Monday, December 11, 2006

An open letter thingy

This comes from a few things that happened last week, kicked off by the trip down memory lane in my last post. Seeing an old flat mate who now is a GP in the Wild West of England it soon became apparent that though we are separated by more than 100 miles of geography and at least three variations in dialect, the jobs we do are essentially interchangable, and all the pressures and changes wrought on us here in Ambridge are mirrored in his neck of the woods.

Then again, on Thursday last, two colleagues and myself met up on the home-from-school run since we each have a half day. Between us we could muster more than seven decades of accumulated GP experience, and again it was interesting to see how similar our experiences were despite being in one inner city, one leafy suburban and one far more rural practice.

Also mid-week our newly elevated senior partner was bemoaning how stressful he feels the job is becoming. As he pointed out, with the trend to ever greater sub-specialization in hospital practice, secondary care medicine has become increasingly "routine" for much of the time with teams of doctors knowing more and more about smaller and samller areas of expertise, but leaving the patient as a whole somewhat in limbo whilst they ponder all the implications of a given condition on their one tiny area of interest-- and as often as not quickly discarding them when it became aparent that there was none...

The final thing that crystallized this post was the realization (epiphany being far too grand a word for the accompanying sentiment) that we were all, severally, a bunch of miserable gits, old before our time. So I have a question to pose, but before I do I want to set the scene.

As jobbing GPs we have always been taught to look at the whole person and not just the initial symptom presented. To use a seemingly banal analogy the consultation of a mother bringing a child with a sore throat will play very differently if the mother is 16 than if she is 36, if an older sibling has died of flu, or suffered with leukaemia, if granny lives two doors down the road or (as is more often the case these days) in Spain, if the child in question lives in a mansion or a refuge and so on and so forth.

Embedded as we are in the community, with a longitudinal view of patients and their families, the surrounding communities, cultures,and prevailing conditions, we feel excellently placed to take such matters into account and deliver the best care to every patient that presents to us. And yet, down the years we have steadily seen that embedded experience diluted, first by combining together to provide out of hours cover from co-operatives, then by loosing it altogether to faceless monoliths supplied by PCTs. There has also been a trend to sub-specialization within General Practice so that patients are increasingly filtered into little mini clinics for asthma, heart disease, warts, family planning..... you get the picture.

I would still argue that our attempts to hang on to the last vestiges of "family practice" can make us more effective in the long term. By "being there" through the minor ailments of childhood, through adolescence, childbirth, chronic disease and even palliative and terminal care we develop relationships with families that allow us to view them in the context of their "back story" and them to see us against the background of our shared triumphs and adversities.

This is the "added value" of traditional "General Practice". The perceived wisdom from on high is that this "value" does not stack up against the consumerist agenda of instant access, speedy treatment, and "quality" measured as tick box questions about smoking and ethnicity for all and registers of obesity with no evidence based intervention to apply once the registers are gathered. If it can't be counted, the present regime wants nothing to do with it. And if you have to wait for it then it must be a poor service that is being delivered. All that's needed, they contend, is IT access and a "Doc-in-a-box" available 24/7.

So the question is this, are we right to assert the values of "traditional family practice" or should we just get over ourselves and embrace the brave new world?


Breath said...

Excellent piece, however, I feel that in the elegiac tone you have answered your own question.

I am fascinated by the cognitive dissonance between the rhetoric of community matrons, community hospitals, health management in the community (even down to the recent proclamations about GPs managing ectopic pregnancies and minor surgeries) and the micro-management that health professionals have to endure.

It is especially odd that there is all this emphasis on equipping GPs with all sorts of special interests from surgery through to respiratory illnesses yet you are being instructed to administer tick box medicine and substitute guidelines for your own judgment.

Ironically, in the understandable emphasis on EBM, there seems to be no way of assessing the true value of the continuity of care, family/community knowledge of a GP. There are no papers that can attest to its value.

Regards - Shinga

Z said...

Of course, once 'traditional General Practice' has virtually disappeared, it will be rediscovered as the great new thing. And many people will be paid (I nearly wrote 'earn' but corrected myself) much money for writing pontificating papers about it.

Wendz in France said...

Oh no question. Family Practice is worth fighting for. Wherever I happen to be in the world I always find one doctor I am comfortable with and stick with him/her ..they get to know me and can, as you said, see the whole picture and treat accordingly. I loathe clinics.

And now in France they have this new initiative that we have to choose one primary family doctor and stick with him or we don't get fully refunded by the State for each visit.

potentilla said...

And maybe there's a bit of a compromise, quite likely one that your practice has anyway, particularly about appointments for working people. There are plenty of practices who will only let you book an appointment up to 48 hours ahead or only let you book an appointment by ringing between 8.30 and 9.30 by which time you are late for work anyhow and may not have an appointment to show for it at the end and that assumes you can get through in the first place....and no evening or weekend surgeries.....

The tick boxes and quite likely the whole QoF thing will go away, you just have to sit it out if you can stand it.

Doctor Jest said...

shinga-- thanks for those kind words. the thing is I know what I think is important. it's just that this appears not to chime with the policymakers at the DoH. it strikes me that to them at the moment what we ought to be about is a) prescribing more drugs NICE says we should while simultaneously cutting the drug budget.
b) keeping everyone out of hospital so we can shut them all down (the hospitals that is, not the punters).
c) seeing everyone within 10s of their arival at surgery at whatever time they please and giving them all the time they need for their 13 point list of problems.

Problem is, seeing as it is they that pay us lowly pipers perhaps we should just update our songbooks and get on with it after all.

z-- ooh goody. perhaps I should start lining my self up to contribute a bon mot or two myself.

wendz-- once again I'm very glad to hear you are so well provided for in France. what an enlightened policy, encouraging continuity financially. unless of course that leaves you stuck with some old duffer like me as your GP ;-(

potentilla-- we never did go the "advanced access" route. it is a blatant attempt to make waiting targets unmissable at the cost of being a royal pain in the proverbial for 90% of our "paying" customers. hope we never have to.

thanks to you all for the input.