When should I call for help?

GP registrars are expected to seek help from their supervisor for patient’s they are not competent or confident to manage alone. In your first term of general practice your supervisor will assess whether you are ready to consult without review of every consultation. Once this occurs it will be up to you, with guidance from your supervisor, to determine when to call for help.

As each registrar has a unique training background and set of clinical experiences it isn’t possible to create a standardised list of clinical situations when help should be sought by all registrars. Instead, an individualised plan is required for each registrar. This document is intended to guide a conversation between you and your supervisor about when supervision will be needed.

The ‘call for help’ list was developed through research with registrars, experienced supervisors and medical educators. Some of the problems on the list are present because a registrar is unlikely to have encountered them before. Other problems on the list are high-risk for all GPs and even an experienced GP might seek help from a colleague. Finally, some problems are on the list because, although a registrar may have encountered them during hospital training, management in general practice is different. For example, troponin levels are routinely used for chest pain presentations in hospital but are unlikely to be used in mainstream general practice.

Items may need to be added to the list because you have identified an area where you will need help or because your practice may have a special interest or serve a particular patient demographic not covered in the list. The list doesn’t include every clinical situation when help will be needed, and you should feel free to call for any problem when you perceive you need assistance. Over time, you will work with your supervisor to know which problems need to be discussed during a consultation and which can be left to discuss at a later opportunity.

In addition to the list of specific clinical problems to trigger a call for help there is also a list of ‘uncertainty flags’, a list of ‘new and challenging consults’, and a list of ‘professional and legal scenarios’ These lists should be self-explanatory.

How to use this document

Read through and become familiar with the list of ‘uncertainty flags.’ These are broad markers of uncertainty that indicate you should seek assistance. The ‘new and challenging consults’ and ‘professional and legal scenarios’ are specific circumstances where, particularly the first time you encounter them, your supervisor is likely to want to be consulted.

The remaining items on the ‘call for help’ list are clinical problems. For each of the items on the list of clinical problems complete an assessment of your confidence to manage the problem. Bring your completed list for use in a discussion with your supervisor about when you are likely to need to call for help.

Keep the list handy during the term. Some registrars who have felt reluctant to call for help have found it reassuring to see the breadth of circumstances where help is expected to be obtained. Your supervisor may add other reasons to call that are relevant to this practice.

Uncertainty flags

Considering sending patient to Emergency Department

A patient you are unsure about sending home

Third presentation for the same issue without a clear diagnosis or plan

If you think you have made an error

If you think there is going to be a complaint (disgruntled or dissatisfied patient or relative)

When you are unsure who to refer to

Abnormal Pathology or imaging results that you don’t understand

Prescribing medications you are unfamiliar with

‘Heart sink’ patients: i.e. patients you are finding overwhelming

When a patient attends asking you for a ‘second opinion’

New or challenging consultations

Nursing home visits

Home visits

Issues of cultural safety particularly for an Aboriginal and/or Torres Strait Islander patient

Procedures being done for the first time in the clinic (excisions, implants, joint injections)

Making a new major diagnosis (cancer, diabetes, IHD) and starting management

Breaking bad news to patient (cancer, HIV, adverse pregnancy outcome)

Pre-operative assessment of fitness for anaesthetic

Professional or legal

Certifying competency to sign a will or other legal documents

Workers' compensation consultations

Driving assessment

Consultations involving determining whether someone is a 'mature minor'

Commencing a drug of dependence (S8) other than for palliative care

Repeat drug of dependence (S8) prescriptions

Reference: Ingham G, Plastow K, Kippen R, White N. A 'call for help' list for Australian general practice registrars. Aust J Gen Pract. 2020;49(5):280-7.

Call for help list

Practice name

Registrar name Date of plan

Primary supervisor name Stage of training

Clinical Problem	Your confidence to manage independently in general practice
Not at all	Somewhat	Very confident
Emergency medicine/Acute presentations
Acute significant systemic symptoms: collapse, rigors.
Extreme abnormalities of vital signs
Acute onset of shortness of breath
Severe abdominal pain
Chest pain
Severe headache that is new or sudden onset or associated with vision change or meningism
Concussion/post head trauma
Trauma with high risk of injury e.g. high speed or rollover MVA
Post collapse, possible seizure
Acute eye - unilateral red, painful, vision loss, or periorbital swelling
Sudden loss of hearing not due to wax
Fracture
Nerve, tendon or serious muscular injury
Acute red swollen joint
Possible malignancy
New bowel symptoms in a patient over 50 years of age
Painless haematuria
Lymph node enlargement without simple explanation
Unexplained weight loss
PR bleeding
Testicular lump
A new or enlarging lump
Iron deficiency
Skin lesions you are unsure of diagnosis and whether to excise
Breast lump
Persistent cough
Mental health
Acutely suicidal patient
Acute psychosis
Paediatrics
All neonates
6-week baby check
Australian immunisation schedule immunisations (including catch ups)
Unwell child under 2 years of age
Failure to thrive under 12 months of age
Developmental delay
Child and adolescent mental health consultations
Child abuse or unexplained injury
Eating disorder
Women’s health
Antenatal consultations
Irregular vaginal bleeding
Post-menopausal bleeding
Postnatal depression
Cervical screening
Aged and palliative care
Dementia or delirium (acute cognitive decline)
Deciding whether to start or stop anticoagulation in elderly
Palliative care
Elderly patient not coping at home
Elderly patient with multi-morbidity recently discharged from hospital
General medicine
Poorly controlled diabetes
Pyrexia of unknown origin
New neurological symptoms or signs
Severe exacerbation of asthma or COPD
Rash you are unfamiliar with
Domestic (intimate partner) violence
Dependence/Addiction/Pain management
Chronic pain management
Managing alcohol/drug dependence
Sexual health
Patient requesting STI screen
Travel Medicine
Pre-travel consultations
Unwell returned travellers or international visitors
Other problems relevant to this practice or to my own clinical weaknesses that I may need help with