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

 

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