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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

Can I ask you a question?

We have been interviewing recently-both for a new partner and a lead nurse to replace two team members seeking the hallowed ground of retirement. We thought long and hard about appropriate questions to ask to bring out the best in the candidates, and we are very happy with our chosen replacement colleagues. I was keen to ask the question “Describe yourself in three words”, as I was hoping for someone to be brave enough to answer “Succinct”. In the end this question did not feature, but I think it could have told us an awful lot about the individuals, and even their consulting styles.

We all have different consultation techniques, finely honed over the years and constantly undergoing change. I would probably describe mine as “minimalist”-rather like conversations with my wife where I have learnt to say little, listen carefully, nod and grunt at appropriate times and leave the door open for further discussion if needed. I feel comfortable in this role, but it is perhaps more a reflection of my natural persona than any learned technique-some of my more verbose partners will consult very differently and our patients of course will often select where they feel most understood, so it is nice to have such variety in the practice.

Just occasionally I get shaken out of my comfort zone, and this is often when the tables are turned, and the person sitting in front of me starts asking me the questions. “Hang on a minute” I think, “I’m Paxo, not you” (Can you imagine him as physician…? )
I was recently stumped by a patient I was counselling about a vasectomy, when he suddenly asked me “Have you had one doc?”

Where do you start when answering that-a straight yes or no would be perhaps the easiest way, but the implications of the enquiry go much further. What might they ask next-“I’m struggling with the fall out of my affair, have you ever had one doc”? This type of questioning almost takes the conversation out of the consulting room and into the pub, a few mates sitting around having a drink and picking over marital difficulties-that’s not where I see myself with patients, but maybe it is an indication of them feeling confident in asking for advice. There are no set boundaries for the patients in the consulting room of course-just social convention and we can learn a lot about patients from the questions they ask.

The obvious Catch 22 question I think is “What would you do doctor?” The almost impossible question to answer-trying to separate my own learned experiences and medical knowledge, from the patient’s. Despite having a broad overview of the evidence behind medical treatments, it is very difficult not to let individual observations affect my decision making process, and distill that to answer the question I think the patient is trying to ask, with reference to their own particular circumstances, not mine.

Would I take medication to turn my yellow toenails clear again? No-not after I have seen one nasty medication induced hepatitis I wouldn’t, but I’m not the 19 year old flip flop model looking for work so that’s quite a tricky one to answer…

In general, as a patient I would be inclined to do very little, take very few treatments, and rely heavily on nature taking its course, particularly in acute illness. In reality, some patients take a different view on life, and here I will just try and present the pros and cons of treatment (or not) as best I can. The really tricky ones are where the benefits of treatment are not clearcut-for example with palliative chemotherapy. What would I do? I really don’t know, and as there are so many differences in our situations, I also don’t know what you (the patient) should do-but we will sit down and work through it together.

So what to do the next time a patient says “Can I ask you a question?”
Run for cover? If they ask me “What would you do doc?” I will give them the best answer I can think of…

“Well I would ask my doctor of course.”

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Uncategorized

Need a job?

My senior partner has just announced his retirement after 30 odd years working at the frontline of primary care . Before the ink is even dry on his letter to us, our thoughts turn to how to replace him. Who, in this day and age of political meddling of the highest order, restricted budgets and the promise to work for longer and longer hours, would want a job in primary care?

A friend of mine is involved in opening a new café in Brighton which has a strong cycling theme (http://www.velo-cafe.co.uk/). What a great idea-cycling and coffee have always been a perfect match so to bring them so close together seems obvious (especially as it is virtually on my doorstep).So what will he look for when employing new staff for this exciting venture and how will he sell his project to them? Presumably attributes such as an interest in cycling, coffee or both  would be a good start? An interest in people? A believer in good customer care? This is beginning to sound like my perfect replacement partner-substitute patient for customer and we’ve got a deal!

In reality of course, there are lots of attributes that we look for in a new partner, and there must be many ably qualified doctors out there to fill such a role. It seems, however, that many of them are not looking for a partnership role, but choosing to bide their time and see how the political landscape settles down over the coming years before committing themselves to a permanent post.

Well-my message to them would be…don’t be put off primary care. The nation will always need GPs, and we need good ones. The organisation of healthcare is changing, but there will always be a requirement for good primary care teams. We also need interested doctors to be involved in shaping the future of primary care-this can be done alongside our daily work if you are part of a good team. We need Queen Bees and workers-you can develop your role over time and there is huge scope now in primary care to take up interests in a variety of clinical and non clinical areas.I feel you would be best supported in this as part of a good partnership-one in which you can rely on your colleagues, and they can rely on you.

I suspect in 20 years time our health care assistants will be performing coronary bypass surgery in the basement as a daycase, but we will still need someone to look after individuals and their families in the community. Despite the chaos around us, we can still focus for 10 minutes at a time on the patient in front of us-this will always be our prime objective, and is what makes our core job so special.

Come and join us.

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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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