Being a GP – more than a doctor?

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.

  1. SL Dawlatly 2014. Do Our Consultation Models Meet Our Patients’ Needs? BJGP May 1, 2014 vol. 64 no. 622 245
  2. Primary Care: Today and tomorrow, report by Deloitte Centre for Health Solutions
  3. GP or social worker? A historical Perspective – guest blog on John Cosgrove’s blog
  4. ‘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.
  5. Bryson, 2012. Honouring Personhood in Patients. http://www.wphtrust.com/Honouring%20Personhood.html
  6. http://karisneighbourscheme.org/
  7. P Tate. The Other Side of Medicine.
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Are GP surgeries like supermarkets? Is bigger better? Published in BMA News 10.5.14

In recent years there has been a trend for GP practices to merge. It seems the primary motivating factor, at least initially, was fear. Fear of being taken over by private contractors, commissioning groups or the monsters that hide under my children’s bed. Perhaps there is the belief that bigger is better, bigger is safer, bigger is more economically viable.

With merged practices there will still be, more or less, the same number of doctors and nurses as before because availability to patients has to remain at the current level, as a bare minimum. However, it is behind the scenes where savings can be made with centralisation of management, secretarial and IT support. Receptionists are probably safe, as someone has to answer the phone within a minute, or whatever arbitrary figure is being touted this week. It doesn’t take a genius to work out that if 8 practices merge then you don’t need 8 managers, 16+ secretaries and 8 IT support chaps/chapesses.

So if it makes financial sense to merge practices, why might I be opposed to the idea?

It’s like food shopping.

Do you prefer the faceless, nameless, corporate megastore that is access-all-hours, with a different till operator each time you go? Or do you prefer your local butcher knows who you are and where you went on holiday last summer?

Do you prefer sterile, neon strip lights, regulation posters and wipe-clean seats? Or the rough and tumble flower stall, whose holder knows your name and when your wife’s birthday is, or who your even wife is, for that matter?

Do you like the one-stop mega-shop with all its shiny machines under one roof to tell you what’s wrong with your life? Or would you rather be directed to the local expert who can help you with your tricky situations?

Do you take comfort in the same shiny brand at the front that means relentless pursuit of corporate values, where customers, or do I mean patients, are as much a priority as profit margin and market share? Or do you prefer to see what has actually be grown and produced in local fields and picked by hands that shake your own?

You may even prefer to shop remotely and order online from the comfort of your home or phone? Or would you rather embrace the warmth of humanity?

Do you enjoy the self-service beep, beep of the blood pressure machine in the waiting room, the self-service counter totting up the value of your life? Have you used your own bag? Or would you rather enjoy a chat at your local before your usual is issued?

 “How are you Mrs Boggins? It’s really good to see you!”

Getting on the Bus

elinlowri

Getting on the Bus

‘We’re so grateful for the fact that they didn’t suffer at the end of their life’

‘Why didn’t they have a scan and a biopsy? It might have saved their life’

Sometimes it’s hard to know what ‘Doing the Right Thing’ is. Those questions could have been asked of me by relatives about exactly the same patient. In fact, they have been asked of me, repeatedly, about very similar patients. What is the difference between those patients, those relatives? Or is it me? Am I too nihilistic in my approach? Should I be more aggressive in my ordering of tests and treatments? Are their expectations reasonable or unreasonable?

We were taught, at medical school, a lot about pathology. We learned lists of causes for abnormalities of a thousand different, tiny systems. We learned rare, eponymous conditions that we should always be alert to, like constantly watching…

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Do our consultation models meet our patients’ needs?

Latest essay published in British Journal of General Practice http://bjgp.org/cgi/content/long/64/622/245

Reference as BJGP May 1, 2014 vol. 64 no. 622:245

I’ve had to learn that I can’t usually meet the social needs of my patients, even when I was working as a GP registrar near a charitable neighbourhood scheme that uses a network of volunteers to offer friendship, guidance, advice, and practical support to anyone in the local community.1 So when one patient told me that she needed swabs because she had started working in a brothel, to earn money to pay back her debtors, my heart broke because my ability to help was so limited. No-one told me how to cope with that brutal situation at medical school and I’m sure it isn’t covered by the RCGP curriculum. In fact, I’m not sure if anything could have prepared me for someone disclosing what she did.

I have slowly realised that the biopsychosocial model isn’t perfect and, increasingly, it seems to be back-to-front as it gives precedence to the medical, or biological needs of the patients. I quickly reconstituted a sociopsychobiological model, where the assessment of social needs consisted merely of sympathetic, non-judgemental listening. She already knew that there was nothing I could do to help with her debt or awful situation; I just needed to come quickly to the same conclusions. Next, psychological assessment and support was offered; I was ‘there’ or ‘here’ if she needed to talk about ‘things’. This left me focusing, paradoxically, on her biological needs, though it was obvious these were the least of her problems.

I was lucky that she was clear about how I could help. Since then, though, plenty of patients have expected their social, psychological, and even existential needs to be met by me and I have had to, hopefully gently, disappoint both them and myself. Which leads to the consideration of a different model for reflecting human needs.

In 1943, a hierarchy of human needs was proposed by Maslow.2 These needs are often represented as a pyramid, with a base of ‘physiological’ needs (including food and warmth), followed by ‘safety’ (including health), then ‘love/belonging’, next ‘esteem’, topped off by ‘self-actualisation’. One aspect of the theory is that you can’t meet higher needs if the lower ones aren’t being met. This explains why it is pointless trying to convince my patient who survives on a weekly budget of £17.50 to take his medicines. As he often goes hungry, his more basic physiological needs preoccupy him and take priority over his health and safety.

Predictably, this model also has its limitations in practice. It doesn’t need to be turned inside out, but perhaps it is simply too much to aspire to, because as a doctor I generally try to meet a narrow band of need, towards the bottom of the pyramid, which depends on physiological needs (food/warmth) being met by society and the patient not looking to drag me up their pyramid to meet their ‘higher needs’ of belonging, esteem, and self-actualisation. I can try to give them respect (part of the penultimate esteem level), or even have empathy and compassion towards them, but in the context of a 10-minute consultation this is likely to be ineffective if they have unmet needs at the lower level of love/belonging.

Maslow’s model is a useful reference tool when things don’t go to plan. It highlights that we should be signposting patients to other agencies to meet their pressing basic needs before, and as well as, trying to meet their health needs. Whether we should stray from just meeting health needs is a debate that strikes at the core of what it means to provide holistic care, but perhaps each GP needs to know their limit.

So, one model appears back-to-front, at best, the other merely serves to demonstrate my limitations as a GP. Neither explain how I can help a patient who has to work in a brothel.

© British Journal of General Practice 2014

REFERENCES
1. http://www.karisneighbourscheme.org (accessed 11 Apr 2014).
2. Maslow AH (1943) A theory of human motivation. Psychological Review 50(4):370–396.