on using my brain

The Nice Lady Doctor is not feeling very nice today. I am a little bit cross about a fellow medical blogger who reminded me that some colleagues think we GPs practise “dumbed down medicine”. I would challenge any of my readers who think that the work of a GP lacks intellectual stimulation to consider the following:

I have ten minutes to do an entire consultation, and most of the time I have no idea what the patient is going to say when they sit down. I must establish a rapport (easier with some patients than others), take a history whilst simultaneously tying in the current story with what I know of my patient from previous encounters, tune into the patient so that I pick up verbal and non verbal cues, decide whether and what to examine, discover the patient’s own (spoken or unspoken) worries, all the time taking into account the psychosocial factors which put the complaint into context. Once I have gathered enough information to make a working differential diagnosis and decided whether or not further investigations are necessary, I must then explain it all to the patient in a manner that he will understand, preferably also offering him options about what he would like to do in order that he is involved in decisions being made about his own health. This explanation must incorporate what I’ve gleaned about the patient’s own health beliefs, and must also be based on current guidelines with an evidence base if possible and based on a good and thorough understanding of good medical practice. If I have prescribed I try to ensure that the patient takes the medication safely and appropriately. I must then check that the patient and I are both clear about what happens next, and make sure I have a metaphorical safety-net in place so that if I have missed something important or if the patient needs reviewed and followed up, that the patient knows what to look out for and when to come back.

And of course, I’m not doing this knowing that my patients have been pre-sorted into “cardiac patients” or “paediatric patients” – I have to know enough about every speciality and about every age group to be a safe primary care doctor. That means pulling on all my experience, and not only that, having a good understanding of what I don’t know – and enough clinical acumen to know when to refer to secondary care. I must also be prepared to take some risks – I can’t do thorough examinations and full batteries of tests on every patient else the NHS would be swamped, and moreover, it’s simply not necessary (see Dr David Haslam’s wonderfully elegant article on the GP “risk sink”).

Just remember, I have ten minutes to do this, and once the patient has gone I have to do it all over again, another forty or so times a day. Some patients will have more than one problem, some patients will have a complex history, others will be aggressive, or mentally ill, or pregnant, or demented, or very young, or needing an interpreter, or not very bright, or educated and demanding. When I’m not seeing patients in the surgery I’m doing the same thing, but on the telephone without the benefit of being able to examine the patient or pick up non verbal cues. Or perhaps I’m doing it all in someone’s home, with poor lighting and no examination couch or access to notes, and a cat weaving round my ankles.

When I’m not seeing patients, I’m spending time keeping up to date so that I can offer my skills on a background of good up-to-date knowledge, responding to other professionals’ concerns about patients, following up ongoing patient issues by reading correspondence from other medical teams, and signing fifty to a hundred repeat prescriptions (each of which needs to be checked to ensure that I’m prescribing responsibly).

So I’m puzzled that people consider what I do to be somewhat inferior in terms of intellectual rigour. Because it sure doesn’t feel like that from where I am. Maybe when we GPs are doing all that we do, we do it with such a lightness of touch that we make it look easy. It’s the only explanation I can find for the very essence of general practice being so misunderstood.



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14 responses to “on using my brain

  1. ageing student

    I am constantly amazed that any doctor can be expected to make an accurate diagnosis under the conditions that you describe (and which I know are the norm in general practice). I work in finance where I get at least an hour to interview a prospective mortgagor and we never finalise the deal without a second interview to tie up any loose ends. Mind you, our customers often have to wait two weeks or so to get an appointment, which I don’t think would go down too well in your line of business! I guess the time averages out over the course of a surgery session with some patients taking 15 or 20 minutes and some barely five – at least having sat in my doctor’s waiting room recently for over an hour that is the way it seemed to work out. (Why an hour? Apparently the computer malfunctioned and dumped my appointment from his list, but that’s another story.)’

  2. Brett

    Well said, nice-lady-doctor!

    I’m happy in general practice, finding it challenging, tiring, taxing – but definitely stimulating. Yes, some days coughs and colds predominate, but not that often, and my memories of hospital medicine are not of day to day mental stimulation. Another IV on ward 9? Yawn.

    Sadly, such “dumbing down” comments were to be heard in hospitals when I was contemplating a GP career, and obviously they still are today. Sigh.

  3. The Armchair Daddy

    The ‘young irish doctor’ you refer to does not understand General Practice. He or she mentions one of the pros of being a GP is that it is less stressful than hospital! General Practice is easy to perform in a mediocre fashion and extremely challenging to perform well.

  4. This totally sums up what I’ve been trying (and failing) to explain to certain people at my medical school! I made the mistake of saying that I’d consider general practice as a career, not because it’s an easy option but because it seem genuinely interesting and challenging, just in a different way to hospital medicine. Needless to say a crowd of wannabe surgeons etc basically said I was lazy and clearly thinking about it for the easy life… guess they’re the halfwit’s not me.

  5. I have grown up knowing lots of doctors, some who are now in their eighties, some who are around my age (late 50’s) and some who are in their 30’s. All of them have specializations, like gynaecology,surgery, internal medicine , pediatrics and so on. As a rule, I have found that those amongst these that were never averse, and in fact enjoyed being like a GP in various circumstances, were the more capable ones. My gynaecologist is actually my family doctor. She knows us, our systems, our susceptibilities, our family and genetic situations, and does NOT think it beneath her to treat us and many other folks to come to her, male and female. I have discussed this with her (as she is also a friend), and she feels all this enriches her knowledge base and expertise, and she also enjoys the experience.

    So maybe all doctors are not the types who look down on GP’s. I have known superspecialist brilliant medal-winning doctors, who are totally at a loss while communicating with patients. So nobody likes them.

    I would like to congratulate you for doing the GP stuff. This is what is most useful to the general public. Just dont pay any attention to those who called it dumbing down etc. They dont know what they are talking about.

  6. Jambo

    I think your post raises interesting points. A lot of the essential GP skills and competencies you mention (multi-tasking, empathy, rapport building, ICE etc.) fall neatly into the realm of emotional intelligence. These are the same skills required of decent therapists, nurses, educators etc. Emotional intelligence doesn’t get the kudos it should in our society, perhaps because it is a competency closely associated with the feminine.

    Doctors in hospitals can get away with having minimal social skills as they see their patients so infrequently and can discharge at will with minimal accountability to the patient. It’s presumably a lot harder for GPs to get rid of their patients. It’s interesting that under his list of disadvantages, Oncall blogger lists ‘Patient contact – sometimes that quite annoys me’. I worry for his future patients if he does go into a job that requires patient contact. I would argue that it is far easier to master the intricacies of the latest surgical research then to master sophisticated social skills and for this reason would see the demands of the GP job (done well) appear to be more challenging.

    Because of the challenging nature of the skills required I think it’s possible that some GPs are just too burned out to put the time and effort into displaying the competencies you mention and so may appear to be cruising through their day in the fashion of an automaton. This is perhaps why GPland is accused of lacking intellectual stimulation.

    I also think the intellectual prowess of many hospital doctors is somewhat overrated. How many specialists have truly mastered all areas of their specialisms to the degree that GPs master theirs? Take for example, endocrinologists – great if you are a diabetic but if you happen to have CAH, Addisons, pituitary tumour, thyroid disease etc. you’re going to be waiting a long time for a diagnosis and a decent treatment plan.

    So GPs out there, don’t feel disheartened, patients value your intelligence (when it’s displayed) and can see through the hospital doctors’ hollow rhetoric.

  7. GPs rock. Personally I hadn’t thought about being a GP until this year but now it is definitely in the “top 6” (all of which I like equally and reckon I could enjoy doing for a few decades).
    There is a lot of ignorance (sometimes I wonder if it is fear of some sort) out there about GPs, and certain people can be quick to criticize. Conversely I remember seeing a patient on the methadone program who came through ED when I was doing ED, who was drug seeking and was given morphine “to make her ********** going away” by a busy and stressed locum”. I thought that that was a huge shame because I know her GP and know that he would have been doing a lot of work to help her get herself off illicit drugs and get her addiction under control.
    And of course the idea that GP is not as intellectually stimulating is rubbish. All specialties are as stimulating as you make them. I have met surgeons and physicians who have very limited interest in continuing their medical education or about learning anything that is outside their sphere of commonly seen conditions, so that is not true.
    *Hugs*. Hope you feel happier soon.

  8. I want to sincerely apologise for my own stupid choice of words which has caused you such offence Nice Lady Doctor.

    I think my words do betray an ignorance that pervades junior hospital doctors but it is not a view I seriosuly uphold.

    I’ve tried (not very well I’m afraid) to explain myself a bit more clearly on my blog:http://oncallblog.blogspot.com/2008/10/dumb-doctor.html

  9. Think GPs have a difficult job, given the 10 minutes you speak off. From the patient side it is often difficult to convey, condense in that time, what is truly the cause, but admire greatly the time and effort that GPs give.

  10. Scribbler

    Tazocin on October 25, 2008 said:

    I want to sincerely apologise for my own stupid choice of words which has caused you such offence Nice Lady Doctor.

    Well, you don’t see that very often around the blogosphere. Well done that man.

  11. yogimama

    Fabulous post, NLD. I wish you were my GP! x

  12. Country Doc

    Enjoy your postings very much and while you practice in a far different health care system in which I am a family physician there seems to be so many commonalities. Patient care is patient care. Would love for you to check out my blog and even consider contributing a post or two at The Country Doc Report (http://thecountrydocreport.wordpress.com)

  13. JenButler,FNP

    Also as a primary care provider I have to say that the original comments made about GP’s by this blogger should be saved for her to look at again in 5,10,and 20 years. At that point this opinion i am sure will be much different.I believe it is MUCH more difficult to know a lot about everything, than a lot about one thing.The most difficult being the ability to even know where to begin. In order for a specialist and a patient’s insurance to agree to accept the referral, a diagnosis must be already established by the GP.Another point, if the specialist feels like it isnt in their field, the patient gets sent BACK to the GP once again. And i would certainly like to know where this free time is i have been missing for the last 10 years. Maybe we are the “dumb” ones to take on such a big job with such litle credit.
    However, I do commend the original blogger for the apology to NLD.

  14. It is difficult to be a GP, it is, but as a junior hospital doctor in A&E receiving referrals from local GPs, one wonders about the practice of ten minute medicine.

    I receive many completely inappropriately referred patients, for things like exercise-induced angina, uncomplicated UTI, even a swallowed FB that has clearly progressed into the small bowel. I appreciate that it is hard to take the time to deal with these things appropriately, but ten minutes just isn’t enough time to manage a complex patient.

    What I find difficult is that A&E is used as a dumping ground by GPs who don’t want to be any more than referologists. An F2 shouldn’t be reading a GP referral and wondering what they can add to the management.

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