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Forward Planning

Do you want to know what the future of primary care holds? So do I. This is how the future is being shaped at the moment:
Appointments
We will provide non urgent appointments within 48 hours (under one proposal). That’s non urgent. Urgent appointments presumably within 48 minutes-unless it’s an emergency in which case obviously (or not) A+E might be better.
If they are open.
You stand roughly a 92% chance of being seen there within 4 hrs of attending as an emergency.
If you are not sure which A+E to go to then please ask a friend. Or your family. If you are really still not sure, you could always go to the nearest one. Or go to your GP (then repeat the process ad nauseum or until feeling better).
If you have had an accident or have an emergency then please do not attend your GP as they are trying hard to reach targets. The main target is the desk-aimed at by their head. Fortunately the blow is frequently cushioned by paperwork from NHSE/CCG/CQC etc etc.
Development
Primary care services are looking to integrate-with anybody who will have them. Applications must be submitted with details provided of exactly how many extra votes this will provide for the relevant political party come May 2015.
All applications will be considered-if looking to include alternative non NHS providers then those that pay a modicum of tax in the UK will be given greater priority. For example-Café Nero over Starbucks, Butlins Health over Amazon etc.
Applications must be submitted by hand, and should be signed in original ink on the back of the Elgin Marbles by Aneurin Bevan. Must be with NHSE by 3pm this afternoon to access part of the £2.54 extra initiative, cost cutting, vote winning, frail and clueless political party fund. This fund is not ring-fenced and can also be accessed at the House of Commons bar so please apply early.
Retention
The workforce is clearly under pressure and the government is trying to work out why this might be. They are going to ask people nicely if they would consider a career in General Practice. To help lure them, they will slag them off in the press, fiddle around with their pension, reduce the overall primary care budget, ask them to spend hours each week trying to commission services whilst running a business and trying to see patients, and help them to maintain focus by ensuring they spend as little time as possible at home. Interested? Please fill in the 26 page wellbeing assessment form which you can obtain from your GP and ask for an appropriate referral.

Oh well-you can only do your best, even in the most testing of conditions. The majority of GPs I know simply want to get on with the core work of caring for patients. I admire (and feel sorry for) those that have the energy and will to engage with the political process of organising primary care.
I for one will be eternally grateful when that boutique coffee shop finally opens beside the Citizen’s advice bureau office just along the corridor from me…
Richard Cook
January 2015

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Medical, Uncategorized

What’s in a name?

“Before you go Mrs Jones-just to let you know that I am your named doctor as of 1st April.”

“What do you mean?”

“Well, I’m going to look after you-care for you medically and all that. I will be working with associated health and care professionals to deliver a multidisciplinary care package to meet your needs.”

“Eh? Isn’t that what you’ve been doing for the last 20 years?”

“Well, yes, but that doesn’t really count-I wasn’t officially your named doctor. The point is, I’m really going to take control now and care for you.
Look, I’ve even got a new badge-do you like it?”

“But didn’t you care when I lost Albert? You seemed to care for him, you organised the hospice team and you looked after me when I got upset and couldn’t work for a while ?”

“Of course, but…”

“What about when I had my heart attack-you sent me down to A+E and you even came and saw me in the hospital as well. Surely you were looking after me then?”

“I know, but the point…”

“And when I had my lump-you sorted out all the treatment for me, arranged for the nurses to keep an eye on me, and chased up the specialist when they lost my records and I didn’t have an appointment?”

“Yes, I know but..”

“What is this-some kind of April Fool joke? You’ll be telling me it’s some ridiculous political idea to boost votes soon!”

“Ah, well, there is this idea floating around that GPs should, well, look after their patients and act responsibly.”

“Who’s idea is it?”

“Um, Jeremy Hunt’s.”

“Jeremy Hunt? The racing driver? I thought he was dead?”

“No, no-the politician Hunt. The Health Secretary. Our named leader of health.”

“Oh-I don’t worry about politics. He’ll probably move on to education in the next reshuffle. I know that you will be here for me-I can rely on you. I trust you.

And I like your badge.”

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Uncategorized

The doctor, the patient, Skype.

It is over 50 years since Michael Balint wrote about the consultation model, and there have been many other worthwhile contributors to education around this area since then. It is an area of our day to day work that can always improve, and will develop and change over time as we acquire new skills and learn more about our patients. The vast majority of our consultations take place face to face, but over recent years we have made increasing use of the telephone to triage and consult with patients. Some doctors like this more than others-and patients feel the same. But what of Skype? How does this fit in to current consultation models?

I like technology- smartphones, gadgets, touch screens and all that, but I really don’t like Skype. Socially, I view the phone as a means to an end-a communication tool, bullet points needed, a minimum of conversation. Texting is great for me-I can do it when it’s convenient, short quick messages, get the points across and move on. I have never been a great conversationalist (just ask my wife…) so prolonged phone calls are not really for me. 100 free minutes on my mobile phone contract-that will last me the year not the month. I can see why others feel differently and use the phone to keep in touch with family and friends- and Skype for many will be an extension of this. For me-I find it awkward and stilted with the worst bit being the goodbye. Is it OK to hit the end button now? Are they still looking at me? Shall I let them do it first? I have used it a few times to talk to the kids when I’ve been away without them (rare in my line of work)-and I can cope with the social indecision with them. But patients? What will it add?

 I spend a lot of time consulting face to face but also over the telephone-especially in the out of hours setting and I feel comfortable with the processes involved. Much of what we learn from patients is from the narrative itself, with any examination needed a supplement to that. I am left wondering what Skype can add to this from a doctor’s perspective and can really come up with only a few examples. Will it aid us in making a diagnosis or should we look upon it as a system that might help patients (and politicians) more than doctors? Is it possible that patients will be reassured by simply “seeing” their doctor-I doubt it.

As with all things new, no parameters of normal have yet been developed-so knowing whether we are doing it “correctly” is going to be difficult to judge. When mistakes or complaints are made-who will judge what a “normal GP” would be expected to do? It is possible to record Skype calls but it does not look terribly straightforward so this may be an option for some and could be useful to both patients and doctors.

 I am struggling to think of a long list of conditions that I might be able to deal with over Skype that I would not otherwise deal with over the phone. Confirmation of minor skin conditions maybe-urticaria, viral rash or even shingles spring to mind. Cellulitis ? A vague swelling somewhere? External thrombosed  piles? It may be that the only way forward is to suck it and see (not the piles), embrace the technology if it works, tread carefully, safety net and, if in doubt, arrange a face to face consultation.

 The next step, of course, will be a daily skype update from the care home staff….

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Medical

The Hand of Comfort

Hand

I am a man. Really I am. And men don’t cry-correct?

Well this one does-not very often, but when I do it is usually a good moment to pause and reflect on the circumstances. Just to check, you know, that I’m still a real man.

Shortly after the birth of our first child, I stayed up one evening to watch Life Is Beautiful, the wonderful Oscar winning film starring Roberto Benigni (1). This film should carry a health warning-beautiful yet haunting as it shifts from delight to horror over two glorious hours. The following morning I tried to describe the film to my wife as we sat in bed over a cup of tea, enjoying a rare moment of peace from our newborn daughter. I didn’t quite manage to get the words out as I choked on the raw emotion of the film I had sat through the previous evening, and tears flowed unexpectedly. My wife looked puzzled, but comforted me as I tried in vain to describe the movie, my emotions associated with it and the new responsibilities I now carried as a father. My wife is still yet to see the film 11 years on-I think the time will come.

Over my medical career I have been reduced to real tears on three, sadly memorable, occasions. These episodes were all slightly different, two involving the death of children and the third an unexpected finding of advancing cancer in a young patient. Each situation remains fresh in my memory but especially the first, despite occurring over 20 years ago-the emergency bleep, a collapsed child, manually ventilating for several hours in our small paediatric unit, the evolving fear of those involved, and the baptism at the bedside by the hospital priest. That day I, and others, will never forget.

On each occasion the tears came suddenly, uncontrollably after the events-that is to say, I managed to hold my emotions whilst I was with the patient or their family, and support them in their most difficult hour, but their trauma entangled me, and abruptly hit me, as I later tried to explain the case to colleagues or my wife (also a doctor). They looked on, reaching out to me, feeling my vicarious pain, and most importantly, they comforted me. A touching hand, a small embrace, a hand on the shoulder from a receptionist, doctor colleague, nurse or my wife was recognition enough-recognition that it was alright to be like this, to be human and upset. Somehow the touching helped-bodily contact soothing the wound.

As doctors we touch people frequently. The handshake as a patient enters the room, the blood pressure check or a physical examination. Mostly this is with implied patient consent-we will seek specific consent for a more intimate examination, but what about the comforting hand? We are doctors, but also we are humans. I would have no difficulty in physically comforting a distressed child, loved one, colleague or even a stranger as a fellow human being-but what about a patient? The human part of me says “don’t be silly, it’s OK” but the doctor part of me says “do be careful”. Our relationship with patients is like no other, and needs to be carefully observed.  I read this account (2) and it resonated with me. There is very little worthwhile work on how patients feel about touch that I could find, although there are many discussion forums that have covered the subject. This was a nice, small, primary care based study that is worth reading (3).

So can I be a real man, a doctor, and a human all at the same time?

I think that understanding your “weaknesses” can be your greatest strength. In my case, one of these is an acceptance of the effect that dealing with difficult cases can have-protecting patients from this but seeking support from those around me when needed.

On several occasions I have found this difficult- I have reached out a hand and withdrawn it, unsure of my role for a moment, leaving patients untouched. This problem can be amplified with female patients. A male doctor, a female patient, a human touch. I have several times been comforted by my (female) GP partner, and I know that in my hour of need I will look for the Hand of Comfort.

References:

  1. http://m.youtube.com/watch?v=64ZoO7oiN0s&desktop_uri=%2Fwatch%3Fv%3D64ZoO7oiN0s
  2. http://articles.latimes.com/2011/oct/24/health/la-he-practice-touch-20111024
  3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3289810/
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Medical

1984

1984 was a great year-not just for George Orwell lovers, or for me as I embarked on my medical education. Daley Thompson won his second Olympic gold medal in the decathlon event, and in securing his place in athletics history also broke the world record. Picture the scene afterwards if you can, as journalists jostled to talk to the great man draped in Union flags and his gold medal. “Daley-well done on your double Olympic success. Are you now going to consider specialising?”

Daley-Thompson_2308638b

How will you respond next time you are faced with that question? As a GP, I have been asked many times about my lack of specialisation-the implication perhaps being that I have failed in my profession. How do I live with the daily thought that, in some circles, I am viewed as a sub-species, a “not quite made it” doctor?

I think we should celebrate our generalisation, our ability to see all comers and usually generate some sort of management plan. We often bemoan the lack of a generalist in secondary care and have recently welcomed with open arms the rapid access to a clinic for those patients who just “aren’t really that well”-this has filled the gap of an urgent outpatient appointment which seems to have died a death.  We can’t all specialise, and we certainly don’t all want to, a bit like Tesco really-come to us and we’ll do our best to sort you out, try not to miss anything important and refer on to a proper doctor when needed.

To paraphrase Fletcher in the great Porridge TV comedy, my specialty is “the statement of the bleeding obvious”. By this I mean that our day to day work is a combination of sharing our medical knowledge, common sense, and our own life experiences with patients. All these three can be helpful at certain times and in different situations but I often wonder if my own experiences of life’s tricky situations, and learning from how patients deal with these are the most helpful for me as a doctor, and also for some of my patients.

When dealing with parents struggling with behavioural issues, people grappling with trying to give something up, or suffering from stress in the workplace, it is frequently not my medical knowledge that I draw on. It is very often my own or learned experiences, combined with common sense that can be most helpful to patients. Of course, the medical knowledge helps-knowing a little bit about lots of things won’t win me a gold medal, but it might just get me on the podium for those patients presenting without a barcode on their forehead.

Barcode

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Medical

The decline.

I was out cycling with a friend recently when he told me about the comments of an ex professional cyclist. When asked about how he enjoyed cycling after his retirement, his reply was, “it’s all about managing the decline”. We chatted about how difficult this must be, to reach the peak of a sport, and realise that your time is up and how to deal with that recognition. As I watched my friend disappear in to the distance, I mused over my own peak-had I reached it yet?

Decline

It was later in the day, on recovering my breath, that I began to draw an association with our role as primary care physicians and the “management of decline”. We see many patients every day, of all ages, some ill and some not so ill. With the ever increasing age of the population, we are of course seeing larger  numbers of  patients who are past “their peak”, whose health is declining, and many of them also struggle to come to terms with this, and will frequently seek help in how to manage it. More specifically, it got me thinking about those patients whose health is deteriorating, for whom there is no prospect of improvement, and coming to the realisation that we perhaps should be focusing our efforts jointly with patients on “managing decline” rather than cure. One difficulty is accepting this, or understanding when that point is close to being reached, or has already been passed.

I am not talking about the patients on a clear cut pathway of treatment and transition into palliation. The oncologists and palliative care teams will be seeing a lot of these patients, and of course usually manage this transition well. I am talking about those suffering a gradual decline and being managed mainly in primary care-perhaps living with dementia, heart failure or simply old age.

A few years ago I heard of a patient living with alcoholic liver disease. His GP advised him during a consultation-“look, we’ve discussed this before, if you don’t stop drinking then you are going to kill yourself”.
The patient paused before answering-“I know that doctor. You have told me before, but you didn’t tell me it would take this long”.
The penny dropped, the doctor realised at this point that the patient understood his predicament. He was not going to stop drinking-he wanted help and support in “managing his decline”. The relationship changed, the doctor stopped looking for a cure, and they worked together with a shared understanding of the management plan.

plan

So what can we learn from this? As a doctor, I have learnt to keep listening, asking questions and to constantly revisit the management plan to ensure that wherever possible patients, carers, families and doctors are all singing from the same hymn sheet. We perhaps should consider this more readily, even in those patients without an obvious “terminal illness”, helping patients accept illness and to manage their ill health. We should not be afraid or surprised of what patients might tell us-offer them opportunities to discuss their fears and expectations, encourage them, allow them to voice their darkest thoughts . Above all, support them in that difficult journey from health, through their peak, down the inevitable decline towards death.
Patients may have formed their own conclusions about their health well before we realise, and discovering this sooner rather than later will help them and doctors alike.

Richard Cook
August 2013

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