Author Archives: Adam Staten

Adam Staten

About Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.

General Practice: The Game of Inches

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

Latest posts by Adam Staten (see all)

Anybody who was a fan of movies, sports, or Al Pacino in 1999 is probably familiar with Pacino’s famous ‘game of inches’ speech. Pacino was playing the part of coach to a struggling American Football team and it was with this speech that he inspired his team before they ran out for a make or break match. Many consider it to be a paradigm for motivational speaking.

In it he describes American football as being a game that is won or lost by inches. The inches are the fine margins found everywhere on the pitch that determine the outcome of the match; the inches by which a crucial kick is made or missed, the inches by which a touch down is scored or stopped, the inches between a ball being caught or fumbled.

The general practice consultation is a game of inches or, more accurately, a game of seconds. In a world of increasingly complex patients and increasing administrative burden every second within the ten minutes counts. Squeezing every second is the difference between running to time or running late, it is the difference between satisfying the patient by dealing with their second problem or getting an unpleasant comment on the friends and family test, it is the difference between having the time to make the right decision or the wrong one.

In between looking at that funny mole and ticking the QOF boxes, it is easy to let the note taking seconds vanish from the consultation. How often is a complex and draining consultation summed up with a couple of rushed and inadequate sentences that hardly do the interaction justice as we hurry on to see the next patient? How often do these rushed entries leave us indefensible in the eyes of the law and the GMC should things turn out badly?

It seems unlikely that our patients are about to become more straightforward and, whilst we might wish it, the administrative burden of our roles is unlikely to diminish any time soon. But there are ways that we can squeeze those vital seconds, ways in which we can make that part of the consultation count.

How many of us ever learn to touch type?

For example, almost every interaction we have with patients results in typing and yet how many of us ever learn to touch type? A proficient touch typist can type as quickly as someone speaks and it is a skill that is relatively straight forward to acquire with a few minutes of practice each day over the course of a few weeks.

Of all the technology in our rooms, the keyboard is amongst the most simple and yet most of us use it badly. Data from NHS England suggests that the mean number of words typed in a GP consultation is 29.¹ This seems very little given the often complex nature of the consultations and probably reflects the time pressures involved. This data was from an audit of 200 consultations and data acquired from the same audit suggested that a GP who touch types rather than using the ‘hunt and peck’ method of typing could save 17 minutes each day, or nearly two consultations worth of time, based on 40 consultations per day.

Perhaps better yet is to stop typing altogether. Voice recognition technology is not new but it has taken some time for it to become capable of handling medical dictation. At my practice, most of the GPs now dictate directly into the patient notes, both for consultation notes and for letters, obviating the need to type at all. We use Dragon Medical which can transcribe at a rate of 160 words per minute, but there are numerous other medical transcription software packages that are capable of the same.

The ten minute consultation is bursting at the seams as is, arguably, the whole of general practice. If a seismic shift in the way we work is not soon forthcoming then, for now, we need to work in the inches. We need to find ways to make every precious second count and there are relatively simple technologies available already that can help us do that.

Reference

1. https://www.england.nhs.uk/wp-content/uploads/2016/03/releas-capcty-6-topic-sht-6-3.pdf

Book Review: The State of Medicine by Margaret McCartney

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

Latest posts by Adam Staten (see all)

thestateofmedicine300The State of Medicine is an eloquent, passionate, comprehensive, and, in many ways, dispiriting overview of the repeated damage inflicted on the NHS at the whim of successive governments. The frustration of the author, a GP from Glasgow, pours from every page, every paragraph and every sentence, as she contrasts the efforts of doctors to practice evidence based, safe, humane and cost-effective medicine, in a system that is routinely upended and overhauled according to manifesto sound bite, political opinion and, occasionally, outright self-interest.

Whilst the general themes of this book will surprise few who work in the NHS, the actual facts and figures, such as the vast sums wasted on management consultancy firms, may make the eyes of even the most hardened cynic water.

Each chapter begins with an interview with someone who is able to give a different perspective on our collective woes. Amongst these are some real gems that offer unexpected insights into different niches of the NHS world. The words of an A&E consultant who was working at Mid Staffs during the scandal may send a there-but-for-the-grace-of God shiver down your spine, and the thoughts of a Nobel prize winning economist will have you bewildered that there are still so many advocates of insurance based health care systems.

Dr McCartney offers a clear account of the follies of the last few decades and a personal view of where and how the NHS should proceed from here with ideas such as buffering the NHS from policy makers, funding it properly, treating health professionals with respect, and actually basing policy on evidence.

The message of this book is important. We must hope that it reaches a general readership, or, hoping even more bravely, that it reaches an audience amongst the political classes.

Medicine in an Age of Empires

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

Latest posts by Adam Staten (see all)

file000480371600

Photo by clarita at Morguefile.com

I recently attended a talk at the hospital post-graduate centre where the speaker introduced herself as the hospital’s new ‘heart failure consultant’ rather than the new cardiologist. This set me thinking, as many things do, about the strange nature of secondary care medicine. Single organ specialisation is now a thing of the past, apparently our hospital based colleagues are best employed dealing with single problems of single organs. Many of the same thoughts occurred to me when I listened to a lipid specialist describe the difficult and technical differentiation of familial hypercholesterolaemia from poly-genic hypercholesterolaemia in patients with a cholesterol of 8. They all ended up on statins by the way, and they did very well.

This degree of sub-specialisation has, of course, big knock on implications for the way we deliver care in general practice. If, as a hospital consultant, you establish yourself as the lead for a niche service then you really have to tout yourself as the best person to be dealing with that particular problem, perhaps even the only person who should be dealing with that problem. If you want to spend your time looking after malfunctioning left little toes then you need to tell everybody else to leave the left little toes to you because they simply won’t do a decent job of it. Here, guidelines are key. Guidelines are both the supply route and the fortification of all the little medical empires that spring up all around us.

For me this is the best explanation for all the guidelines that at some early and arbitrary point advise that the GP ‘consider referral’. At this point many of us will obediently refer to the specialist only to find that the specialist almost immediately loses interest in the patient and passes them on to his team of specialist nurses who then efficiently steamroller the patient along a single issue algorithm. The single organ’s single problem is often dealt with wonderfully well but how often is the patient left at the end of it feeling slightly bewildered and taking a handful of tablets every day that they don’t really understand?

Perhaps this is all well and good. While the new service functions it allows us to unload all our left little toe problems to the hospital but, about thirty seconds after its launch, the new left little toe service will almost certainly be swamped by GPs following the guidelines. Suddenly our patients are waiting an age to receive treatment that we really could deliver ourselves. But there is a new problem now because, if something goes wrong, we’re left defending a decision not to refer to our specialist when the guidelines told us that we should have done.

At this point the guidelines are no longer an aid to us but they serve only as a length of medico-legal rope with which GPs can be hanged. Disempowered by the guidelines that tell us to refer, we are left either not providing standard treatments for our patients or facing the risk that, if something goes wrong, we could end up in hot water.

In circumstances like this it is good to ask Cui Bono? And not just because saying stuff in Latin makes you seem frightfully bright. This fragmentation of care often seems to be to the detriment of the patient and it can certainly make it harder for us to take management decisions. Sometimes the greatest benefit is to the consultants in maintaining their role as guardians of their own niches.

If we are to achieve the shift of patient care back into the community then guidelines should be written with a view to helping the generalist and not the specialist, and written by people who understand what it is to be a generalist. I could go further and suggest that we should stop funding consultant led services whose practice can be boiled down to a single A4 sized flow chart and spend more of our precious money on generalists both in and out of the hospital.

Time for the old guard to join the social media fray?

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

Latest posts by Adam Staten (see all)


OLYMPUS DIGITAL CAMERAThe news is everywhere. I don’t mean this in the way that I might if I were a dewy-eyed aspiring journalist, seeing fascination and potential scoops in everything around me. I mean that news coverage seems to be literally everywhere; on the TV, on the radio, on the computer, on the phone in my pocket, on a big screen in Waterloo train station. It’s inescapable. And when it comes to health news, or more particularly doctor news, it never seems to be good news.

Headlines such as: “1 in 4 cancer cases missed: GPs send away alarming number of patients” (Daily Mail, 1st March 2011), “These overpaid doctors must stop whingeing” (The Times, 28th May 2014) and “Study reveals scale of errors on doctors’ prescriptions” (The Guardian 2nd, May 2012), are depressingly commonplace.

Even when we try to recruit the help of mainstream media it seems to get turned against us. The BMA tried to make the point that ten minute appointments are potentially dangerous for patients so that general practice might get the support it needs to provide longer appointments.  To convey this message the ticker feed of the BBC news channel informed the viewer that “GPs are putting patients in danger with ten minute appointments” as though it is out of sheer contempt for our patients that we refuse to give them any more of our time.

It’s not just us. The junior doctors were subject to The Sun’s ‘Moet Medics’ smear campaign and, when the consultant contract negotiations re-opened recently, the BBC obligingly ran a story entitled “NHS consultant paid £375,000 in overtime” to point out that it isn’t only GPs who are workshy and overpaid.

I thought it was just me making my wife feel uncomfortable by screaming at the TV in the evenings, but a recent study in the BJGP exploring why younger GPs are leaving the NHS found that 63.4% of them are also pretty miffed at this continual public abasement.1 Thus far, shouting at the TV seems to have achieved relatively little but there is an alternative. The junior doctors used social media pretty effectively to counter a lot of the negative media coverage during the last round of strikes. The noise on social media outlets revealed widespread public support for the juniors, which helped to strengthen their resolve and legitimise their cause.

Unfortunately, I suspect that many GPs, dare I say many older GPs, are wary of being too vocal on social media, with a hint of concern that opening a Twitter account is akin to giving your patients a key to the back door and painting a target on your back for the GMC to aim at.
This is a shame because social media is our best tool for getting across our side of the argument and it is also a fantastic way of opening up a dialogue with the public. These arguments would be well explored by the reluctant older generation of GPs who have earned experience and gravitas by passing through the mill of the NHS over the last few decades and who can spot the same cycles of mistakes re-appearing over the horizon.

Having a good rant on a blog is incredibly cathartic, I can feel myself relaxing as I type, but it is also a way to reach thousands, potentially tens of thousands, of people in a matter of hours which is exactly what some successful GP bloggers do.

Social media is an effective means to counter the denigrations of our profession and, so dependent has the mainstream media become on social media that, if we make enough noise, we might even begin to influence them. And that might even mean the occasional positive headline.

Reference

1. Doran et al. Lost to the NHS: a mixed methods study of why GPs leave practice early in England. Br J Gen Pract Feb 2016, 66 (643) e128-e135

You’re the Doctor

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

Latest posts by Adam Staten (see all)

When a patient says ‘you’re the doctor’ it can mean several things. Sometimes it means ‘I trust you and the advice you’ve given me’, sometimes it means ‘I don’t like what you’re saying but I don’t feel like I’m in a position to argue’, and sometimes it means ‘just get on with it and do what you’ve got to do’.

Whatever it means when a patient says this, it always feels like a kick in the teeth to me. Since my first day at medical school, the day on which I underwent my Balint lobotomy, I’ve been told to be patient centred. I’ve been taught that there really are no doctors and patients just symbiotic, therapeutic alliances from which mutually agreed treatment plans will emerge.

So when a patient tells me that I’m the doctor I feel like they’re not playing the game. When a patient says this, my inner consulter screams, ‘No! I’ve handed over to you now, just like Roger Neighbour told me to, we need to share this decision like Pendleton suggested, and then we’re going to modify your health seeking behaviours like Stott and Davies wanted’. But an astonishing number of my patients haven’t read any of Neighbour’s work. Even fewer seem to be familiar with the Cambridge-Calgary model, which may explain why some of them don’t seem to get in when I’m ‘closing the session’ and seem instead to want to talk about more problems.

A recent BMJ article, written by a patient, talked about this experience from the other side. The author spoke of feeling bemused and uncomfortable when her GP asked her questions like ‘what do you think is wrong?’ or ‘what do you think we should do about this?. Interestingly, the author found the relentless pursuit of her ‘ideas, concerns, and expectations’ was actually damaging to the therapeutic relationship as it resulted in her losing faith in her doctor.

This is unsettling but not surprising news. The fact that a number of patients simply want to be treated as a patient is obvious to us all from everyday practice. Many people simply want to be told what’s wrong with them and what to do to make it better.

There is an assumption in medical education that this dynamic, the one in which the doctor is in control, comes naturally to all doctors and so doesn’t need to be taught. But even if this type of consultation does come naturally to many doctors, we spend years of training disempowering doctors from taking on an authoritative role in a consultation by punishing them every time they do so in an exam situation.

The current paradigm for the medical consultation is heavily weighted towards eliciting ideas, concerns and expectations, and the MRCGP clinical skills assessment mark scheme reflects this. This encourages rigid adherence to consultation models so that the appropriate boxes can be ticked on the mark scheme. And this can be really detrimental to the natural communication skills that many doctors already possess, turning them from instinctive consulters to consulting play actors.

Articles such as that in the BMJ are evidence that we need to ensure that our doctors can consult flexibly, are able to recognise different consultation dynamics, and are able to be the doctor when that is what the patient wants them to be.

Tasked based medicine and the generalist

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

Latest posts by Adam Staten (see all)

photo-1463171379579-3fdfb86d6285Perhaps I have had a run of bad experiences but I sometimes feel that our secondary care colleagues are beginning to act as technicians and not physicians, directing themselves to a particular task to rule in or rule out a particular diagnosis, and ignoring the fact that the patient is suffering from symptoms, not from a diagnosis. For instance, you may refer a patient complaining of acute onset shortness of breath to the medical team, querying a PE, to have them sent back to you with ‘no exertional desaturation, d-dimer negative, no evidence of PE’. So now you find yourself with a breathless patient who mere hours before was tantalisingly close to investigative possibilities that would have given you an explanation for their breathlessness, but who is now back in the community, still breathless, and as distant from those investigations as they were when they first came to you.

I don’t hold this against those working in secondary care, they are usually as swamped as we are, and they get given a task, get on with it, and then move on to deal with the mountain of other tasks awaiting them. But this task based approach to medicine makes for some very clunky and uncoordinated care for patients with complex or difficult to diagnose conditions. These patients can end up batting back and forth to the hospital being seen by different specialists in different specialties to get the investigations that they need.

It may just be the local guidelines and protocols where I work but I often feel that I make referrals simply to get a particular investigation done. Colonoscopy for example. There are certain patients who clearly need a colonoscopy, such as those with suspected inflammatory bowel disease. I can take the history, take the bloods, check the faecal calprotectin but then, at the final diagnostic hurdle, I have to refer, and so my patient will wait weeks to see either an SHO or a registrar in clinic who will take the history again, probably repeat the bloods, and then agree that they need a colonoscopy.

Part of the problem has been the inverted investment strategy of the last decade that has seen the number of hospital consultants increase at double the rate of GPs. This burgeoning cohort of consultants are sustained in purpose by the artificial rationing of investigations and the production of guidelines where every step is caveated with the advice to consider referring to a specialist.

Clearly resources are finite and we will always need appropriate stewardship of diagnostics but is this not best done at arms-length by specialists, rather than with face-to-face consultations?

In this month’s BJGP Sampson, Barbour and Wilson explore the use of email communication between primary and secondary care and their findings suggest that its use is patchy and limited.1 But should this not be the default means of accessing secondary care investigations for the majority of our patients? A brief email exchange between GP and specialist to guide and rationalise investigations is surely a far more effective use of everyone’s time and money than sending patients to have an outpatient appointment to have investigations arranged that could have been arranged weeks before?

This would enable GPs to do what they are supposed to do: provide holistic and co-ordinated care for their patients. It would also allow consultants to do what they are supposed to do: be consulted. There is some evidence that working in this way can cut the need for outpatient appointments by up to 50% in some specialties which would certainly ease the pressure on the whole system.2

As outlined in the same paper, there are some potential problems with email communication, particularly around the issue of confidentiality, but there are already systems in use around the country that have overcome these issues. Surely the use of these should be much more widespread.

NHS England’s Five Year Forward View has lofty ambitions of moving care back into the community. Allowing GPs much freer access to the full range of diagnostics will hugely facilitate this aim.

References

1. Sampson, Barbour, and Wilson. Email communication at the medical primary–secondary care interface: a qualitative exploration. Br J Gen Pract 2016 Jul; 66 (648)

2. Roland M, Everington J. Choose and Consult over Choose and Book. Health Serv J 21 Jan 2016

Home surveys and colonoscopies: coping with risk and reassurance

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

Latest posts by Adam Staten (see all)

DSC05260Today I am writing from the most middle class circle of hell; the circle of hell where sinners are stuck in a perpetual home buying chain. Of all the costly obstacles to selling and buying houses, I have found the home survey amongst the most frustrating. The survey of our house was bizarrely damning and, whilst the surveyor found no actual evidence of things having gone wrong, he was full of apocalyptic ideas of things that might go wrong.

Annoying though all this was, I felt some kinship with the surveyor. I recognised the words of a man who was covering himself against future litigation. Lines such as ‘this type of guttering can leak, if it leaks it might cause damp, if there is damp the woodwork might rot’ brought to my mind entries in children’s medical notes which effectively read, ‘this child has the snuffles, I can see no evidence of meningitis, sepsis, Kawasaki’s etc. etc., but should any of these things happen take the child to hospital.’

Our surveyor suggested going to some pretty extreme lengths to make sure all was well. He suggested tearing up some floorboards to make sure the floor joists weren’t rotten, dismantling the bathroom units to make sure there were no leaks, and re damp-proofing the house in case the existing damp course was insufficient. Essentially he would remain unsatisfied until our house was reduced to a pile of rubble atop which he could stand and declare ‘there was nothing wrong with that house.’

He was suggesting causing quite a lot of damage looking for problems that probably weren’t there. And this made me think of the new cancer guidelines which are based on symptoms with a positive predictive value of 3%. These symptoms trigger investigations which, of course, have inherent complications and risks. Some studies have found that colonoscopy, for example, can result in up to 4% of people being admitted to hospital within 30 days of the procedure. Even prostate biopsy has a mortality rate.

So are we now like my surveyor? Are we not to be content until we can stand atop the psychological and physical rubble of our patients and declare ‘there was no cancer here’?

The home survey was essentially pointless. It reported so little hard fact that a buyer either had to just ignore it and go ahead with the purchase anyway or, like our buyer, take it all at face value and walk away. So this begs the question, is the way we practice medicine becoming pointless too? Is our clinical assessment of no value without investigations to back it up? Will we reach the point where the guidelines will make it indefensible for us to say that someone doesn’t have cancer without the caveat that they should be subjected to a battery of invasive procedures just to make sure?

Our buyer could not be reassured without the fabric of the house being placed in jeopardy. How many patients will wish to jeopardise their own fabric for reassurance? As society becomes more risk averse, striking the balance between reassurance and investigation is surely going to be one of the trickier issues our profession faces in the coming years.

The Joy of Diagnosis: how to attract candidates to general practice

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

Latest posts by Adam Staten (see all)

file8841261948414Diagnosis is one of the most rewarding aspects of medicine and is one of the most attractive features of general practice.  There are few areas of medicine, arguably just general practice and the Emergency Department, where you get the opportunity to encounter a patient ‘fresh’, no prior history, no prior investigations, just you, the patient, and your clinical acumen. In general practice we often get the opportunity to make a diagnosis several times in the same ten minute period and, for me, the less investigating and referring I have to do to make a diagnosis the more satisfying it is.

I think this is an undervalued part of our job. An attempt to sell a career in general practice to medical students and junior doctors usually involves talk of holistic and continuous care, variety of work and variety of opportunity but rarely do you hear an emphasis on the pleasure of seeing droves of patients teeming with fresh pathology. True, much of the pathology is mundane, but then much of it really isn’t, and the enormous challenge in our job is recognising pathology in all fields of medicine, surgery, psychiatry, paediatrics and on, and on.

By far the bulk of medical diagnoses in this country must be made in general practice and yet it seems to me that we allow our thunder to be somewhat stolen by the physicians who set themselves up as the master diagnosticians and the keepers of arcane knowledge. Take the differences in the membership exams for the colleges of GPs and physicians as an example.

The MRCGP is an incredibly pragmatic exam, focusing on common conditions, current guidelines and safe management. It culminates in the clinical skills assessment which is run like a morning surgery but, as it uses actors for patients, features no real pathology. This is the one weakness in an otherwise excellent exam.

In contrast, the MRCP is an unashamed peacock of an exam that bears only the faintest resemblance to reality. I remember learning in great detail about the diagnosis and treatment of Waldenstrom’s macroglobulinemia in preparation for the first part of the written exam as the condition seemed to crop up over and over again in the mock exams. My new found knowledge made me feel all fired up to go out and diagnose my first patient. Then I discovered the incidence was between 2 and 6 per million and I find that, seven years on, I’m still waiting to make that diagnosis and I’m not quite so fired up.

The pinnacle of the MRCP exam is PACES in which there are several stations where you get six minutes to examine a single organ system of a patient in virtual silence. You are then given an opportunity to talk confidently to the examiners about an illness you have probably never seen before, and may well never see again.

In some ways the difference in emphasis is backward. I have never known a secondary care physician make a diagnosis without a battery of investigations to back it up, but it is rare for a GP to make a diagnosis without a heavy reliance on clinical acumen.

Clearly there is a balance to be struck. A detailed knowledge of weird and wonderful conditions can induce the paralysis of the differential when confronted with a strange array of symptoms, but the one advantage of the MRCP is that it forces candidates to trawl the wards looking for clinical signs and so it ensures that they become confident in hearing heart murmurs and tipping spleens in a way that the MRCGP doesn’t.

As guardians of NHS resources, is it not worth us ensuring that our new trainees feel more confident in clinical examination and less reliant on investigation? To this end, should the MRCGP have more emphasis on recognising real physical signs? I think that confidence in examination enhances the pleasure of diagnosis, and I think the pleasure of confidently making diagnoses should be at the fore of marketing our specialty to prospective candidates.

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.

The Locum: Assassin of Independent Contractor Status

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

In the June issue of the BJGP there was a debate as to whether GPs should maintain their status as independent contractors. To me this seemed like a macrocosm of the decision that all newly qualified GPs have to make when it comes to finding a job.

Since the new contract for general practice it seems to have become the norm for a new GP to take a salaried job which provides stable employment and predictable pay without the burden of extra responsibilities born by partners. Generally this is considered a stepping stone to partnership.

But the status quo is being upset by the increasing popularity of locuming. Dr Larry Locum seems to be the man who has his cake but eats yours. Advocates of this way of working describe it as a Nirvana of convenient working hours, minimal responsibility and good pay. The appeal is obvious and, as the pay for salaried roles gets squeezed, the appeal is growing. Although this life has potential to be unstable many of my cohort feel that this is more than offset by the flexibility and the remuneration.

Whilst many still see a period of doing locums as a prelude to seeking permanent employment there is a growing number of GPs who feel no compulsion to take either a salaried role or a partnership after years of enjoying locum life. Interestingly, medical chambers are also filling up with GPs who have been partners but now wish to locum.

Could this way of working pose an existential threat to the partnership model?

Without wishing to sound mercenary, a big part of the problem is pay and, in particular, the complexity and opaqueness of partner pay. Ask a salaried doctor how much they get paid and they can tell you their pay per session. Ask a locum and they can tell you the going rate. But ask a partner and their eyes glaze over and they start talking in tongues, using phrases like ‘notional rent’, ‘local enhanced services’ and, of course, the ‘QOF’. Meeting the shifting targets of the QOF alone seems as fiendish as a battle of wits with Professor Moriarty. This complexity, combined with the fact that partners often seem to work harder and bear more responsibility than their colleagues, makes partnership seem daunting and uncertain.

Clearly there are less tangible rewards in partnership. People talk of the ability to guide your practice in the direction you wish it to go, or the emotional satisfaction of nurturing your own business but, to the uninitiated, these rewards can seem fairly trifling compared to the possibility of losing your house if things go really wrong.

Compared to becoming a locum, where the pay can be closer to that of a partner, becoming a salaried GP is increasingly seen as an under rewarded role and yet it is still the predominant job type on offer in the jobs market. Whilst many practices seek to employ salaried doctors the logical choice from the perspective of a GP registrar is between seeking one of the few available partnerships or doing locums, or at least having time free in the week in which to do locums on top of a part-time salaried role.

This tension between the demands of new GPs and the supply from practices is in danger of making the locum role the norm with the attendant possibility of sleep walking the partnership model of general practice out of existence. Without partnerships the debate over the independent contractor status of GPs will be moot, it will simply cease to exist.