Everything you know about going to the doctor is wrong

Everything you know about going to the doctor is wrong

You’ve been going to the doctor all your life.  You know how this works, right?  Wrong.  In my last blog I gave you “10 insider tips I bet you don’t know about your GP” (https://drjongriffiths.wordpress.com/2018/01/30/10-insider-tips-i-bet-you-dont-know-about-your-gp/), and now I’m going to tell you how you need to change your approach to going to the GP, and why.  Do you think your GP’s primary aim is to ‘get you better’?  Do you wait for your doctor to ask all the right questions during the consultation?  Do you feel cheated if you don’t walk out without a prescription?  If so, you’d best read on…

Your doctor is probably looking to assess rather than looking to treat

This is really important to understand, and often where things can get off to the wrong foot in a consultation.  What is your approach to going to the GP?  If you have a bad cough or sore throat, what are you looking for from your GP?  If the answer is that you go in order to be ‘made well’, then I would suggest you change that approach.  Your doctor knows that the majority of acute illnesses get better themselves.  Coughs, colds, sore throats, earache, tummy ache, vomiting, diarrhoea, rashes etc all tend to be ‘self-limiting’.  When your doctor sees you she (or he) is not thinking “What do I need to prescribe to sort this out?”, they are instead thinking “Do I need to treat this?”

There is a fundamental difference in the two approaches.  One has the expectation of a treatment; the other has the expectation of a professional opinion.  If you go expecting the former, you are setting yourself up for disappointment, and potentially confrontation when your doctor has other ideas.

My tip: Go to your GP for their expert opinion, not necessarily for them to make you well.

  

Your doctor will learn more from the story you give than the examination they perform

People often go to the GP in order to be examined in order to work out what is going on.  It’s important to realise that the history is much more important than the examination (doctors use the word ‘history’ to mean the story that you give – i.e. your description of the symptoms you have).  This means that getting your story straight is really important.

When you first sit down in the GPs office, they are likely to start things off with an ‘opening gambit’ – an open question inviting you to say why you have come.  Each doctor will likely have come up with something that they are comfortable with such as “What can I do for you today?”, “How can I help you?” or “What seems to be the problem?”  Regardless of what they say, this is your opportunity to explain why you are there.  Be as detailed and specific as you can.  Don’t just say “I have a sore throat” and wait for more questions.  Instead try “I started with a runny nose 4 days ago, then when I woke up the next day I had a bad throat.  It has got worse rather than better and I’ve been taking paracetamol at maximum dose for the past 3 days.  I am not eating anything as it’s too sore, and I’m not drinking much either.” You see the difference?  A good doctor will follow up with another open question, such as “Is there anything else?” which will allow you to provide even more detail not just about your symptoms but also about your thoughts, ideas and concerns.  Adding “I had tonsillitis a couple of years ago and this feels just like that, I wondered if I had it again?” is helpful as it lets the doctor know where you are coming from.

Be clear about how long things have been going on for. You would be surprised how often people say things like “I’ve had this cough for ages”, or “It’s been like this for a long time”.  Don’t leave your doctor guessing – if they have to resort to asking “Has been days, weeks, months or years?” then you have probably been too vague!

Get as much out as you can in that first minute or so, fully explaining your symptoms as well as your own ideas or concerns about what’s going on.

In addition, be upfront about any “list” of problems you might have that you want dealing with.  If you read my previous blog you will remember that I said “Your doctor does not like lists”.  I think this is largely true, although a list declared at the outset that can be tackled together with your GP is not always a bad thing – just be aware of how much time you might have (usually no more than 10 mins to include time walking to the room and the computer entry).

My tip: Tell as much of your story as you possibly can in the first two minutes of your consultation.

 

 Your doctor really wants to know why you are there

It might be obvious to you, but may not be obvious to them.  Take the previous sore throat scenario.  If you don’t tell them upfront then your GP is left guessing.  It could be for any of the following reasons or a multitude of others:

  1. You want antibiotics
  2. You want to rule out tonsillitis
  3. You are worried you might have glandular fever
  4. You are worried you might have throat cancer
  5. You want a sick note

I hope you can see that the doctor will manage a consultation looking to reassure about throat cancer very differently to one where you are not looking for anything other than a note for work.  It does help your doctor if they know what your motivations are.  Don’t be offended if your GP says “Why have you come?”  It’s really hard to frame the question without them suggesting you didn’t need to be there (which is not the intent behind the question!).  Above all – don’t treat this as a ‘test’ for your doctor to see if they are good enough to work things out for you – surely you want a partnership with them in order to get the best outcome – for you!

My tip: Be very clear why you have attended to see the doctor, and do that at the start of the consultation.

  

Your doctor may not be able to say what is wrong with you

And that does not mean that they are not a good doctor!  Your doctor will be hoping to make a definitive diagnosis, but more often than not they will instead be looking to make a list of ‘differential diagnoses’.  This is a list of conditions which all share similar symptoms.  On that list there will be conditions that your doctor will wish to actively rule out, and if they can’t, they may wish to investigate further.  Sometimes they can do this within your consultation.  Sometimes they will need to arrange further tests.  Sometimes they will want to see you again to see if things have settled.  Sometimes they will send you away with instructions about what to watch out for to prompt a return visit.  Which approach is appropriate depends upon your history and the examination findings.  Do not be surprised or disappointed if your doctor cannot tell you, for certain, what is wrong with you.  It is more likely that they can tell you what you don’t have.  This is a key part of what GPs do – try rule out important, serious, life-threatening conditions. Whatever is left may not need treating, or even diagnosing!

Very often your GP will use time as a tool to aid diagnosis.  This might mean that you don’t get a definite diagnosis on your first visit, but when you come back (not better), then this will trigger further tests.  This does not mean that you should have had the tests the first visit.  Don’t be fooled by the ‘better safe than sorry’ mentality – having too many tests is also bad for your health, resulting in, potentially, side effects from the tests and/or ‘over diagnosis’.

My tip: Don’t worry if your GP can’t tell you what is wrong first time!

 

 

Your Doctor is not just a gatekeeper for a prescription

It is not all about the drugs.  Remember the first tip.  What you really want is an opinion, maybe a diagnosis, and only treatment if you need it.  Sometimes when people go to their GP they feel that it was a waste of time if they don’t come away with a prescription.  NOT TRUE!  The assessment and evaluation and opinion that a medication is not needed at this point in time is of great value.

Here’s another thing.  Why would you want to take a drug that you didn’t actually need?  Do not be fooled by the better safe than sorry mentality.  There is risk associated with every course of action.  Taking prescription medication comes with a risk (that’s why you need a prescription, you need someone qualified to decide if you need it, someone qualified to decide if the potential benefits outweigh the potential risks.  The risks vary from drug to drug, but for commonly prescribed antibiotics they include side effects such as diarrhoea, allergic reactions, thrush, rashes and interactions with other medications.  There is also the risk of increasing antibiotic resistance that comes with increased antibiotic prescribing, and, of course, the financial cost to the NHS of the prescription.

My tip: Don’t be rushing to take prescription drugs.

 

 I hope you can now see that there is more to general practice medicine than meets the eye.  Understanding how your GP is approaching their consultation with you can help you adjust your approach with them.  Being on the same page as your GP can only help this process and get you the help you need when you need it.

Please share these tips and follow the blog for more content!

If you want to ask Dr Jonathan anything, then find him on Twitter @DrJonGriffiths

 Dr Jonathan is a GP at Swanlow Surgery in Winsford, Cheshire, and Chair of NHS Vale Royal Clinical Commissioning Group.

 If you liked this, why don’t you also try:

 https://drjongriffiths.wordpress.com/2018/01/30/10-insider-tips-i-bet-you-dont-know-about-your-gp/

 https://drjongriffiths.wordpress.com/2017/09/28/the-school-told-me-to-come/

 https://gpandhuman.com/2018/02/01/think-of-your-gp-appointment-like-a-train-journey/

 

Advertisements

10 insider tips I bet you don’t know about your GP

10 insider tips I bet you don’t know about your GP

We’ve all been to the doctor, right?  We know how it works; we know how to get an appointment and what to say when we go.  I’m always surprised at how little people do understand about how their doctor’s surgery really works, and how to get the best out of them.  Most people don’t realise that a GP runs a small business and that they get paid a set fee to provide all of your care.  Do you have any idea how long your appointment slot is, or how many patients your GP will see each day?  Hopefully you won’t need to visit your GP very often, but a bit of insider knowledge can help you when you do need to go!  How many of these insider tips and nuggets did you already know?

 

  1. Your Doctor would like to give you more time
    • Most GPs provide just 10 minutes for an appointment. Although this might not seem very long you must remember that this has increased over the past 20 years from a typical 7.5 mins per appointment, and from even shorter appointments before then.  GPs can choose to offer longer appointment times, but there is a balance between length of appointment and how many appointments they make available.  This is obvious when you think about it – do you offer fewer, longer slots, or more, shorter ones?  What would you do?  Depending upon your reason for attending, 10 minutes might be more than enough time, or woefully inadequate.  Got a sore throat?  You might be in and out in 5 minutes.  Hearing voices and suicidal?  You might be in there for half an hour, or probably longer. Your doctor will rely on a variety of problems presenting to balance these demands on their time, and hopefully will run roughly to schedule.  Often they will run late.
    • You can help this by understanding how long your appointment slot is (just ask when you book), and working with your doctor to get things done in the time allowed. If you already know you are going to need more than 10 mins, ask reception if you can have a longer slot. They will probably be happy to oblige.

 

  1. Your Doctor does not like lists
  • Well, let me clarify this. Your Doctor would advocate you knowing what you are coming for, and if writing this down in advance will help you, then I would suggest you do so.  However, bearing in mind point one above, if you only have 10 minutes and if you pull out a list of 5 problems this is pretty stressful for your GP.  Were you expecting 2 minutes per problem?  Be realistic.  Prioritise what you want from your doctor.

 

  1. If you arrive 10 minutes late, you have missed your appointment.
  • What I mean is that if you are 10 minutes late (or more), then you are not just late, but your appointment slot has come and gone. The next patient is now due.  Remember that the impact of being late is not just on your doctor.  They may be prepared to finish their surgery late in order to see you, but what about all the other patients who have booked in and arrived on time?  If you arrive late, this is who you are causing hassle for, all the people around you in the waiting room.  I guess I’m just asking you to think – is this fair?

 

  1. Your Doctor is not telepathic
  • Pretty obvious, right? Yet it seems that people think their GP will know what they are worried about, which of their problems is a priority for them and what their hidden fears are.  A good doctor will no doubt explore all of this with you, but you can short-cut this.  Be up front about what is on your mind.  If you are worried because you think your rash or lump might be cancer, then say so.  If you want to exclude some rare condition because your mother had it – let the doctor know.  Try not to leave your main problem until the end.  You would be amazed how many people get through the whole consultation and then, at the end, say something like “While I’m here, can I mention this chest pain I’ve been getting?”

 

  1. Your Doctor is a specialist
  • They have just specialized in being a generalist! Don’t make the mistake of thinking that there is a hierarchy of doctors, with GPs at the bottom and hospital consultants at the top. Your GP will have spent a minimum of 5 years in training AFTER medical school. They are experienced doctors qualified to look after you. Sometimes people think that going to A&E means you get to see a ‘proper doctor’ – remember that the junior doctor in A&E is likely significantly less experienced than your GP. Many people think that being a GP is the hardest job a doctor can do. If you are concerned that you might need to see a specialist, then talk this through with your GP – they are in a really good place to decide with you if that is what is needed, or not.

 

  1. Your Doctor is self-employed
  • Did you know this? Why does it matter?  GP partners own the business of the practice and are ‘independent contractors’ to the NHS.  Many members of staff at the surgery, including some of the doctors, will be employed, but by the surgery not by “the NHS”,.  This has a number of implications:
  • Firstly, your GP receives a set amount of money per patient per year to provide all of their care. It doesn’t matter whether you see your GP every week all year, or don’t attend for 5 years; your GP gets the same amount of money for looking after you.  You must not think that by seeing your GP you are ‘doing them a favour’ by bringing in money for your attendance!  The amount of money your GP earns varies from practice to practice (they are all individual small businesses) but the average is around £140 per patient per year.  This is really good value (less than 40p per patient per day), particularly when you consider this is the money the practice receives to provide all the services and pay all the staff including the doctors.
  • Secondly, this means that your doctor’s surgery is contracted to provide certain things, and not others. It’s worth remembering this as this is why you will sometimes be asked to pay for things.  In simple terms your GP is contracted to provide medical care, but not to do things outside of this such as the multitude of letters they are asked to sign.  If ANYONE asks you to “get a note from your doctor”, you should really question this before heading off to the surgery.  Many of these requests are unnecessary and just seek to move a perceived risk from one person to the doctor, who may not be in a position to carry that risk.  Check out this website first for more info:

http://www.ganfyd.org/index.php?title=Get_a_note_from_your_doctor

  • The payment GPs receive is not affected directly by referrals or prescribing – the costs for this are in a separate budget. If your GP decides to prescribe an expensive medicine for you they are not paying for it themselves.  People often think that GPs switch medicines to cheaper ones in order to personally benefit financially.  NOT TRUE!  They are doing this to help the NHS budget as a whole, which I would hope we would all be in support of.
  • Because they are small businesses, they bear any increasing costs themselves. Rising indemnity fees (insurance against being sued) have to be paid by the doctor themselves.  A doctor working only 2 days per week can be paying £6,000 per year on indemnity insurance.  Why does this matter to you?  Because if they are paying £6,000 on that they are not spending that £6,000 on another receptionist, or nurse, or another doctor.  The higher the costs, the less likely the surgery is to be able to add in additional services.  So, bear this in mind when you are thinking of suing your GP!
  • Despite what The Sun might tell you, your doctor does not earn £700k per year (unless your GP happens to be the sole one in the country that does … )

 

  1. Your Doctor wants the best for you
    • If your GP decides not to refer you on, or not to prescribe anything, or not to investigate you it is not because they are trying to be difficult or just trying to save money (don’t forget, their take home pay is not affected by these things). It’s usually because they don’t feel you need any of the above.  They also understand, probably better than you, the risks associated with over referral, over treatment and over investigation.  This is not a game where you need to see how much you can get from the NHS.  This is about keeping you healthy, investigating when appropriate, and treating when we need to.  Bearing this in mind, your GP will not mind explaining it to you – just ask.  If you were hoping for an X-ray, mention this and have a grown up conversation with your doctor about the pros and cons of doing that.

 

  1. Your Doctor is not taking part in a medical drama.
    • When you watch the TV, watch out for the doctors. I bet, 9 times out of 10, that they get the diagnosis right, first time.  I’m afraid this is not real life.  Many conditions are not at all obvious, and time is the only sensible way to start to differentiate between them.  GPs often get vilified in the press for not picking up serious illness (“I attended my GP 3 times before they referred me with my cancer…”).  In reality serious illness often initially presents the same as mild, self-limiting illness.  A cough, for example, can be caused by many things, from a simple viral infection to lung cancer.  The patient who presents to their GP with a cough that they have had for less than a week is unlikely to get a chest X-ray on the first visit, but if it has failed to settle after 3-4 weeks, then that’s a different story.  Be aware of this and remember that this is complex stuff.  In particular, ask about the things that you should watch for and under what circumstances you should return for review

 

  1. Your Doctor might play golf, but probably not in their lunchbreak!
  • The traditional view that people have of GPs is that they see a few patients in the morning; a couple of visits, then are free until evening surgery at 5pm. Plenty of time for 18 holes in the afternoon?  The traditional view is out of date.  Most GPs see 18-20 patients in morning surgery, followed by visits, and then a further 18-20 patients in the afternoon.  Many GPs see more than this.  In addition to these face to face consultations, there will be phone calls and paperwork.  Paperwork is an essential part of patient care, but takes time.  It consists of looking through the results of the investigations that have been ordered, reading letters from consultants, acting upon these letters (consultants will not infrequently give actions for the GP to undertake), signing prescriptions (signing prescriptions is one of the riskiest things that GPs do – be aware of this and don’t be upset if there is a query over your medication – this might just mean that the GP is taking the trouble to check that this is safe for you and won’t kill you) and arranging the investigations and referrals from the previous surgery.  The waiting room may be empty, but that doesn’t mean the GPs are all putting their feet up.  That’s a lot of patients seen, and a lot of decisions made. If you are waiting for the results of an investigation, this can be stressful, and you quite rightly will want the results as soon as possible.  Here are some things you should consider:
    • If the test was arranged by your hospital consultant – that’s who you should go back to for the result. Ring the consultant secretary (ring the hospital switchboard and ask to be put through) and ask when the consultant is going to convey the results to you.  If they try to palm you off by saying they will send the results to your GP, explain that you want the results from the specialist who arranged them who is in by far the best place to give appropriate advice.
    • If your GP did arrange the test, the smart thing is to make sure you know from the outset when and how you should expect to get the results. Are they going to phone you, or do you need to call?  Speaking to the receptionist if you are uncertain is the way to go – explain your problem, and ask how to proceed – they will probably be able to help you.

 

  1. Your Doctor has entrusted their reception staff with an important job
  • And that job is not just to make things as difficult as possible to make an appointment! The receptionist’s main job is to deal with enquiries, book appointments and generally ensure all is running smoothly.  They are not medically trained, but they will have a really good understanding of the services on offer. My advice would be to entrust them with a rough idea of the problem that you have.  This way they are able to direct you to the most appropriate course of action. Don’t forget that everyone who works in the surgery is covered by the same confidentiality clauses. You can trust that the receptionist is NOT going to be talking about you to others. Increasingly doctor’s surgeries include clinics run by nurses, physios, pharmacists and more.  If you ring and insist on an appointment with a doctor, without explaining that it’s because you have a bad back, you might have missed out on seeing the physio – probably a better option for you.
  • If you are polite and friendly to reception, they will be polite and friendly to you. They are not trying to be obstructive, they are just doing their job – you might be anxious and stressed, but try to keep calm.  The receptionist can be key in getting the right help as quickly as possible – just remember, that help might not be the GP.

 

So, how many of these top 10 insider knowledge facts did you know?  As with all things, the more we know about how things work, the better able we are to work with the system and get what we need done.  I hope these facts and tips have been interesting and helpful to you.  If they have, why don’t you share them with a friend?!

 

If you want to watch something from Dr Jonathan about the value of the Generalist – check out his TEDx Talk online https://youtu.be/-BfcvI49GCw

 

Dr Jonathan Griffiths is a GP at Swanlow Surgery in Winsford.  He is also Chair of NHS Vale Royal Clinical Commissioning Group.

 

If you have a question for Dr Jonathan, why don’t you find him on Twitter @DrJonGriffiths

I am a GP

I am a GP

I am a General Practitioner.

 

Over the past year I have actively tried to promote General Practice as a career, trying to both encourage medical students and doctors in training to consider choosing GP, and also to encourage a General Practice workforce that is, in some places, struggling.

 

A couple of the things I have done in the last year to promote General Practice particularly stick in my mind – a blog I wrote called “Best job in the world?”, and my TEDx Talk “Choosing to be a Jack of All Trades”.

 

Check them out here (I’d especially like you to find time to watch the TEDx, I’m rather proud of it!)

 

Best Job In The World?

 

Choosing to be a Jack of All Trades

When I published the blog, I was expecting some push back, and readers did not disappoint – it’s always fun when you have to google the insults to find out what they mean (“Panglossial piffle…”).

 

I wasn’t really expecting anything negative to come from the TEDx though. And nothing has, really. It’s just that while at the RCGP Annual Conference last week and on Twitter subsequently I have felt a few anxieties about General Practice develop in my mind.

 

My TEDx Talk is unreservedly positive about the value of the generalist. If you are a GP or consider yourself a generalist in any other walk of life, then I suggest you watch it – it will give you a positivity boost! Regardless of how great I think GPs might be, however, clearly there are others whose experience of General Practice is not as positive.

 

On the first morning of the conference the Health Secretary Jeremy Hunt attended and addressed us all. During the brief question time at the end a Kent GP, Stephanie de Giorgio, made the clear point that many GPs are struggling to cope. There is increasing demand, difficulty in recruiting and GPs are suffering, resigning and in some tragic cases have ended their own lives. You can watch the question and response via this link:

 

https://twitter.com/Channel4News/status/918477328749121536

 

Not quite the glorious description of General Practice I have been looking to promote.

 

The following day, at the conference ‘NHS Question Time’ Roy Lilley was typically challenging and suggested that the Primary Care business model was ‘screwed’. He articulated the ask of many of our patients – that we are available as a family doctor providing continuity, chronic disease management, a known and friendly constant face through our illness, but that we are also able to accommodate urgent need as well as being available in the railway station for him to drop into during his daily commute. These seemingly contradictory requests are in fact what, increasingly, our patients want. Depending upon where you work as a GP more or less of your patients are looking for this ‘full service’. In the urban Cheshire town where I work there are not as many commuters, although when HS2 arrives in nearby Crewe, then we’ll see what happens!

 

So, there are two perspectives that caused me to pause and think. The third was a twitter exchange I had. During my session at the conference, where I delivered my TEDx Talk (have you watched it yet?) there was a Medical Student (@the_littlemedic) who also happened to be a talented illustrator. She created a graphic of the session which she subsequently tweeted.

 

Graphic from @the_littlemedic based on my TEDx Talk

 

This was picked up by many both at the conference and some who were not present. One was “Tired Old Man” (@tired_old) who took exception to the premise behind the graphic which implies that generalists, and GPs in particular, are able to take a holistic view of people, thinking outside the box and looking to help. He said that his experience of General Practice did not align with this – he did not feel that his GPs knew or cared who he was. He pointed out that he was only allowed to mention 1 problem at a time, and that GPs did not seem to know patients or their families. He was keen to ask if there had been a session or a graphic dealing with the reality of patient experience.You can read some of his tweets here:

https://twitter.com/tired_old/status/919134509513302017

https://twitter.com/tired_old/status/919133279307096064

https://twitter.com/tired_old/status/919203903979302913

 

This is quite a challenge to a hard working, well meaning GP.

 

So, who is right? Is my positive view of General Practice just naïve optimism? Is the reality a whole lot worse than I choose to believe?

 

As with many things I suspect there is no one right answer here. There are undoubtedly many GPs who are stressed, struggling, overworked and burning out. On the other hand I know many happy, balanced GPs who still love their jobs. Most GPs are caring, dedicated individuals who are constantly adjusting their services to meet the needs of the population they service, I struggle to think of (m)any who don’t care about their patients.

 

This doesn’t mean that we can always meet all of their needs all of the time, particularly when we seem to be faced with ever increasing demands, not all of which appear reasonable. It is no surprise that groups like Resilient GP http://www.resilientgp.org/  have arisen trying to support GPs in their day to day practice, and others like the GP Survival https://www.generalpracticesurvival.co.uk/  to help support and campaign for increased investment in Primary Care.

 

We also need to consider Roy’s point – how do we meet the many and diverse needs of the people we are trying to serve? I struggle with a model that has me being family doctor one day, and a train station walk-in GP the next. Perhaps, though we do need to embrace both models. Perhaps we need to work in ways that addresses both needs. Simple things like a joined up IT system would help – wouldn’t it be great if the GP walk-in centre had access to your electronic record? Where they could see your history, arrange investigations, arrange follow up back at your surgery at a time that is convenient to you? Wouldn’t it be even better if the GP working at said walk-in centre was one of your own family GPs, just working their weekly shift there, or even a GP from a neighbouring practice perhaps. There are many models and one of my fears is that someone will pick one and ‘roll it out’ to us all – that never seems to work. As Roy said to me in a tweet “It has to come from the ground up. Nothing works top down.”

 

https://twitter.com/RoyLilley/status/918832926107820033

 

So what am I trying to pull together from these various thoughts following the conference? I guess the following:

 

  1. That I still believe in General Practice as the bedrock of the NHS. That it is able to meet the needs of patients in a holistic and caring way that takes into account the diverse needs of the population.
  2. That many people don’t necessarily experience General Practice like that – patients and GPs alike.
  3. That the changing demands upon general Practice probably do mean that the traditional business model will struggle to meet those needs.
  4. That we therefore need to change. We need to look at alternative models that allow us to still provide the family doctor medicine, while also meeting the needs of the 24/7 “I can go to Sainsbury’s at midnight, why not my GP” culture.

 

Not surprisingly I have blogged about the challenges facing General Practice before. Interestingly, the blog that speaks to mind also features Roy Lilley. You can read it here (Outside Context Problem). The scary thing is that I wrote this blog 2 and ½ years ago. The question is, what have we done to prepare and change in the mean time? I think in some areas, a lot, but in others not enough. One message I took home from the conference was that the answers and solutions are in our hands. I acknowledge that the framework that sits around us can be a challenge to that, and the resources that need to flow into Primary care need to come from elsewhere (NHS England/CCGs), but one of the wonderful things about General practice is our ability to adapt and change. We need to see beyond the traditional models of practice and embrace the new. That means thinking about federations, working at scale, the GP Five Year Forward View, Accountable Care Systems, Integrated Care and more. Some of these might not work, or might not work in your area, but you really need to do something. The challenge to us all is that we need to take action now to ensure we are still operating as effective General Practice in another 2 years time.

 

Dr Jonathan is a GP at Swanlow Surgery in Winsford, Cheshire, and is Clinical Chair of NHS Vale Royal Clinical Commissioning Group.

 

Follow Jonathan on Twitter @DrJonGriffiths

Risk

Risk

The sound of running feet followed by a twang, a thump and then a crying child. These were the noises that grabbed my attention while I stoked the fires of our portable pizza oven at our Cornish campsite. Not the noises you want to hear while trying to relax on the last night of your holiday. First check – is it my child? No. Not good news though as it is my nephew, 7 years old, and he is not a happy chap. Dad (my brother-in-law) is quickly there, and we determine that he’s hurt his arm. Then I hear the inevitable, “Don’t worry, Uncle Jon is here, he can have a look at it.”

 

I think these scenarios present an interesting challenge for the GP. They are, on the one hand really difficult to manage, and on the other, really easy. They are difficult because it is really hard to give a confident diagnosis in this acute phase. As a GP you NEVER see someone with an injury which is only a few seconds old. We all know that children will cry when they fall over, whether there is a serious injury or not, and it is impossible to know in those first few minutes whether this is likely to be anything more serious than a bruise. In some respects the person most able to determine whether there is a problem or not is the parent, who does know how likely their child is to be crying like this with a minor injury. I suspect, however, that there is an expectation that you should know. That you should be able to instantly say whether something is broken or not, just by looking at it. It happens in the movies all the time after all. So, you feel immense pressure to be able to get this right, even though you know you probably can’t really tell.

 

In contrast, the scenario is easy to manage because what to do next is really simple – you watch and wait. If he calms down and starts moving his arm, you’re probably ok. If he doesn’t, then he needs an X-Ray.

 

He didn’t settle down.

 

He had spent a week participating in reasonably high risk activities. Body-boarding in reasonably rough seas, hard-core coasteering, climbing over rocks on the beach and cycling at high speed around the campsite. He broke his arm tripping over a guy rope. Isn’t that a lesson for life? We worry about the obvious, risky things, but fail to notice the simple ones. How often have you heard the same story about how people get injured? Occasionally it is from the high impact road traffic accident, but more frequently it is a simple trip or slip. I have been physically present 4 times when someone has had a fracture. Only on one of those occasions would I have predicted a fracture based on the level of injury.

 

So what is the lesson here? A couple of things I think. The first is that we need to be aware that it isn’t always the obvious, high risk items that will bring us crashing down, but often it is the less obvious issue that slips under the radar. As a CCG Clinical Chair I have spent more time dealing with things relating to issues like removal of sutures or irrigation for ear wax than you would imagine, yet I bet you would never have predicted this would be a major problem. When we run our risk assessments we rightly focus on the things that we can see looking ahead, but you don’t know what you don’t know (I’m sure you all remember Donald Rumsfeld’s famous quote on this[1]). I’m not suggesting we need to put everything onto our risk registers, but that we need to keep alert, keep our eyes open, and watch for any warning signs of problems we were not expecting. Game of Thrones fans might relate to this recent quote from the ever-sneaky Petyr Baelish, “Don’t fight in the North or the South. Fight every battle everywhere, always, in your mind. Everyone is your enemy, everyone is your friend. Every possible series of events is happening all at once. Live that way and nothing will surprise you. Everything that happens will be something that you’ve seen before.”

 

The second point I wish to make is related – we are poor judges of risk. We see risks in things that are relatively safe, and ignore risks where they are present. Participating in ‘high risk’ activities is often much safer than you imagine, because you take precautions and are alert to the danger. Meanwhile we are blind to the risks of everyday activities like driving or crossing the road. We also have a distorted view of the likelihood of disastrous events occurring. The media has heightened our sense of risk for terrorist events[2], plane crashes, murder, child abductions and other high profile scenarios, all of which remain, thankfully, relatively infrequent compared with car crashes[3] (for example). Not many people spend their lives worrying about having a car crash, however, but I suspect a good number are worrying about terrorism and considering avoiding places like London and Barcelona at the moment.

 

Our failure to properly understand and respond to risks also factors into our approach to medicine. Conversations between clinicians and patients too infrequently explore the risk-benefit ratios in question for treatment options, and we often perceive greater risks in our actions (whether this be starting or stopping therapy) as opposed to our inactions. There is also an increasing culture of ‘better safe than sorry’ and of wanting to investigate to eliminate all risk, without consideration that increasing investigation can increase medicalisation, ‘over-diagnosis’[4] and carry its own risks.

 

These are complex issues and far too overlooked.

 

So what do we need to do?

  1. Consider, inquire about and understand the risks that you face.
  2. Be aware that there are many unexpected things that could suddenly arise and cause you a problem.
  3. Try to keep your view of risks proportional to reality.
  4. Explore the risks of treatment options with your doctor, including the risk of not doing anything!

 

My nephew needed 3 hours in surgery and 4 wires to fix his fracture. He’s doing ok now though!

[1] https://en.wikipedia.org/wiki/There_are_known_knowns

[2] http://www.telegraph.co.uk/news/0/many-people-killed-terrorist-attacks-uk/

[3] https://www.gov.uk/government/publications/annual-road-fatalities

[4] http://www.preventingoverdiagnosis.net/?page_id=1176

 

Dr Jonathan is a GP at Swanlow Surgery in Winsford, Cheshire, and Clinical Chair of NHS Vale Royal Clinical Commissioning Group
Follow Jonathan on Twitter @DrJonGriffiths

Not Very Well

If you ask former GP Registrars at our practice to name a tutorial I used to do, there is a fair chance they will say “The one with Peppa Pig!” This is not because I think the Peppa Pig tutorial was better than any other, but more because they got to sit and watch an episode of a children’s TV program!

 

I would encourage you to watch it yourself. The episodes is called ‘Not Very Well’. Here it is on YouTube – you will have to deal with the adverts but it’s worth it – and less than 5 mins long. While you watch it I want you to think about Dr Brown Bear – his approach, the service he offers and his treatment. Go on, do it now and then come back…

 

At first glance Dr Brown Bear offers an excellent service. He answers the phone himself, quickly assesses the situation (Peppa has a rash and doesn’t feel very well), he tells Daddy Pig to put Peppa to bed and says he will come straight round. This he does, and before you know it he is there with his doctor’s bag and calm confident approach. He examines Peppa (essentially by looking at her tongue), declares that she “just has a rash” and that it is “not serious”. Everyone is greatly reassured. Peppa asks if she needs medicine. Dr Brown Bear declares that the rash will clear up by itself, but that if she likes he could give her “just a little medicine”. He has the medicine to hand in his bag and gives her some himself. As he leaves he says that he will come back later to check on her. Cutting to the end of the episode we see him do exactly this, arriving as the last of her spots disappear to declare that all is well.

 

Remarkable service. Surely the kind of service we would all like to have? Only this week I was chatting to someone I had met for the first time who commented how in the past the GP would visit for all kinds of things, “like chicken pox”, but that that didn’t happen any more – they clearly felt that home visits to children with chicken pox was a better service than the current one.

 

Let’s look at a few of the things Dr Brown Bear does, however, and see if we really think this is good practice:

 

  1. Answers the phone on the first ring. How many times have you played ‘fastest finger first’ trying to get through to your GP? I have been there myself, primed at 7.59am to call the surgery exactly at 8am in the hope of getting through for an appointment. Dr Brown Bear has his surgery sorted. But I’m curious as to why he has no reception staff? Is it really a good use of resources for him to be answering the phone himself?
  2. Visits immediately. Again, great stuff for the patient, but is this appropriate use of resource? There is a reason we don’t visit children with chicken-pox, and that is because they don’t need visiting. They can come to the surgery (or actually stay away form the surgery altogether and wait to get better!) I know that Daddy Pig has a car – I’ve seen him drive it in many other episodes, so I’m struggling to see why the home visit.
  3. The confident declaration that all is fine. This is what patients like to here – a confident doctor who knows what’s going on and who can tell you with certainty that things will settle. I have some issues, however,  with the cursory examination, and I think medico-legally he is leaving himself wide open if anything does go wrong. I would love to be as confident with my diagnoses and prognoses as he is, but life it not quite like that. I don’t see any safety-netting, nor leaving any room for the possibility that he has got the diagnosis wrong.
  4. Prescribing, issuing and administering medication. Let’s overlook the lack of an FP10 prescription pad, the ability to carry all required drugs round with you and the lack of checking off the dose and batch number, but let’s NOT overlook the fact that Dr Brown Bear has just said that the rash will clear up by itself! What is he playing at here? Why prescribe necessary medication? You will probably have realised by now that I have issues with this consultation, and this is surely the most unforgivable action.
  5. Repeat visit later.  I guess you could argue that this is the safety netting I was talking about earlier, but 2 home visits in 1 day for a child who could have come to surgery and who on the first visit was declared to have “just a rash” that would “settle by itself”? Clearly Dr Brown Bear doesn’t work for the NHS – he is either on a fee per visit or just has too much time on his hands.

 

All of the above suggests to me that the writers of this Peppa Pig episode have a very different model of General practice in their head than I do. They appear to have a very old-fashioned Dr Finlay model where the doctor knows best, the patient can expect immediate service and where nothing is too much trouble.

 

Having said all that, this cartoon is surely just a children’s cartoon isn’t it? Where is the harm in such an episode? We are not expected to think that life is really like this are we? Well, no, but I do have some concerns. I am concerned about the expectations that this raises. I am concerned that it encourages people to even think “wouldn’t it be nice if my GP provided that service” or for them to somehow look back and think that the way we practiced medicine in the past was better than how we do now. I think this episodes does encourage those thoughts – and don’t forget who will be watching Peppa Pig – it’s not just the children but their parents and carers.

 

And it’s not just Peppa Pig. Go out and look for children’s books about visiting the doctor. You could essentially write one now as they all have similar elements:

  1. Child wakes up feeling poorly – typically rash, sore throat, cough or earache
  2. Parent (usually mum) rings doctor and gets immediate appointment
  3. GP examines child
  4. GP declares diagnosis and provides prescription
  5. Child is better by the end of the day after taking prescribed medication

There are so many things wrong with this portrayal of events, but particularly the bit where a prescription is required every time. Where are the books that encourage a bit of self care? Where they point out that a sore throat usually takes 3-7 days to get better, but will do so on it’s own? That coughs can take 3 weeks to resolve and medication is not usually needed?

 

Children’s books and TV programs might appear trivial, but they are teaching our children, their parents and their carers about what to expect in the world, and they are getting this wrong. We need a new narrative describing the role of the GP and what people should expect from us. We need to move away from the idea that, as I overheard a parent saying to her child as she brought them down to my room “the doctor will make you better” – that may be the case, but more often than not, particularly with acute childhood illness, the child will get better by themselves.

 

The NHS has changed from what it was, and General Practice has changed too. We all need to understand this and change our expectations. I think General Practice has got better, not worse, and although there are significant challenges currently with overworked, under resources doctors and surgeries, I think the care given is as good as it ever has been. If you want to take a glimpse at people’s views of what General Practice is to them then you could do much worse than searching Twitter for the hashtag #GP150w (the brainchild of Jamie Hynes – excellent stuff) where you will find a vast array of people who have described General Practice in only 150 words. It really is worth a look, and I doubt if anywhere will you find anyone visiting unnecessarily or deliberately prescribing unneeded medication!

 

My final comment is to reinforce the need for us to reconsider our expectations and be aware that children’s story writing may be raising expectations above what can realistically be delivered. I recently blogged about the GP Patient Survey, perhaps those practices who received lower scores are victims of not coming up to the standards set by Dr Brown Bear?

 

Dr Jonathan is a GP in Winsford, Cheshire, and Clinical Chair of NHS Vale Royal Clinical Commissioning Group

 

Follow Jonathan on Twitter @DrJonGriffiths