When I was a surgical house officer I remember having the responsibility of looking after a small group of final year medical students. I asking them what they wanted to learn, pointing out to them that knowing enough to pass their final exams was not the same as knowing what it took to be a half-decent junior doctor. The two are not completely mutually exclusive, but they needed to learn both.
In a similar way being able to pass postgraduate GP exams and being a GP are two quite different things as well. Aside from the time management, work-life balance juggling, team dynamic finesse in partnership, management of a clinical team, financial astuteness and box-ticking, that is. The fact is many patients don’t present with medical problems. Generally speaking they are either coping badly with a tough social situation, be it work/relationship/financial/neighbour/housing-related (tick all that apply) and sometimes think that they have a medical/psychiatric condition as a result, or they are seeking practical assistance in the aforementioned social areas. So even though I went to medical school a lot of the time I find I am not practicing medicine. I’m doing something else. Or am I?
And this is where I get confused. Is dealing with the social problems of patients practising medicine, or is it a hiding to nothing, a waste of time and not what I am trained/qualified to do?
A friend of mine says that unless he can treat the whole patient, he doesn’t feel like a whole doctor. This alludes to the concept that it is a false division to separate the social from the medical, from the psychological and even the spiritual. There is no denying that the social determinants of health are incredibly influential – but can we, and should we try to even influence these social determinants, other than advising about diet, exercise, alcohol and smoking? I can fully understand the temptation to try to “solve” social problems. I am aware of a need within me to want to help, to “do the right thing”, to feel I’ve done a good job, to feel like I might have done something to make the world a better place. Maybe I try to solve all sorts of undifferentiated problems through a need to not feel a failure. Perhaps I allow myself to grasp the reality of the awfulness of some of my patients’ lives and I just can’t help myself being helpful. It’s a weakness of mine.
However, if I get better at doing that, will that feed into the perception amongst patients that that is actually my role, my job; problem-fixer, compassionate listener, letter-writer, advocate? Will the “real” medicine get gradually squeezed out? How exactly does one listen to the social context of a patient’s health problem, letting it form the backdrop, without being moved by it, to try to help? What if the converse is true, that getting involved in the social situation of a patient helps the biological aspects of their health? After all it’s all just health to the patient; the divisions are ours, not theirs.
I’ve written about a patient1 who had to give up work due to cardiac problems. He managed to save his house by switching his mortgage to interest-only, but on benefits it left him with barely enough money to eat. He would regularly go hungry and sit at home in the dark to save money. He always booked early consultations and turned up early – so we sometimes had a bit of extra time. I found out about food banks for him and spoke about his situation – then about his health. He told me later that after seeing me he starting taking his secondary prevention medicine as he felt that if I could take an interest then perhaps life was worth living. By taking time to simply be human with him and discuss his situation it led to him wanting to look after his own health – maybe because he felt as though someone cared.
As life expectancy in the UK gets longer, one would think that the health of the nation was improving. Perhaps health inequalities are to blame and that the advances in life expectancy are skewed results, thanks to the increases in the upper classes of society. Maybe medical issues are not on the agenda so much, but other anxieties are bubbling up in the psyche of a species that evolved from a creature that was more likely to survive if it worried about where the next meal was coming from, where the next dangerous beast was hiding and how to keep the fire burning all night. Are we hard-wired to worry? The reality is that the number of consultations with a GP per head of population is increasing2 and although the picture is undoubtedly complex I can’t help but wonder what proportion of this are the aforementioned patients with the problems that can’t be solved with medical school or RCGP curriculum knowledge, or likely can’t be solved at all.
There are some that feel that GPs should take a stand and not consider trying to solve these social problems – the cost of doing so means that less health matters can be dealt with3. There is logic to the argument, but how does one stop the patients in a system where there is free access to a GP, even if political parties think even that needs improving?
Can patients be educated into seeking help for non-medical problems elsewhere? Whose job is it to do that? Is anyone going to do that for the sake of wealthy, overpaid GPs? Do GPs have time to do the job of educating, beyond the limited time of 10 minute consultation? If all the GPs in the practice where I worked said, “I have listened to your situation, it’s largely a social problem, I can’t help – shall we measure your blood pressure instead?” or something to that effect, I imagine we would fail the Families and Friends Test, become deeply unpopular and would also feel quite helpless too. Though in reality we may be helpless, it doesn’t sit right with me to reinforce that feeling.
Another tactic for reducing demand for appointments that are for problems we can’t help with, would be doctor-led triage. Perhaps we could screen out patients before they make appointments, to make sure they are not coming with impossible questions and requests. It may work, though they could get wise to this and arrive with a medical problem and then present the unanswerable as a “just before I go doctor” conundrum. Doctor-led triage may work, but may also mean a big shift in a way of operating for many GPs.
It seems that patients usually need one of two things – someone to talk to about the crap they are going through and to validate their suffering, and someone, perhaps not always the same person, to help them with the mess of their lives. The latter type of problem-solving may have been done by the Citizens Advice Bureau in the past, the former by other members of the patients’ communities, back in the rose-tinted days. Maybe services could and should be set up to help deal with these – but in a time of austerity I doubt whether anyone would invest in such schemes.
Public Health England is unlikely to provide or commission “listeners” and “helpers” for our patients, and therefore to protect ourselves, GPs should consider setting services up ourselves. That is if you can escape the circular argument that in doing so you are further abdicating the government and society on the whole of their responsibility of performing their roles of social justice. The argument of self-preservation and not just the desire to provide sustainable holistic care should motivate GPs to be able to divert patients to “listeners and helpers”.
Can it be done? Some would say yes, though the data are largely anecdotal and based on quality assurance measures, there are practices that refer patients to listening services and run charitable neighbour schemes4,5,6. They report that patients referred require less psychotropic medication, less hypnotics and don’t come to the doctor so often. When I worked in such a practice it was great to be able to refer someone to a befriending service because they were lonely, or the advocacy drop-in group as they were about to be evicted.
My worry is whether that particular practice makes those services work because of their commitment to holistic care and the particular make-up of the personalities and their moral code that guides them. It’s hard to know, at this stage, if it is translatable to a sceptical, secular majority. In an age where evidence is king it would be great to prove its worth with a randomised controlled trial to test the hypothesis that intervening with trained listeners and helpers does actually change outcomes of prescriptions, referrals and consultations, not just patient reports of wellbeing. General practice may not be able to wait for that. At least they have 19 years’ experience of trying to do something to both serve their patients and protect their own sanity, instead of simply complaining that GPs don’t do enough “real” medicine. I would hope there is something to learn from that.
What is it then, to be a GP? Is it more than being a biomedical generalist, interested in the measurable and/or treatable? Is the “other side of medicine”7 optional or essential? Does that differ from person-to-person? Does this dilemma cause some of the issues with resilience and morale that GPs reportedly face?
I wish I had the capacity to care about the whole person that sits in front of me and pours out their life to me. Sometimes I do, often I don’t. Perhaps it is my weakness that I wish I could be better, do better, care more. I’m not quite sure why, perhaps a moral imperative to a higher power or a way of life modelled by significant others. There’s no sign that the issue of unsolvable problems being brought to the GP will get any better by itself and more importantly no sign that anyone other than GPs can do something to turn the tide.
- SL Dawlatly 2014. Do Our Consultation Models Meet Our Patients’ Needs? BJGP May 1, 2014 vol. 64 no. 622 245
- Primary Care: Today and tomorrow, report by Deloitte Centre for Health Solutions
- GP or social worker? A historical Perspective – guest blog on John Cosgrove’s blog
- ‘Chaplains for well-being’ in primary care: analysis of the results of a retrospective study. Prim Health Care Res Dev. 2014 Jan 22:1-13.
- Bryson, 2012. Honouring Personhood in Patients. http://www.wphtrust.com/Honouring%20Personhood.html
- P Tate. The Other Side of Medicine.