“Please, you help me? You help my wife?”

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I had a bit of an epiphany recently. In fact, let us call it a rejuvenating time in my career.

One of my patients had come to the front desk asking for help. He was desperate. He said his wife was very ill. The last three nights they had been to the emergency department and  sent her home with some anti-reflux medication. He wasn’t convinced. He said she was worse. Now – with no appointments available – he wanted us to do something.

He saw me from the corner of his eye whilst I handed some administrative chaos to the staff. He caught me and said “Please, you help me. You help my wife?”

Guess what? I was due home three hours ago.

I started to have a momentary cognitive ethical dilemma: home to my family or see this chap’s wife? I told him to bring her now. He went home and came back immediately, some 45 minutes later.

She was very ill, pale as a ghost. I did all the vitals and examined her, realising she was in septic shock. I had to bring in the Resus trolley and call for help. After two hours she was admitted to the nearest hospital in their ITU, where she was kept for over two weeks.

There’s no blame at the moment – just momentary stressful chaos. Targets have come before patients and so she was tossed from pillar to post. At least that’s how they felt.

Two weeks, four additional medications, one stoma bag and two surgeries later, this lady found herself at home with no care package. What now? The NHS is just about managing in my part of town, and social work is at the brink of dangerous decision-making. We are overwhelmed.

The husband attended my clinic a few days later. I managed to sort out (with help) a care package for the lady.

He comes straight for me, cries, hugs and then kisses me once on each cheek. His Arab culture took the better of my western professional boundaries. Truth is, just for a moment I embraced the hug and his culture.

Just those few seconds meant the world. It meant I could work for a few more years without needing any thanks, any gratitude or any welcome. Although I wouldn’t say no if someone wanted to!

I’ve got used to not being thanked.

We very often forget the reason we have been working. For me, it’s to manage a good nights sleep, knowing that I’ve done something worthwhile. Quite difficult, but sounds so simple.

It has been tough over the years, going from one career to another,  yet the hardest time has been in General Practice. I feel like I’m playing catch up. People used to say, “it’s really great in general practice, you get to follow the patient through a journey.” So why don’t I feel the greatness at times? The journey comes with endless bureaucratic administrative burden…that’s why!

Seldom do we get a ‘pat on the back’ in the NHS. In fact, we don’t. Times have changed and we are being reminded to do that to our juniors, even if no one bothers to do it for us.

It’s not right and I now look to thank my trainees, patients, carers and the multi-disciplinary team I work with. All of them are doing a very difficult job and struggling to cope. I thank them all.

We all need to be embraced and recognized every now and then. If it wasn’t for this job and its continuity I would’ve never have seen the patient again, and would not have been able to help them, and I would not have known what happened.

He would not have returned and I would not have felt supported. Or had my thanks.

Dr Mateen Jiwani
Clinical Lead GP
West London
NIHR CLAHRC fellow

Why Deep End GP?

a1BRdJKuAt a careers event, I was once asked what my most satisfying case was from my time in GP. Several sprang to mind: a few “clever” diagnoses, people I’d helped through
depression, patients, and families I’d helped through a diagnosis of cancer, their treatment and toward a good death. But one particular case from recent memory sprang to mind. Between the GPs and the local hospice team, we had guided a young Slovakian man who lived in a terraced house with 15 other family members through his oncology and then end-of-life care for metastatic cancer.

Here was a desperately poor man in a desperate situation right on the margins of society who had been given the best medical care possible and permitted to die comfortably with his family around him. This was the civilising force of the NHS demonstrated in all its wonder.

Although working in a poorer area can be tough – higher consultation rates, more mental illness, earlier onset of multimorbidity, more social complexity – you get out what you put in. It constantly amazes me how those with very little often show the most gratitude for our meagre offerings. Whilst GPs working in so-called “deep end” areas struggle with stress and burnout, they are a motivated, kind, positive, caring and passionate group who demonstrate great respect for their patients and real intellectual engagement with their work. They make wonderful and inspiring colleagues.

Deep End GPs care for the people who slip through the cracks in society: the young with multi-morbidity who do not fit neatly into a single organ system of hospital specialism and who are not old enough to meet a geriatrician; the disabled caught in the poverty trap; the alcoholics with severe depression who cannot get help from the mental health team due to their ‘dual diagnosis’; the young frazzled single mums for whom getting through each day is a miraculous piece of survival; the working poor who lead sicker shorter lives merely as a result of being born in the wrong place at the wrong time; the multitude suffering from illness due to loneliness, addiction or the after effects of abuse; and the millions who don’t have access to the healthcare they need thanks to the Inverse Care Law. Making a small difference to these problems or offering small kindnesses can have a massive impact.

Deep End GPs see lots of pathology and lots of people needing real help.

If you are looking for a cause to devote a career to, you would struggle to think of one that is more worthy or interesting.

And right now is a great time to be involved. Teams of GPs are coming together to provide specialist inclusion health services (see the Faculty of Inclusion Health), highlight the problems faced by deep end GPs (see Deep End Glasgow and the recently formed Yorkshire and Humber Deep End group), create educational and service partnerships to provide help and advocacy those most in need (see Partnership for Health Equity) and forcefully lobby for equitable funding of primary care (see the Tower Hamlets Save our Surgeries Campaign).

Unconditional, continuous, personal care provided for all patients whatever the problems they are faced with is the essence of UK primary care. Come and join us at the deep end and help deliver healthcare and humanity to people who would otherwise be drowning. Help send a message: that all lives are equally worthwhile and that the basic humanity that underpins the NHS remains intact.

Tom Ratcliffe is a GP in West Yorkshire and a founder and driving force behind Yorkshire and the Humber Deep End GP. 

Lauren and Bill’s positive story of leadership

IMG_0920This is the story of a GP registrar (Lauren) her trainer (Bill) and their quality improvement project for general practice. Most registrars pick an audit for their quality improvement work, but Lauren chose a leadership project instead.

Not all GPs feel comfortable with the ‘L’ word, but Lauren and I both agreed that when we work in practices or wards that are well led, everyone benefits: the staff that work there and the patients they looked after.

We began exploring the skills you need to be a good leader. We were not thinking Churchill or Shackelton. We didn’t need to be standout or charismatic leaders. Instead, we thought simple attributes like communication skills, empathy, humility, being able to negotiate a shared vision and having a degree of staying power were all helpful.

More than anything, we agreed we preferred to be led by those who are good with people, and so when it’s our turn to lead, we have to be good with people too.

We asked ourselves, how can we turn our conversations about leadership into a concrete project? Lauren had the great idea of creating a profile book: a resource to acknowledge the achievements and accomplishments of colleagues in the practice. It’s essentially a book of headshots and condensed C.V.s. It’s a great resource for GP registrars and other new starters to the practice. It helps them quickly discover who’s who and guides them to the right doctor to approach if they want some more specialist clinical advice. Or some career advice for that matter. It’s a real people project and that is one of its greatest strengths.

An immediate benefit of writing this book was the recognition of the talent we have in our practice. There were so many impressive C.V.s; so many additional qualifications; such a variety of expertise and experience. The profile book helps us not take or colleagues for granted. That’s important. We should celebrate our achievements in general practice!

A longer-term benefit is that new starters in the practice will feel more quickly welcomed into our working community. We hope it will assist in a cultural shift, encouraging registrars to network with the wider community of doctors in the surgery. This is how we hope the profile book will make a difference, a change for the better. And good leadership is all about driving changes for improvement.

Key institutions, like the RCGP, are talking more and more about clinical leadership. But it’s easy for leadership to be left as an abstract idea. That’s why we wanted to come up with a concrete initiative like the profile book. It has been a really positive quality improvement project for us. We have enjoyed working on it and have heard nothing but warm and grateful feedback from our colleagues in the practice. For Lauren, this was a more engaging project than the typical audit. Lauren has led it brilliantly.

We would encourage all GP registrars to think about a leadership project and all GPs to consider how good leadership can further improve their working lives.

General practice needs good leaders, and there is no better way to develop your skills than to get involved with leadership projects!

Lauren Roberts & Bill Laughey