“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

 

 

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

My protector when I needed protecting. A #mygreatGP story

Hi, I am not a doctor – in fact I am a long term patient, being diagnosed with depression one year ago.

My GP at my local surgery is amazing. She saved my life – probably literally as you never know where you might end up when your in the dark tunnel on your own. But also my career, my marriage, the relationship I have with my children.

The more I look back, the more I realise how ill I was. I didn’t see that at the time, she did. Her expertise as a practitioner, her care and how she has supported me throughout my treatment has, one year later, left me feeling empowered and increasingly independent in managing my own care. She will always say it was my hard work, but it wasn’t – it was team work, her ability to move between knowing when I needed her to take charge of my care and when I was ready to take responsibility.

She was my coach when I needed a coach, and my protector when I needed protecting.

When I was having a very very very big wobble (found a lump, not a great thing for someone with high anxiety!!) I know she pulled rabbits out the hat to get the results back to me so I was reassured and OK!

Yesterday, I found out she is moving and we discussed how my old career (teaching) and her career can only become manageable by having multiple responsibilities and not just working full time in one career.

OK so frankly, I’m gutted. Not for me (well, that’s a lie, I am – I was looking forward to the day we could decide together I didn’t need the pills anymore). But frankly her care saved my life, and the way the career now is, she feels that being a full time GP is unsustainable.

So, as a result, there might be another mid 20s male who cannot cope…or 30 year old mum, or 16 year old teenager….and they wont get the treatment I get. Because more and more GPs, and totally understandably, find full time GP an unsustainable career. This makes me sad and angry. I come from education where we are loosing talent by the buckets every year, and thats bad enough, but loosing talent in medicine means this – more people will die, or continue to fight long term conditions on their own.

My GP saved my life and we need more like her to save others.

Neil Gilbride
A patient

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