All posts by Samir Dawlatly

BMJ Blog via @bmj_latest: How general do we want general practice to be?

Do GPs and their availability exist for those without medical need? Do they exist for those without medical need, in the hope that a brief interaction will contribute positively to an episode of theoretical future care?

Full article can be accessed here:

http://blogs.bmj.com/bmj/2015/03/26/samir-dawlatly-how-general-do-we-want-general-practice-to-be/

See no evil, hear no evil, speak no evil – of patients

If I am unhappy with my own GP I can take a number of actions. I can complain to the practice manager of my surgery, I can complete a friends and family test, anonymously as well as leaving messages on the NHS Choices website, again anonymously. I can also use social media to talk about my GP, call a newspaper or even lodge a complaint with General Medical Council. One of my own patients has written directly to the Parliamentary Ombudsmen and brings in the acknowledgement slip with her each time she comes in.

That I can’t reveal anything more about her, in an effort to protect her confidentiality illustrates the issues that doctors, including GPs, have in talking about the minority of patients that make their life and work a struggle at times. Reported case studies need patient permission and many bloggers who write in the medical press change the details of patients that are rude, inappropriate or simply daft, in order to protect their identity.

When it comes to the issue of trying to provoke debate about what some patients actually come to the GP about, this issue makes it very hard to know what to do. It seems that GPs are to “See no evil, hear no evil and speak no evil (of)” their patients. The customer, sorry patient, is always right and according to the health secretary knows better than the doctor. How can you compile a record of how the GP system in the UK is, albeit in some cases inadvertently, abused by patients.

Resilent GP debated the posting of the “inappropriate use of GP appointments” survey report. After being posted on the website, it was withdrawn after concerns about whether patients’ confidentiality was being breached. Careful reading of the report will show that this is not the case. It was restored so that healthy debate can continue. The Resilient GP partners have stated publicly that they feel that it is not unethical to raise real life examples of inappropriate appointment use. This is done by the ambulance service..

Although there are concerns that there is no fixed definition of an inappropriate consultation and that “naming and shaming” such inappropriate uses will discourage patients from attending their GP with vague symptoms that could belie some serious cause, I would argue that we don’t seriously think that speaking to your GP about the colour of the fluff you find in your belly button (true story) or any of the “symptoms” listed in the survey could result in a medical diagnosis other than health anxiety. Furthermore, by educating patients not to use up appointments with such things we may actually improve access for those that actually need it, for their serious, even life threatening conditions. Therefore, in order to improve access for patients in need, we need to first identify and discuss the problem of inappropriate GP appointment use, then decide how this problem should be tackled by the general practice, public health authorities and society as a whole.

Parasitic symbiosis

Patients need doctors. Doctors need patients. There is, in fact, a two-way relationship between the two groups. The more obvious aspect is the fact that patients need doctors. Patients need doctors to diagnose, advise, prescribe and reassure. There are other facets of this aspect of the patient-doctor dynamic, of course.

Mistletoe on an overhanging tree branch

Perhaps more interestingly is the recognition that doctors need patients. Firstly, we need patients to give us a purpose. I would not be a GP unless there were patients needing a general medical service in the area. Without the need there is simply no job, without the demand there is no need to offer and be paid for a supply. The job in itself, also offers satisfaction and fulfilment as one can feel that a difference is being made, however small, and that the world might be made a better place as a result of the work that we do. I would argue that patients give us that feedback verbally, non-verbally, consciously and unconsciously by trusting us with their secrets, hopes and fears.

Issues arise, however when doctors, for whatever reason, develop a psychological dependence on being needed and liked by their patients. This may be due to lack of meaning or fulfilment in other aspects of their life, or because of underlying psychological issues. The consequences of this can be damaging both to the healthcare system as a whole and to both the patient and doctor. What happens is that doctors make decisions in order to please their patients, not because of what is correct, leading to inappropriate treatments, investigations and referrals.

In an ideal world, however, the dynamic relationship between a doctor and his patient is symbiotic. Many GPs work with the same group of patients for many years and so this relationship can be long lasting. The doctor gives the patient what he/she needs and the patient, usually unknowingly reciprocates.

As with an overly needy doctor, the patient too can upset the dynamic when they are parasitic, sucking the lifeblood out of the doctor, constantly drawing upon the doctor to make them feel better. I would also hazard a guess that most of these types of patients would have psychological pathologies that some would categorise as personality disorders. As doctors we have all met patients who have manipulated our emotions to make us feel bad and themselves a little better.

It is important, therefore, to recognise that one (or one’s colleagues) can fall into the trap of wanting too much to be liked by patients. Furthermore, a number of patients are emotionally parasitic, and need dealing with as we would deal with any parasite; we need to protect ourselves from them and even consider treating and/or distancing ourselves to ensure that we don’t become infested by their life-sucking behaviour.

Access is key

At a friend’s surgery a number of things were conspiring to restrict the appointment availability. One part time doctor had gone off on maternity leave, a partner was on sabbatical, they were trying to recruit an additional nurse and they had just switched to a new computer system as the old one was about to become obsolete.*

As a result the receptionists and doctors were having to constantly apologise for the lack of availability or routine appointments. There were posters and messages on WellTV in the waiting room.

I couldn’t help saying to him, “Well why don’t you send out a letter, or put up a poster for your patients saying something like, ‘Thank you to our valued customers, patients for putting up with us through this difficult time. By way of thanks we would like to offer you a free appointment with your doctor of choice. To claim your free appointment simply call or speak to reception  and use the bonus phrase, “Yes, I really feel that I need to be seen today”’, or whatever?”

He looked at me, and I winked mischievously.

On a serious note, the current deal that the British public have with access to general practice is amazingly good. It is taken for granted that one can speak or see a doctor at your own GP surgery, free of charge, at almost any time during the working week. There are ways around every appointment system and GPs are aware of the patients that can make it suit them.

The fundamental problem with having access to general practice free at the point of delivery is that it has the potential to lead to infinite demand. This in turn leads to rationing, whether it is called rationing or efficiency savings. Access is in fact the gateway, or bottleneck, between demand and healthcare services.

Bizarrely, the government response to rising demand is not to commission research to investigate why demand is so high and how it can be managed, but to foment consumerism in healthcare and match access to demand. The logical conclusion to be drawn from this is that infinite demand will lead to infinitely easy access – not just 12 hours per day, seven days a week, but 24 hours a day, every day of the year via face-to-face consultations, telephone, text, email and Skype.

At present access is a flimsy gate held in place with rusty nails in rotten wood. In order to preserve British general practice in some functional form, then either demand has to managed and curtailed or a stronger, more robust gate is needed.

This is imperative. And yet none of the political parties in the UK are bold enough – or even see the need – to manage demand for healthcare.

Society must support GPs to find and implement solutions.

*this situation is fictional