Monthly Archives: December 2015

GP trainees: a subtle thread of generalism in secondary care

DSC02665Adam Staten is a GP trainee in Surrey and is on Twitter @adamstaten.

The current struggle to recruit into general practice has been well described and the concern around it has rightly focused on how a shrinking workforce will continue to provide 90% of patient contact in the NHS without imploding.

Having recently completed the last of my hospital placements as a GP trainee, I have been reflecting back on my time in hospital and have come to believe that falling numbers of GPs in training will also impact secondary care services in a number of subtle ways. The on-call rotas for many specialties are bulked out, and in some cases sustained, by a steady flow of GP trainees. Even at the embryonic stage of their careers it has been my experience that GP trainees tend to take a more holistic approach than their specialist counterparts who are often necessarily focused on gaining procedural experience. More than this, GP trainees are often the only members of specialist teams with any recent general experience and these teams rely on their GP trainees to stem the haemorrhagic tendency for in-house referrals that can swamp hospital services.

I have been surprised at times how quickly doctors lose confidence and competence in vast areas of medicine once they enter a specialist training pathway. Even those working in the general environment of A&E often consider whole specialties, most notably psychiatry and gynaecology, as outside of their remit. I can’t deny some frustration in being the psychiatry SHO called upon to ‘risk assess’ a stream of teenagers who have attended A&E drunk and upset after an argument with their partners, or in being the gynaecology SHO receiving referrals for every woman with a set of reproductive organs in anything less than perfect working order. Often a gynaecology referral is completed with the phrase ‘I haven’t examined her because you’ll have to do it anyway’, a logic that serves only to perpetuate the referring doctor’s own skill fade.

There is a great deal of risk in this pigeonhole approach to medicine. I have seen this recently in the form of a young woman who was unable to walk unaided and who was triaged directly to the antenatal ward, despite the presence of upgoing plantars, simply because she happened to be pregnant. She was later urgently transferred to the local neurosurgical centre for treatment of her spinal cord compression secondary to TB.

By way of contrast, during these 2 years I have had frequent cause to speak to GPs: while accepting referrals, in seeking more information about patients, or while trying to arrange a discharge. Not once have I encountered a GP who begrudged the conversation or flinched at what, at times, have been almighty dumps from secondary to primary care. It is that level of confidence, competence, and willingness to take responsibility to which we as GP trainees should aspire. Even before we finish our training, GP trainees are valuable to much of the health service as a subtle thread of generalism woven into the secondary care tapestry that, in some small ways, eases the frequent dysfunction and disjunction of secondary care teams focused on single organs.

While serving this purpose we should counter the frequent question: ‘Why are you wasting your time with general practice when you could be a good specialist?’ with what I feel is the more obvious question: ‘Why on earth do you want to devote your career to 25 feet of bowel lumen or to two aerated sacs of flesh or to the prostate and testicles when the whole of medicine could be open to you?’

General practice should be an easy sell and we all need to be more enthusiastic salespeople of it for the sake of ourselves and our secondary care colleagues.

Junior doctor dispute: The politicisation of a generation

24900_701854411339_8280213_nThuvaraka Ware is a GP Registrar working in Camden. She tutors medical students at UCL in community medicine and believes primary care research will shape clinical and public health policy over the coming years.

I am a junior doctor. I went through medical school, foundation and speciality programmes with relative ease and multiple accolades.  I married a guitar playing, Aston Villa supporting historian I met at university who entered policy work.  I would scoff at his insistence that politics was important – I truly believed that I was doing the only true and noble job in the world. Politics was beneath me.

Experiencing the furore of our contracts dispute I now realise how completely and naively politically illiterate I was.  To disengage with this process and say it does not concern us for we are public servants has proved detrimental.  If the health secretary has done nothing else, he has at least caused a political awakening amongst our generation and I am not ashamed to say that at times this has been thrilling.  I have attended marches, canvased local support, given interviews, written and appeared in newspapers and journals and signed numerous group letters to various news outlets.

Social media has played a central role in this. Facebook groups have allowed us to feel connected to almost every other junior doctor in the country in some way, answer queries, debate responses and celebrate victories. The twittersphere, has enabled rapid dispersal of information and opinion.   Both these have helped nurture and spread the message of an essentially grass roots campaign, like #meetthedoctors, to fight the imposition of a contract that is unsafe for patients and unfair to us.

The unravelling of this dispute in the media has strengthened the resolve of many of my peers to become more politically active.  Many believe that the media have to take responsibility for their role in exacerbating this dispute – you may recall the now retracted 1998 Wakefield study and subsequent rise in incidence of measles as an example.  Indeed the online national survey by Gan et al1 to explore the ‘Hunt effect’ suggested that in the months after reporting of Jeremy Hunt’s irresponsible interpretation of the Freemantle epidemiological study2, there were patients presenting later than they would have to emergency services, afraid the weekend care would be suboptimal.  Patient care was potentially compromised as a consequence.

By engaging with the press, we are able to project our concerns whilst also being able to hold them accountable to what they write – my peers have written letters to the Independent Press Standards Organisation (IPSO) and a complaint about a report on our pay was recently upheld by the BBC.  This increased engagement between our media and the scientific community can only be a good thing, hopefully leading to an improved relationship long term.

As we enter the next chapter of this dispute with a clear mandate for industrial action it is life affirming to realise that we are not alone.   Many patients, allied health professionals and other emergency staff understand the nature of this fight and stand with us.  Becoming politically aware does not have to mean just engaging with politicians and the status quo.  It is also the way we connect on a meaningful level with those around us to make our immediate and extended social, cultural and economic environment relevant and bearable.

Although I am yet like a child taking my first steps in this new landscape, my feelings of political apathy are diminishing and I sense that change is possible.  I’m aware that our contracts debate will take many months to resolve.  But I am hopeful that our political awareness and social responsibility will survive the crest of this campaign post crisis, whatever the outcome.

 

References

1. Gan HW in response to BMJ 2015;35:h4596. Available online:  http://www.bmj.com/content/351/bmj.h4596/rr-52
2. Freemantle et al., Increased mortality associated with weekend hospital admission: a case for expanded seven day services? BMJ 2015;351:h4596