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 After being posted on the website, it was withdrawn after concerns about whether patients’ confidentiality was being breached.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.

7 thoughts on “See no evil, hear no evil, speak no evil – of patients

  1. What is the main reason for GPs feeling increasingly under pressure? It seems that Resilient GP has decided to target ‘inappropriate’ GP use by patients. And in an attempt to define what inappropriate GP use they have asked GPs to report the weirdest and wackiest reasons that patients have ever seen them.
    Is this a useful exercise? Does it help us to think about how to deliver sustainable healthcare? I don’t think so.
    Thank you for the open platform that allows me to comment here.

    1. Thanks Anne-Marie for your comment and contributing to the debate.

      Trying to answer your questions, for what it’s worth (as I don’t see my opinion as being any better or more correct than anyone else):
      – What is the main reason for GPs feeling increasingly under pressure?
      Multifactorial. I think inappropriate use of GPs is a reflection of the rising demand for health care and in particular primary care. The reasons are complex. It has not been “targeted” by Resilient GP – they do other work and have other publications and discussions on other factors influencing resilience, including developing personal resilience and making sure that local systems foster resilience as well. The survey just happened to “go viral”.

      Is this a useful exercise?
      If it has sparked a debate about the finite resources available and the consequences of whether this country wants unlimited access to GPs for both medical and non-medical reasons then funding and resources need to reflect that.

      Does it help us to think about how to deliver sustainable healthcare?
      Really good question – as above – I would see the survey as a starting point for a debate as the organisations that purport to respresent GPs are not addressing this issue.

      Some more thoughts on the issue are coming out soon on BMJ Blogs.

      Take care

  2. Resilient GP post

    I’m interested in the justification you’ve used for the ethics, “this is done by the ambulance service..” A better justification might be for you to publish your thoughts about what risks or harms might have arisen and what steps you took to avoid them. In any study an ethical consideration is, ‘could we have achieved our stated aims in a less intrusive, less risky way?’

    General practice is faced with patients who have ‘health anxiety’ (as you put it) all the time. There is a considerable literature about this going back about 100 years. Michael Balint had a lot to say about it in the late 1950’s and there are Balint groups and academic papers still being written about it today. If ‘educating patients’ was an effective intervention, the literature, along with Balint groups would probably have dried up about 80 years ago.

    Feeling frustrated by, irritated by and hating patients are part and parcel of any healthcare professionals’ life (myself included) I remember feeling ashamed at having these feelings and being afraid to mention them for fear of what my older, wiser, more compassionate colleagues might think. Some people have these kinds of thoughts more than others, but knowing that they are normal and that we all get them from time-to-time, is deeply helpful and undoubtedly contributes to the resilience we all desperately need. I’m with the Fat Man though, quoted at the beginning of Wear’s classic paper:

    “You can’t make our jokes with the ones outside all this… Some jokes have to be kept private, Basch. You think parents want to hear schoolteachers make fun of their kids?” House of God. Samuel Shem.

    Wear’s paper on the use of cynical and derogatory humour (which, to be clear, you have not used) shows that doctors and medical students have very different attitudes to what is and what is not acceptable to say about patients. And in a public forum, what patients might think about what doctors say about patients is extremely important too. It’s entirely predictable that not only will a lot of doctors (and probably patients) agree with your sentiments, but also that many will be upset by what you’ve said and concerned that you’ve provided so many examples with so little context or analysis.

    I’ve not taken your blog at face value, but rather think that it is symbolic of GPs (myself included) feeling unable to cope. I worked an extra unpaid session yesterday morning to do home visits and catch up on paperwork then worked an afternoon surgery which over-ran by 45 minutes, then had to phone 20 patients and then go to an evening meeting about the out of hours service. I got home shortly before 10. My feverish son was in my bed and I barely slept because of him and my own sore throat. A lot, perhaps the majority of GPs are working like this. As I read it, your blog is a kind of catharsis or a cry for help. We don’t take patients’ symptoms at face value, but consider the bio-psycho-social-biographical contexts into account in order to figure out what the symptoms represent. In the 15 years I’ve been a GP and 20 years I’ve been a doctor, patients have always come in with demands that appear on face-value to be inappropriate, but on closer examination represent underlying anxiety, isolation, fear, resentment etc. which in turn are driven by factors out of our control. in an age of austerity it’s very likely patient anxiety and demands on GPs will increase. We will need better ways than this to raise awareness of the issues, forge better relationships with patients, support one-another and enable resilience.

    1. Hi Jonathon

      Hope both you and your son are feeling better?

      Many thanks for your thoughtful comments. Good question about could we have done this another way? (I use the royal we as I am only a member of ResilientGP and not all members of the Facebook group agree in the publication of the survey, it is fair to say). I don’t know is the answer. We could have simply collated all the Copperfield examples over the last 20 years? I don’t think it was expected to get as much attention as it has.

      The survey results were not deliberately written up in a style to be provocative or mocking. It was deliberately written in a very “matter of fact” – perhaps the judgements about the tone have been made before people read it? Most of the list is quotes from patients, the reader can make their own judgements. But I suppose inevitably it would seem we were mocking patients – this was not the intention, if you read this particular part of the introduction (not written by me):

      “The real danger is that if NHS time is taken up dealing with matters that could be dealt with by someone else, the ill will find it harder to access the medical treatment they need that only doctors can provide. This important concept is known as “opportunity cost”.

      We have latterly been raising this issue in public and been met with bemusement by those who never face (or acknowledge) the demands that are presented to GPs on a daily basis.

      The conventional response by GPs to such requests is to seek to understand and even sometimes address what lies behind such enquiries, whether it be inadequate education or family support, concealed anxiety about a possibly underlying health condition, poverty or simply the need for an advocate.

      In the face of unprecedented demand for NHS services in general and the skills of GPs in particular, it is now time to ask whether General Practice is being used appropriately, or whether society could meet some of the needs a GP routinely encounters without recourse to the NHS.”

      I would have to ask the author if there was a deliberate attempt to be humorous/derogatory. I think we all find it uncomfortable to tell a patient, “You didn’t really need to see me today, did you.”

      I find the issue of “health anxiety” fascinating and hope to understand it more. I have written recently in the BMJ Blog site about this.

      I think you are right to not to take the blog at face value and that it is symptomatic of how some GPs feel about the job, with pressure from the government, CCG, CQC, GMC, RCGP, accountants and public. Patient demand and what feeds it is only a small part of what ResilientGP is about, as I have said to Anne Marie above.

      Lastly, I understand fully the theory about whether the “trivial” or inappropriate consultation is important in the grand scheme of the doctor-patient relationship. Perhaps it is, perhaps the patient needs to come to see you about something unimportant to feel they could talk to you about any future embarrassing symptom. I understand that theory, but it depends on continuity of care, which may exist in some surgeries, but not for others. Continuity of record, but urgency of demand and doctor unavailability often means continuity of relationship is difficult. Therefore the value of “Discovered xiphisternum, reassured” is much less these days, I would guess? Furthermore, as alluded to above and by yourself the days when a GP could go home at lunch to walk the dogs are long gone. There are lots of demands on our time and feeling as though our time is “wasted” (a term I use reservedly) is frustrating. Perhaps we should view these types of appointments in the same way that we view DNAs – though I expect we would have a similarly wide range of responses.

      To me, the crux of the matter is whether the NHS is willing to fund the number of GP appointments to continue to see patients free at the point of care for absolutely anything, no matter the opportunity cost.

      Good to hear from you and thanks for taking the time to contribute.

      Get well soon.

      Sam

  3. You haven’t articulated what it is you want to achieve with this list.

    If it is, ‘we want people to know about the kinds of inappropriate things patients ask us,’ then I think you’ve succeeded. But it’s not new as Anne-Marie has shown with this paper from 1979 http://onlinelibrary.wiley.com/doi/10.1111/1467-9566.ep11006793/pdf There are others, e.g. this from 1978 http://peds.stanford.edu/Rotations/humanism_small_groups/documents/3_takingcareofthehatefulpt.pdf

    If you want to show the pressures that GPs are under then there is useful work such as this from Deborah Swinglehurst lookin at the impact of electronic templates: http://bmjopen.bmj.com/content/2/6/e001754.full Then there’s appraisals, revalidation, QoF etc. as you say.

    The questions then include, ‘why do patients consult for these reasons?’ I have a friend who gave up General Practice because he was ‘fed up with trivia’ in 1989. I met doctors with MSF in Afghanistan in 2003 who were running away from ‘trivia’ in the NHS, only to discover that 50% of patients there had medically unexplained symptoms. You cannot run away from patients like this (to NZ) like one of your founder members. You have to find better ways of dealing with them.

    The question then is, ‘what can we do for (or about) patients who consult for these reasons? I would suggest (as I did earlier) that ‘educating patients’ has not worked. And it won’t work, because the answer to the question ‘why do they consult us?’ isn’t ‘because they’re uneducated’. Continuity helps (in my experience) e.g. https://abetternhs.wordpress.com/2014/09/24/patient-reassured/ and in a practice with 12 part-time doctors and 13000 patients and a list turnover of about 12-30% per year we have achieved 80% of all consultations between patients and their usual doctor. It was hard work, moving from 50% two years ago, but we did it. There are many other approaches, too many to list here, but a quite radical one that interests me is using Community Health Workers who can provide personal support, education, preventive care and more: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3681592/

    Thanks for debating and for moving the debate on,
    Jonathon

    1. Hi again Jonathon

      Why was the survey conducted? Very good question. Apologies for not addressing it earlier. It was felt by ResilientGP (I am making presumptions as I am not their spokesman) that the issue of patient demand was not being addressed by groups such as the RCGP, BMA and NHSE. When Jeremy Hunt was asked directly what his response to the “elephant in the room” of rising patient demand at the RCGP Conference in Liverpool, October 2014, his response was that there would be more GPs and more appointments available for more of the time. This just doesn’t seem sensible or sustainable, especially in an atmospher of austerity and efficiency savings.

      I for one was unaware of the to research you have highlighted. The references are useful thanks.

      As ResilientGP was gaining momentum and exposure at events such as Pulse Live and invitations to media functions it was felt that it would be helpful to have a current illustration, beyond the odd anecdote, of the frustration felt by doctors having to deal with anything that could come through the door. As I said previously, it was not expected to go viral, at all.

      What is more difficult to work out is why patient demand appears to have increased. Certainly many non-patient factors (e.g. QoF for instance) are responsible for creating and fueling demand. As I said previously health anxiety is fascinating and multi-faceted with aspects related to fear of cancer, risk assessment, cancer screening, mass media, breakdown of social cohesion and support structures…

      As I have tried to stress, perhaps not strongly enough, the main emphasis of ResilientGP is “to stand up for General Practice”. Pointing out examples of inappropriate patient use of primary care services is a actually a very small part of that, in my opinion. The other factors contributing to the atmosphere in general practice you allude to are important.

      My hope is that the opportunity cost of inappropriate appointments can be discussed and debated, as can the dilemma over whether the risks of placing barriers to primary care (in order to reduce inappropriate appts and DNAs) are outweighed by the benefits of a system that serves patients on the basis of need and not want (though I admit differentiating between the two is tricky, to say the least.) I also see it part of a wider frank discussion and debate about the state of General Practice and whether it is sustainable at present. I guess ResilientGP, its founders and members want to be a voice that is heard in that debate. Now we have had a bit of limelight, hopefully we’ll continue to have that opportunity.

      Sometimes publicity is best generated with controversy. Only time will tell if the ends justify the means.

      My latest blog on BMJ blogs explores some of these themes, but I don’t tend to get many comments there:
      http://blogs.bmj.com/bmj/2015/03/26/samir-dawlatly-how-general-do-we-want-general-practice-to-be/

      EDIT
      meant to add, well done on your continuity. With the advent of 8-8, 7/7 working do you see maintaining that being possible?

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