Fish and chips

Sure, job satisfaction isn’t always about what you get. I’m certainly not a GP for the money, working in an inner city practice which earns 2/3 of the average for my area. We don’t have to worry about “declaring” expensive gifts at Christmas: most of our population are poor, homeless, immigrant and focussing on survival. Which is why on the occasions when we do get patients expressing their gratitude, it really is special.

Like my seafarer patient, in port for a few days, who was so grateful that he left my surgery telling me, “I’m going to bring you a bottle of whisky!” Sure enough, 10 minutes later he was back, a 25cc. bottle of Bells in his hand! Or an elderly farming couple who would not let you leave a housecall without two carrier bags of home-grown veg.

The particular lady I want to tell you about though is an elderly Mandarin speaking lady who visits me regularly. She speaks no English, is a practitioner of Chinese Traditional Medicine herself and has complex medical problems. Appointments are often tiring, always through telephone translation, often covering many issues and rarely taking less than 20-30 minutes. However, she always insists on leaving me something. Usually a bottle of juice, some dried fruit, sometimes fresh fruit, once a bottle of cheap red wine.

On this occasion she had made an urgent appointment with me to discuss a form she was struggling to complete. It needed me to fill some in so, recognising it was a council form, I took her to the council advice desk (which is conveniently on the other side of our waiting area), sat her down, explained what she needed and returned to my desk to sort out the form. A few minutes later I returned to find her … gone! The council advisor had no idea where. She had left all her things and just upped and left. Anyway, I left the form for her and returned to my list.

A few minutes later, whilst sat consulting my next patient,  there was a knock on my door and before I could respond the lady burst back in, placed a bag on my desk and showed me the form. “Read! Read!” she said. Not having time to get telephone interpretation to explain the etiquette of not bursting in on a private consultation I got up, took the form and indicated the address it needed to go to. “Here! Take here!” I said. She appeared to understand, bowed and turned to leave.

As she did so I picked up the plastic bag, noticeably warm and smelling of vinegar, to give to her. “No! You!” she says with a smile, pointing at my stomach.

As she leaves I turn and look at the poor patient in the chair, who seems completely bemused at what just went on.

“I guess I’m having fish and chips for lunch,” I tell him.

It is always nice to feel appreciated but especially so when people choose such interesting ways to express gratitude.

Simon
GP in Wales

The ladies in the hair salon

These aren't the real ladies...!

I changed jobs last year. One day during the last few weeks at my old surgery, Mary came to see me. Mary is in her mid-sixties; an infrequent attender, our only meetings had been around the time when she had become severely iron deficient and anaemic due to an as-yet undiagnosed gradual benign gastrointestinal bleed, which was dealt with swiftly after she suddenly decompensated and collapsed in our waiting room whilst waiting for an ECG. After a short hospital admission she was back on her feet and apart from a couple of follow-up checks and repeat prescriptions for iron tablets, I hadn’t seen her again. Until this particular day.

“Long time no see”, I greeted her as she  walked into my room. She gave me her usual bright smile in return.

She had a cough and was a little breathless. She explained to me that breathlessness had been the only symptom she had experienced prior to her anaemia-related collapse, so she was naturally a bit concerned and was seeking reassurance that it was only her cold that made her feel a bit below par this time.

Whilst I carefully examined her chest and for signs of anaemia she said, “Rumour has it you’re leaving?”

I looked at her in surprise. My resignation had happened quietly and was not advertised anywhere. I had only just started sharing my news with a small number of patients, the ones I felt needed some time to adjust.

“How did you know?”, I replied, “I haven’t seen you for months.”

I put my stethoscope away and my eyes met hers again. “Well, you know. I do Mrs Smith’s hair on a Friday, at the salon. She told me last week. She was most upset. In fact, we all are. To lose you. You are such a lovely doctor. We didn’t talk about much else for the rest of the day”.

It seemed many of her clients that day, and every day, were also my patients. One was a young mum who I had supported through the brutal reality of severe postnatal depression. Another was the wife of an elderly man, together we had cared for him during his final illness. A third an elderly lady with multiple medical conditions whose constantly changing drug therapies were causing side effects and confusion, and we had slowly worked things through together. And so it continues.

They fully understood my reasons for changing my work pattern: the never-ending long days, the constant panic filled runs to get to the childminder on time, the need to feel I could breathe again. But they were upset. Upset to lose me. I had been their doctor and they had appreciated my hard work. I had been a good doctor to them.

Mary did not have recurrent iron deficiency anaemia, she had a heavy cold. But this consultation still stands as one of my most important since I became a GP. It made me think about how important a part a GP may play in another person’s life.

It made me realise that for some patients their GP may be the one stable factor they have in their life at a time when illness makes them vulnerable – a source of trust, direction and support. A significant part of their life.

I feel privileged to be that GP for some of my patients. As general practitioners we have an amazing opportunity to help patients at their time of need and we are ideally placed to be their first port of call when they are ill, and to manage their ongoing medical care. There is almost no limit to the symptoms we may encounter during a working week.

Whilst specialists become experts in a small field, we as GPs need to consider a huge range of diagnoses on a daily basis and become experts in generalism. This requires inquisitiveness and skill. It requires dedication and stamina. It requires the ability to take risks, to manage uncertainty with confidence, and to tolerate not having all the answers.

A good working day in general practice excites me. Not because of the occasional patient who requires an ambulance from the surgery after a collapse in the waiting room, but because it challenges my curiosity and clinical knowledge.  Because it almost breaks my dedication and my stamina. Because sometimes I am not prepared to take risks, because I don’t like not having all the answers.

To have good working days in general practice we need GPs who get excited. Who have great clinical skills, are ambitious to provide the best care for their patients and who have empathy. General practice gives you new and different challenges every day and it never stops. If you get it right, the rewards are countless.

But we also need time. We need sufficient resources. We need to set boundaries and prevent our general practice from becoming misused. Curiosity and dedication are easily damaged if negativity prevails, and even the toughest marathon runner eventually tires.

The ladies in the hair salon make me smile. They are proof that general practice is still important and that we make a positive difference in our communities and to people. They are proof that I chose right when I decided to become a GP.

Hanne Hoff
GP

Instant cures, shared experience and versatility – Dr John Cosgrove

Inspired by the #whyGP project, John Cosgrove reflects on why he chose general practice and demonstrates how he is using social media to spread that message.  Here are just a few of his reasons.

INSTANT CURES


What could be more satisfying than curing someone in the space of ten minutes? I was inspired to become a GP after observing the healing power of the GP consultation itself.

I had this epiphany in Woolwich whilst sitting in with GP Simon Lundy. A mother was worried about the health of her child. Dr Lundy expertly reassured her that it was a self-limiting illness which required no specific treatment and from which the child would make a full recovery. Her relief was palpable.

Such consultations occur several times a day for every GP. Years of training and experience and first class communication skills allow a rapid assessment, a diagnosis based on probability, reassurance or simple treatment and safety-netting in case of a less common cause. This is not “fobbing off” or “missed diagnosis” but pragmatic, family medicine that achieves personalised healthcare with unrivalled cost-effectiveness. This approach should be celebrated: the NHS relies upon it.


SHARED EXPERIENCE

I really value being a part of the same community as my patients. Some colleagues prefer not to live in the practice area lest patients consult them on the street. However, I like that sense of connection with my patients: whether it be simply experiencing the same traffic, power cut or weather event; whether it be having enjoyed the same local festival; whether it, sadly, be a road traffic accident or some other tragedy; or whether (in my case) it be an opportunity for patients to provide feedback on my choral singing!

All of these shared experiences help to build rapport and mutual understanding and respect, putting patients’ health firmly into their social context.

My memory of working in hospital is that special effort is needed to understand a patient’s social context and to maintain their dignity within that sanitised, other-worldly environment.

In general practice, patients often apologise for attending in their work clothes. Of course, apology is absolutely not needed, as it helps to bring to the fore the person rather than the illness.

Understanding the social context is of course vital in any walk of life, but is something that is particularly important in general practice, even if it is not for us to change social factors.

PARTNERSHIP

As a GP registrar, I came to enjoy the sophisticated interactions with my patients. They treated me as their advisor, albeit one whose advice occasionally required me to write a prescription. They did not come like a car to be “fixed” but to work in partnership to understand their health concerns and needs, drawing from my medical expertise.

Doctors have tended to accept blame as a legitimate way of allowing patients to cope. If media, charities, regulators and courts encourage complaints and a culture of blame and punishment, we risk losing this precious partnership. Let us work together to build on this colloboration which allows GPs to help so many patients.

 

PACE

One of the things I really enjoy about general practice is the pace. Every 10 minutes, a new patient walks through my door with a new set of concerns. Beyond clues in their records, I have no idea what they might want to discuss with me.

They might have severe depression and need an emergency referral, or they might have just discovered their xiphisternum and need reassurance that it is normal.

I am not a specialist. I am proud to be an expert generalist. That means, amongst other things, that I am expert in treating common conditions, basic treatment of less common conditions, recognition of what is normal as opposed to what might need further investigation, and considering how different aspects of a person’s health might interact.

This variety and pace is a marvellous challenge and keeps one on one’s toes throughout the working day or even career!

There are opportunities to develop special interests. There are also strong arguments that appointments should be longer than 10 minutes and perhaps even that there should be some kind of triage process (to ensure, for example, that some issues are dealt with by colleagues). However, I am glad to say that the pace and variety of work in general practice is in no danger!

FLAT HIERARCHY

When I was sitting in with Dr Lundy in 1999, the partnership model of general practice was at its height. By and large, if a practice wanted a new GP, they had to take them on as a partner, a fellow principal with whom patients could register with for their GP care.

Clearly, each partner brought different skills to the team, whether it be seniority, expertise in a particular clinical area or responsibility for a particular area of practice management. However, once established in a partnership, each partner within each practice drew an equal share of practice profits (with the exception of seniority payments) and had an equal vote in practice decisions.

Thus, just 3 years after leaving medical school, there was a relatively flat hierarchy and a culture of respect for differing opinions and skills.

Nowadays, many GPs choose a salaried contract over partnership. Nevertheless, the culture of respect remains strong in most practices and is something that, as a profession, we should prize.


VERSATILITY

My GP trainer said he would equip me to practise independently anywhere in the UK.

Wow!

It seemed a tall order at the time, but that is indeed what he did. In reality, with the skills I learned, I could practise just about anywhere in the English speaking world (with the exception of the USA). With NHS contracts about to be revised, that is highly comforting.

However, this versatility is not confined to political geography. There are so many opportunities for UK GPs, trained as they are to an increasingly high standard.

I could work in a town (as a I have). I could work in a rural setting (as I have for many years). I could work in a city (as I currently do). I could work at a walk-in centre. I could direct a walk-in centre (as I do). I could work training tomorrow’s GPs (as I do). I could work as a locum GP, under contract as a salaried GP or in partnership. I could work out of hours (as I have done regularly). I could work with a hospital specialist as a clinical assistant (as I have done). I can undertake minor surgery and joint injections. I could represent my practice to commissioners (as I have). I could work with colleagues to bid to provide new services (as I am doing). I could represent GP colleagues within RCGP regionally (as I have) and nationally (as I do).

These are just a few examples of the opportunities available to GPs. Other GPs work as researchers, as occupational health physicians, in the military, on cruise ships, in Public Health, as politicians … the list is almost limitless!

The medical, interpersonal and management skills honed through GP training are second to none. The only uncertainty at the current time is who pays us.

If this sounds a little like a CV, perhaps it is: my family wish to move and I am looking for a new practice. Just as well I can practise almost anywhere in the English-speaking world!

Fire, drive and passion

British GPJamie Hynes explains how, with his amazing video, he chose to inspire the next generation of GPs. The video is at the bottom of this page.

I received an e-mail from the Midland Faculty asking for entrants to a competition with the aim of inspiring the next generation of GPs. Suggestions were offered for prose of 400 words or less, a poem or a picture. I’ll do those then, I thought.

I wanted an antidote to negativity, to the feeling of adversity and a profession under the cosh.

I wanted to celebrate the positivity of life in General Practice and be unashamedly unapologetic for the intrinsically worthwhile job we do that is warmly appreciated by our patients.

Being a good GP is something to aspire to.

I wanted the video to communicate subtly the essence of General Practice: the individual facets have relevance, but most import is the need to appreciate the bigger picture, hence the big reveal at the end. Broaden the gaze…

My own goosebump moment is “…Maintain that fire, drive and passion I beseech…” which had even more impact as I recited the poem alongside the video clip at the Midland Faculty Summer Ball where the winner of the competition was announced. More difficult after a couple of glasses of wine with the dinner!

A great deal of thanks to the Midland Faculty, Clare Taylor, Hayley Dunn and Jonathan Leach et al for providing the opportunity to create this love letter to General Practice. And to graphic designer Claire Leach who re-shot the video more professionally than I could manage on my iphone.

We do belong to our patients, the community, the fold. When we’re referred to as ‘My Doctor’- well, that feels like pure gold. This is #whyGP

Jamie Hynes
Proud GP, TPD
@ArtfulDoctor

Breaking down the walls – selling rural GP

020115_0302 copyIt was a Saturday afternoon in February and I was up to my knees in Derwent Water setting up a computer on an office desk. Half an hour earlier I’d been conducting a consultation on the jetty and in the morning I was taking a blood pressure in the snow on the fells near Caldbeck. Later in the day, as the winter sun was going down, I was consulting again, this time from the dramatic amphitheatre of Castlerigg stone circle in Keswick.

It wasn’t an entirely typical day’s surgery in Cumbria, but the backdrops were all within the catchment of some of our training practices, and many of these views are enjoyed every day by GPs and trainees who live and work in our area.

We’d taken our consultations outside to make a point, to shout from the tops: we are here, we love it, we want others to join us…

The journey began in December 2014 when our GP training programme joined Twitter. As a trainee I was entrusted to run the site in partnership with one of our training programme directors, Natalie Hawkrigg. We were determined to stand out in the crowded world of social media and it wasn’t long before Natalie (who Honey and Mumford would describe as an activist) had an idea. We were going to conduct GP consultations in unlikely places, take photos and broadcast them on our Twitter site. Through our pictures we would communicate to the social media world the beauty of our local area and the enthusiasm and innovation of our trainees and trainers.

Our GP training programme in Cumbria is small, friendly and flexible. The training practices are spread over a wide area stretching across North Cumbria to Northumberland and even over the border in Scotland.

As a trainee in a rural practice I have found myself dealing with a STEMI in surgery, conducting home visits at a Buddhist monastery and crisscrossing the countryside searching for isolated farms. I love every aspect of it and couldn’t imagine training anywhere else.

In the past the programme has been oversubscribed but in recent years trainee numbers have gone down as GP vacancies have gone up. The secret of our fabulous little training programme was just too closely guarded. The beauty of using social media was that we – the GP trainees and educators – had the freedom to take matters into own hands.

We called the campaign #GreatBritishConsultations and published the pictures on Twitter over a number of weeks. We had a gradual build up of interest and it was eventually picked up by the media and the story was featured in Pulse magazine, our local Cumberland News, the MDU magazine and as picture of the week in the BMJ. Natalie was even interviewed for Radio 4 from her practice in Caldbeck. Many of the photos were framed and put on the walls of the education centre at the Cumberland Infirmary in Carlisle.

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I hope that running the campaign has raised the profile of our area but it is too early to tell whether it will be enough to increase the number of trainees. It certainly boosted our followers on Twitter and gave us the confidence to continue our experiment in social media, and to think up new ideas to keep ourselves noticeable. Having some responsibility for our training programme’s public profile remains daunting but it also fuels the desire to continue our improvement and innovation. This is the sort of thing that can only come from grassroots, trainee-centred initiatives. I applaud our programme for being open-minded, adventurous and for trusting in their trainees who are, after all, the very heart of its existence.

Rose Singleton

GPST3 East Cumbria GP Training Programme
@EastCumbriaGPTP

Photographs courtesy and copyright of Steve Razzetti – www.razzetti.com 

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Why ever not? – Aarti Bansal

Portrait of A Woman Prize, The University of Sheffield, Yorkshire, UKWhen I was a house officer in the year 2000, I asked my ENT consultant if he would be a referee for my application for GP training. He asked me why on earth I wanted to be a GP. GPs were just people who referred on. I was too bright to become a GP and really if I didn’t want to be a surgeon, I should at least become a general physician. I had hoped things had changed in 2015, so I was somewhat dismayed to hear a 4th year medical student tell me she has been told she is too bright to become a GP too! I would like to go back to that ENT surgeon and say what I did to the medical student – are you kidding?!

We manage nearly everything that comes through our door and a lot more today than in the 15 years since I qualified. We are the general physician. They don’t exist in the hospital (with the possible exception of elderly medicine consultants). And if what most of what we did was refer, the NHS would grind to a halt. Personally, I think General practice is the hardest medical job to do well. We make multiple decisions every 10 minutes! Decisions without the ability to monitor closely, or lots of tech on stand-by. We make these decisions safely and in all specialities. GPs are sought after to work in A&E because of this ability to make decisions quickly and safely. The yearly knowledge update books are so thick as to break one’s wrist holding them. We try to help with whatever health request comes through our door. We take responsibility!

And if saving lives is your thing, we do that too. This is not as obvious as it is in secondary care as it is largely done through preventing people getting unwell in the first place. Studies have shown that a greater supply of primary care physicians is significantly associated with lower all-cause mortality, whereas a greater supply of specialty physicians was associated with higher mortality.1

I wonder whether this question of why you would want to be a GP gets asked because of a skewed concept of what health is and what we do as doctors.

If we primarily see our role as medical experts, dispensing of advice and our patients role as passive recipients of this expertise, I admit this role fits better with the specialist than the generalist. But more importantly it fits with an acute illness model where the most important thing is to get the diagnosis and treatment right. In the developing world, where the burden of acute illness is high, this approach still works. Is it Malaria, TB, Typhoid? We need to get this right.

In a developed country like the UK, we deal largely with long-term conditions. Even acute on chronic is really about dealing with the chronic. It doesn’t really matter what speciality you enter into. The diagnosis of Rheumatoid arthritis is given once, the management takes the rest of the patient’s life. Indeed, we often need to help manage several long-term conditions interplaying with each other as multimorbidity becomes the norm in our ageing population.

So what does health mean in this setting? And what is our role as doctors?

The old definition of health seems to exclude anyone with long-term illness. I imagine it is based on an acute illness model. You have a chest infection – here are some antibiotics. Go back to your state of complete physical, mental and social wellbeing. And yet it would be ridiculous to say that 5 x Olympic gold medallist Steve Redgrave, who has diabetes, is not healthy. Who can really define health? Is it the doctor or the patient? Is it objective or subjective? In long-term conditions, isn’t it about what you can and can’t do and how your condition may be restricting your life that is ultimately important? This assessment is individual. In long-term conditions, only the patient can tell me what health means to them. Health is better defined as a ‘resource for living’2 or the ‘ability to adapt and self manage’.3 And what of my role as a doctor? If I want to help my patient to be healthy I have to empower them to manage their own health.

And this is where General Practice is really where it is at.

See, general practice has long understood that if we are actually going to help anyone towards health there has to be a partnership between us. In this partnership we give equal weight to the patient’s story and our medical expertise.

We then share. We don’t keep our expertise to ourselves, we don’t keep the magic secret. We share it with the patient. We share our thinking. Negotiate what is acceptable and come up with a shared plan. Sharing. Partnership. Equality.

And what helps build a sound partnership? Well you need to build a relationship. Trust is key. Balint talked about the doctor as a drug decades ago. Healing can be administered through a caring, trusting relationship. We can help through listening, caring, being a soundboard. Epigenetics tells us that psychological stressors affect us at the same biological level as physical stressors such as smoking, exercise, toxins, contributing to the major diseases of our time.4 Meta-analysis has shown that the positive effect of strong relationships is as protective on life as smoking is deleterious. Individuals with adequate social relationships have a 50% greater likelihood of survival compared to those with poor or insufficient social relationships.5 Medicine is a relational occupation in that we are people working with people. Our relationship with patients has the capacity to help or harm. Healing is not limited to medical treatment and the doctor-patient relationship can be a vehicle for health.

As GPs we get to have long-term relationships with our patients. Our patients are people to us and we are people to them. We are more accessible, practising closer to their environments and the lack of hierarchy and distance (perhaps confused for respect and esteem by medical students), makes for good partnerships, which are key to facilitating health.

Working as a GP is fascinating, challenging (intellectually and otherwise) but most importantly it’s a privilege. So to return to the question I was posed, why on earth would you want to be a GP, my answer is, why ever not?!

Aarti Bansal, GP and Academic, Sheffield 

  1. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health.The Milbank Quarterly. 2005;83(3):457-502.
  2. World Health Organization. Ottawa charter for health promotion. 1986.
  3. Huber M et al. How should we define health? BMJ,2011; 343:
  4. Getz L, Kirkengen AL, Ulvestad E. The human biology – saturated with experience.Tidsskr Nor Legeforen.2011;131:683–68
  5. Holt-Lunstad, Julianne, Timothy B. Smith, and J. Bradley Layton. “Social relationships and mortality risk: a meta-analytic review.”PLoS medicine7.7 (2010): 859

 

The future of the NHS is in GP – Areeb Mazhar

areebGP recruitment is in a crisis. And although the headlines are doing plenty to inform us of the crisis, they are also deterring future students from this hidden gem of a specialty. So it’s more important now than ever, that we share our reasons and motivations on what draws us towards general practice and why medical students should consider it as a career option!

I remember sitting through a public health lecture given by a pair of enthusiastic GPs in my first year. At the end of the session, they curiously asked which of us were considering general practice as a career option. I feebly put my hand up and so did someone else; only two students in a lecture theatre full of 240 students. So, why did I raise my hand?

During my time on the wards, I’ve realised that I wasn’t fascinated by rare medical conditions or special surgical techniques.

What really excited me was the background of the patient, the stories they had to tell me and how grateful they were that someone wanted to listen to them. Without doubt, the medicine still interests me, but I would pick an interesting person over an interesting medical condition every time.

Often in medicine, we sometimes become so laser-focused on the medical aspect of patient care, we forget that we are treating a person. General practice emphasises a holistic approach to the patient; an approach that makes a patient feel like a person. I want to be able to comfort the elderly man who has been diagnosed with prostate cancer two weeks ago or reassure the anxious mother that the rash on her son’s face is not serious. Being in such a position to build long-term rapport and a relationship with a patient would be a privilege.

GPs are at the frontline of medicine and are the first point of contact for many patients. The truly challenging aspect of general practice, in my opinion, is that anything and everything can walk through the consultation room. door

The modern GP must be able to differentiate the child presenting with a headache due to the common cold, from the similar presenting child that may have life-threatening meningitis. This difficulty in taking a comprehensive history and examination in a short time period, without any advanced scans and investigations and using this information to come to a diagnosis appeals to me. It is medicine in its purest form. The incredible variety of medical conditions and patient demographics is not found in any other specialty of medicine.

If those GPs asked our year group the same question today, I’d hope there would be more hands raised. I would hope that our journey through medical school so far has broken down some of the misconceptions and stereotypes attributed to general practice. Not only do I want to be a GP, I want to be involved in recruiting the next generation of GPs and showing medical students the positive light of general practice.

I genuinely believe that the future of the NHS is in general practice; I want to be part of that future.

Areeb Mazhar, Medical Student, Sheffield

The Old Lady Wakes Up – Ben Jackson

dr_ben_jacksonThe old lady had broken her hip and had some sort of reaction to the prosthesis they had used to fix it. Sadly she had also suffered one or two small strokes that had meant that her stay in hospital had been longer than she’d hoped for. In the end it had been decided that she would be better off moving in with her Daughter and family in Sheffield. She spent most of her time in bed but her grandchildren would sometimes visit after school and sit for a while, though they never stayed for very long as she was always tired and couldn’t follow the conversation well.

Eventually a different, local doctor started to visit her. When he asked about the pictures on the wall, he learned what she really loved to do was to paint. Another time he heard her mention something about birdsong and soon understood that she had never minded her insomnia (and indeed thought it a blessing) as her favourite thing of all was to watch the day begin through the bedroom window. He recognised that she still had a lot to live for, and started to gradually withdraw some of the medication she’d been on since she had been ill.

It was then my Grandmother seemed to wake up. Soon she got out of bed, then eventually out of the house. Though she never went home, she did become a member of the village arts group and started to paint again. More importantly for me, the bedrooms she now permanently occupied in the house became my first point of call after school – where there was always a cup of tea, a piece of cake and a smile. By then I’d decided I wasn’t going to be an engineer after all, but a General Practitioner.

Ben Jackson, GP, Doncaster

 

How about #whyacademicGP by Dr Kamal R Mahtani

Kamal Mahtani

My mother tells me that it was from the age of about eight that I first said “I want to be a doctor!” Apparently it coincided with me getting my first toy doctors kit. This consisted of a plastic stethoscope (naturally), ophthalmoscope (for looking up my brother’s nose), syringe (to “give medicine”), clipboard (to take notes once I had “give medicine”) and a hammer (um…to repair Dad’s shed? – only recently realising this was for tendons). Unfortunately it was my younger brother who took the brunt of my first experimental steps as a (very very) junior doctor, with weekly laparotomies on his tummy that were closed with an Elastoplast or two.

By the time I was 13 I started to really appreciate the wonder of science and it wasn’t that long before I proclaimed I would one day “find a cure for cancer”. Well unfortunately I haven’t found the cure for cancer (although I have a much better understanding of the disease), but looking back I now realise that the idea of doing research in medicine, then applying it to patients made so much sense to me, and a seed had been sown.

So you want to be an academic?

My route to a becoming a clinical academic began a little more unusually in that I was already a postgraduate (having done a BSc and PhD in basic sciences) before I entered medical school. Although I knew I wanted to remain academic, I wasn’t sure in which clinical field. However, for me it became crystal clear which medical speciality I wanted to dedicate my career to once I had done my first month-long placement as a fourth year medical student: it had to be general practice.

As Iona Heath said in her monograph – “The Mystery of General Practice”:

“Each person and each context is unique and this is the joy and the challenge of general practitioner care”.

Despite dabbling with thoughts about being a gastroenterologist or a paediatrician, I couldn’t get away from the appeal of being a generalist. Providing long-term continuing care to my patients at all levels, where every encounter was unique.

The desire to be academic didn’t dessert and it soon dawned on me that being a generalist and an academic seemed even more appealing. I increasingly started appreciating the vast amounts of uncertainty and unanswered questions in general practice. So, I wanted to find the most relevant unanswered questions and provide my patients with the answers.

Why is academic GP so important?

Innovation and clinical research can improve the care and services we provide to patients in primary care.   As a marker of this the RCGP have a dedicated team and network to drive this forward. Recognising the importance and growth of academic general practice and primary care research in the UK, the research arm of the NHS, the National Institute for Health Research (NIHR), have committed a further £30 million over the next 5 years to the School for Primary Care Research, to build capacity and capability in the field.

Key to this NHS commitment is the recruitment and retention of innovative and forward thinking academic GPs. A recent editorial in the BMJ highlights the invaluable role that academic GPs play, stating: “Academic GPs make an essential contribution to the NHS through education, research, clinical practice, and service development, usually while continuing to provide direct patient care.” Given the widely stated statistic that 90 per cent of patient interaction is with primary care services (mostly general practice) it’s not that surprising to consider GPs as perfectly placed to work with other primary care researchers in identifying and delivering research priorities to improve patient care and service provision.

There are countless examples of impactful research outputs from academic general practitioners working in research teams that have or will lead to patient benefits. Examples of such work has led to a greater understanding of the: benefits of warfarin versus aspirin in preventing stroke, technology needed to support NICE guidelines to limit the use of antibiotics in primary care, interventions to reduce unplanned hospital admissions, programs to reduced domestic violence in general practice, quality of care from NHS primary care services, and ways to evaluate cardiovascular risk in primary care. Academic GPs are even world leaders in teaching us how to read a scientific paper. These are just a handful of examples of the impactful work with which academic GPs have been involved.

Academic GPs are also at the forefront in providing undergraduate medical education within university settings as well as general practice and community attachments. Teaching provides opportunities for professional development, reflective practice and is an asset to many academic departments, with funding streams available to compensate for teaching time. Many GPs already find teaching undergraduates on placements very rewarding as do patients involved with community based teaching. Some academic GPs go on to devote some if not all of their academic time to lead undergraduate teaching. For example some academic GPs take up 50:50 split clinical academic posts within medical schools and provide dedicated teaching and organisation of entire community based undergraduate curriculums. Access into this can be through more formal routes such as undertaking higher degrees in medical education, while for others this happens more organically through their research or independently advertised posts. The types of medical education to get involved with can be as equally diverse as research topics. Some GPs undertake research into medical education and others go on to become supervisors and mentors to primary care researchers undertaking a PhD.

Pathways to academic GP

My pathway to becoming an academic GP began a little unusually, having entered medical school as a biomedical graduate. Nevertheless about 10 years ago more formal training pathways were created that aided my progression and if anything now offer even more opportunities.

The 2005 report of the Academic Careers Sub-Committee of Modernising Medical Careers and the UK Clinical Research Collaboration, chaired by Sir Mark Walport, laid the foundations for medical and dental graduates to have the opportunities to enter into integrated clinical academic careers. As a result academic GP training is supported in England, Scotland, Wales and Northern Ireland.

In England, with the continued support from Health Education England and Department of Health, careers in academic general practice can begin as soon as medical school ends. The UK Foundation Programme Office (UKPFO) provides opportunities for foundation doctors to spend a portion of their FY2 time, usually 3-4 months, in an academic primary care department. A proportion of the week is spent attached to a GP practice seeing patients with a trainer and the remaining time engaging in academic activities within the department. During my FY2 placement, I was able to discuss with my academic GP supervisor a programme that gave me exposure to clinical practice as well as well as support my interests in research, develop medical education skills, conference attendance and networking with other academic GPs.

The integrated clinical academic pathways continue into GP specialist training with the academic clinical fellowships (ACF). In England, these posts, largely supported by the National Institute for Health Research (NIHR), differ from standard ST1 – ST3 training with the addition of an extra year of training. During ST3 and ST4 years GP trainees usually have a 50:50 split between their clinical time in practice and their academic activities. However there is flexibility to provide time in each area as needed. Many of the ACF posts come with support for Masters level training and conference attendance.

Personally this worked really well for me and if anything, spending two years in GP as a specialist trainee, provided me with an opportunity to get to know and look after a cohort of “my patients” for longer – which they appreciated. It also gave me more clinical exposure and time to achieve all my competencies. I also got a much better understanding of the unanswered issues we faced in our doctor-patient relationship. This meant I ended up bringing more ideas to my academic time. I also utilised some of my academic time to gain a postgraduate diploma in health research.

Clinical academic training pathways continue after GP qualification. Many GP ACFs are encouraged to apply for a doctorial fellowship to undertake a PhD (often 4 or 5 years part-time) in a focused area of research or education while maintaining clinical practice. Many of these are supported by funders such as the NIHR, MRC, Wellcome trust and others. Some GPs interested in academia consider In Practice Fellowships upon qualification. These are specifically designed for those with little formal academic training and wish to enter academic GP. For those choosing general practice from another speciality, prospects exist to slot into academic GP training posts at most levels. If the research idea is good, opportunities are certainly there.

Beyond this there are Clinical Lectureships in General Practice, Clinician Scientist, Post-Doctoral, Career Development and Senior Research Fellowships which can all support your academic GP career. Many university departments often show commitments to the most productive academic GPs by offering them Senior Lecturer or Professor posts after this. An outline, and by no way definitive, sketch of the integrated pathways available to prospective academic GPs is shown below.

Challenges of an academic GP

Despite so many opportunities, there are always challenges. One of the more consistent challenges of academic general practice (and one that I still ensure I stay aware of) is being able to get the balance right between your clinical and academic time. This usually first arises during specialist training ensuring that your number one priority is to gain your clinical competencies leading to your MRCGP while secondary priorities include developing your academic skills. My attitude was that I am always first and foremost a GP. Getting the balance right doesn’t go away later on, if anything becomes a greater challenge as your career grows. Your commitment to your patients is balanced with commitments to ensure academic outputs continue, develop new ideas, gain new project funding and in some cases teach as well, make it sometimes feel like a circus-juggling act. In addition, it’s safer not to think that academic GP involves “time off” from the hustle and bustle of clinical practice. All too common you can find yourself under pressure to deliver a program of work, or preparation of teaching material which easily leads to you to be working unsociable hours to complete. That said time in academia can be flexible which can also work well with having a family life. Plus most doctors are fairly resilient and each academic GP finds a way to get the balance right for them, allocating a proportion of their time for each activity in their week.

Conclusion: #whyGP? #whyacademicGP?

So while being an academic GP is not easy (which aspect of being any type of doctor is?) it can complement and support the care of your patients, be intellectually challenging, stimulating and rewarding (occasionally all at the same time), provide added diversity, build skills in leadership, create added networks and lead to a long term and successful portfolio career.

In a purely self-indulgent way (if you will forgive me), I can honestly say that I love being an academic GP – and here is why. Whether I’m seeing my patients in an inner city GP practice, completing research projects that become part of guidance, supporting the priority of primary care research for the NHS, providing commentary on research, working with current and future leaders in my field or teaching here and abroad – the week is never dull and I feel I’m a better GP for it. My patients seem to like it too, certainly as they have got to know more about what I do outside of practice. Not infrequently do our conversations reflect my academic work and can begin with “so anything new in the world of research then Dr Mahtani?” or better still, in the midst of a shared decision making conversation, they have been known to say “….yes, but what’s the evidence for that?”. It adds a whole new layer to our conversations. Brilliant.

General practice is an amazing vocation and will always need future leaders and innovators. Academic general practice might be the perfect platform to support them.

Try it, I promise you won’t regret it.

Further useful links

 

Mahtani K.R. (2015) #whyGP? How about #whyacademicGP?

 

 

 

 

 

Disclaimer

The views expressed are those of the authors and not necessarily of the any of the institutions mentioned in the article.

Falling in love with GP, Eddy Bridge – Medical Student

Eddy BridgeUntil recently I didn’t want to become a GP. I’ve always assumed general practice lacked excitement and wasn’t intellectually stimulating. However, during my primary care placement, I realised the rewarding aspect of medicine is the privilege of helping others. My time at Friarwood Surgery changed my attitude towards primary care. I now want to become a GP.

Medicine is a science, but being a good doctor involves being able to listen and communicate. I had witnessed how communication failures in hospitals left GPs to console confused or angry patients. I learnt that to take a good history you must understand the patient’s story.

My previous assumptions concerning general practice were completely flawed. How can general practice be intellectually inferior? The varied presentations make diagnoses incredibly difficult. And how can it not be exciting? You literally have no idea what will come through your door. That first consultation builds a relationship that can last until the end of a patient’s life.

General practice is where doctors really help people, by addressing their fears, understanding their beliefs and providing care to suit them.

This is where the real medicine happens and that is why I want to be a GP.