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.