursing staff through direct discussion around specific patients or otherwise discussion on topics selected by the nursing staff. Alternatively protocols can be looked at together and new protocols drawn up. During training, feedback can be given to, and received from, nurses on specific patients.

* Assistance with the day to day running of clinics. This assistance may relate to drug supply such as monitoring of stock, assisting with orders, looking at minimum and maximum stock levels and transport of orders and medicines between hospitals and clinics when needed. Similarly this can involve surgical and other clinical supplies. Another area of support is transporting laboratory specimens to the hospital, bringing back the results and following up on missing results.

* Forming part of the team. Where there are monthly clinic management meetings it is useful for the doctor to be part of these meetings. It can even be useful for the doctor to be involved at the clinic governance level where there are community clinic committees, if the nurses need back-up in that area. In this regard the doctor can also be a liaison between the clinics and the district and/or the hospital where s/he can bring problems to the attention of hospital or district staff and help to develop solutions.

* The doctor can also assist with liaison with other institutions in the district for example social welfare, police and schools.

5. Continuity

In order for doctors visits to function optimally and have the desired results they must occur on a regular basis so that nurses and patients can rely on them. Where visits are erratic, patients lose confidence and the whole purpose of clinic visits from the nursing point of view is lost. Similarly important is continuity, where the same doctor visits the same clinic regularly over a period of time. This is important both from the point of view of team work with nursing staff and also in terms of patient care. If the doctors are changed regularly it becomes very difficult to establish a more useful visit. A minimum rotation suggested per clinic would be six months.

Conclusion

Because there is no clear consensus about the role of the doctor at the clinic, it is suggested that in each district the doctors, nurses and district management work together to establish job descriptions and role definitions for the doctors visit. Clinic nurses feel that many doctors are unsure of what they are supposed to do and are not fully orientated regarding the process. They need to be informed about basic things such as reporting to the sister in charge of the clinic, identifying themselves when they newly arrive in clinics and where and how they can find out what is expected of them.

Primary care doctors need to support clinical nurse practitioners in a consultative rather than in a managerial way. Nurses will continue to be supervised by nurses but doctors play a crucial role in maintaining a high quality of care through seeing referred patients, making use of learning opportunities and improving communication, feedback and liaison with hospital care. Clinical protocols and clearly defined roles are essential for effective functioning. The expectation should be created of shared consultations between doctor and nurse with patients selected according to defined criteria. The numbers of patients to be seen may need to be defined in terms of this as well.

Establishing constructive working relationships in the context of a team approach to common problems is vital. This is another reason why the clinics need frequent visits by a doctor. It is recommended that the process of these visits be documented in different districts with a view to developing consensus and greater understanding across districts and regions.

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Written for HST by Ian Couper (WITS University), with input from Steve Reid (Natal University) and Nzapfurundi Chabikuli (WITS Centre for Health Policy)

December 2002

Contact person is Professor Ian Couper, Chair of Rural health, University of the Witwatersrand

Tel. No. 011 - 717 2602 Fax No. 011 - 717 2558

email : couperid@medicine.wits.ac.za