Tag Archives: AiT

Trainee notes: Life school

IMG_3788Aisha Yahaya is a GP ST2 with Imperial VTS who has an interest in effective communication with patients, writing and a yearly resolution to save her guitar from the dusty corner in which it sits.

Increasingly, I learn more about the way of the world by looking through the eyes of my patients.  As I reflect on my time spent in a large urban GP surgery, I share my feelings and what I learnt from the patient narrative.

Bravery, active listening and understanding. Very often, a patient will come with a problem that has troubled them for a while and their appointment with me is the first time they have mustered enough courage to seek help.  I was faced with this scenario when a patient told me they were uncomfortable with their identity and wanted to change this. In this case I learnt about bravery.  Patients take steps to help themselves by asking me for help or guidance. This is a sign of strength and it gives me a chance to empower them to take control of their health, wellbeing and happiness. I often expect patients to trust me easily and follow my advice, which makes me question why they would do so and how willing I would be to do the same if in their shoes.

I am aware of how perceptive patients can be of their doctor’s mood and a balance must be struck when navigating my feelings and theirs.  The difference between a successful or disastrous consultation could be the blank gaze I give a patient if my mind is elsewhere, compared with a simple nod of acknowledgement or the offer of a tissue when they are crying.  In a room with just the patient and me, there is nowhere to hide and this allows vulnerability to thrive.  In order to gain a patient’s trust I have found that putting them at ease and inviting open dialogue goes a long way. There is a reason why patient satisfaction questionnaires that are mostly aimed at a doctor’s attitude towards a patient rather than their breadth of knowledge, which of course goes without saying.

Bigger is not always better. I am sometimes disheartened when I feel I have not made a difference to my patient’s problem.  Despite this, I learnt that whatever the patient describes as a positive effect could be more important than what I think is significant or obvious. For example this could be the case of a simple lifestyle change in a patient with low mood or chronic disease. My GP trainer picked up on a management plan from my entry in a patient’s medical notes during a follow up appointment and asked the patient about it.  The plan was a single goal that the patient and I were confident they could achieve.  My trainer told me that the documentation and acknowledgement of this plan made the patient feel as though they had been listened to and taken seriously.  I find this encouraging and hopefully the patient felt as though they had genuine support from me and the other doctors.

My job as a GP trainee often doubles up as a life school where sometimes the most important lessons are learnt.  As always, I look forward to the next one.

Junior doctor pay changes will damage general practice: the trainee view

Picture 030(1)Ravi Parekh is an academic clinical fellow in General Practice in North-West London with an interest in Medical Education.

I am a GP registrar working in London and over the past few months I have felt increasingly apprehensive about the future of general practice training in the UK. The latest blow to our training comes in the form of the recommendations from the DDRB report on the future of doctor’s pay.1

This independent report states the GP trainee supplement should be removed (currently 45% supplement) and replaced with “a flexible pay premium” known as a RRP (recruitment and retention premium), with trainees paid for the amount of unsociable work that is carried out, and a possible flexible pay premium adjusted locally, to help target problems with recruitment.

Firstly, in the majority of cases, this change will mean a substantial pay cut as trainees progress from a SHO (ST1 and 2) to a registrar (ST3). A large number of hospital rotations will include a substantial amount of unsociable work, which currently is remunerated with normally between 40-50% banding on top of the basic salary. However, the new proposals will mean despite career progression, increased responsibility within a higher risk setting, and working far more independently in the registrar year, there will be a significant pay cut. This would equate to a substantial penalty for choosing general practice as a career.

The BMA have suggested that the recommendations would mean an average pay cut of 30% to GP registrars.2 In real numbers, this is equivalent to a £15,000 pay cut, with virtually no consultation with the GP community or GP trainees, and now with the BMA leaving contract negations, we have no voice to express our concerns.

Secondly, a number of trainees within my own scheme have significant financial commitments, including families, mortgages and other dependants. With the potential of these changes being imposed onto us in the very near future, this will have a considerable impact on our take home pay, with many of us having to think about whether the job remains sustainable. I fail to understand how this fits into the “drive in recruitment” the government wants to achieve, with the goal of 50% of medical graduates entering general practice by 2016.3

Thirdly, there is a need to examine closer the “flexible pay premium” the recommendations suggest can help replace the supplement and solve the problem with GP recruitment. They state these can be implemented in “some parts of the UK”, with no specifics on how much this would equate to, who would be eligible to receive this, who decides whether this should be provided and what protection would we have for this premium. As a London trainee, I have little hope that this will be provided to London trainees or any other trainees who live in an area of the UK where the recruitment for GPs still remains competitive, and given the increase cost of living in these inner city areas, the impact on us will be increased.

Finally, what message does this send to medical students and junior doctors thinking of general practice as a career? With constant negative press in the media, proposals for seven day working, increased pressures to stop A&E admissions and transferring more services from the acute sector to us in the community, it appears to be that general practice is being treated on one hand as the saviour for all the problems in the NHS with no real increased funding to match these expectations.

Interestingly one of the solutions from the government to reduce pressure on us appears to be hiring physician assistants in general practice. These are people with a health related degree who complete two additional years in University. They can take histories, examine patients, diagnose conditions and propose management plans.  These jobs are being advertised with a salary of £50,000 very similar to the current pay we receive as a GP registrar. These physician assistants need to be under the direct supervision of a GP, who it appears will still hold ultimate responsibility for the patient.4,5

So it appears the public are going to be seen in the future by staff who are not doctors, who have not gone through the rigorous GP training schemes, who have not sat the AKT or CSA exams and are likely to be paid significantly more that those about to become fully trained GPs. I hope my fellow GP trainees, qualified GPs and ultimately our patients are aware of what is being proposed for the future of primary care in the UK.

 

References

1.     Department of Health. Review Body on Doctors’ and Dentists’ Remuneration (DDRB) review for 2015: written evidence from the Department of Health. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/382236/DDRB_2015_-_written_evidence_from_DH.pdf

2.     British Medical Association. Contract proposals for junior doctors. http://bma.org.uk/working-for-change/in-depth-junior-and-consultant-contract/ddrb-recommendations-analysis-for-juniors/junior-doctors-contract-negotiations-faq#5

3.     GP Taskforce Initial Report: Securing the Future GP Workforce Delivering the Mandate on GP Expansion. http://hee.nhs.uk/wp-content/uploads/sites/321/2014/07/GP-Taskforce-report.pdf

4.     NHS Careers. Physician Associate. http://www.nhscareers.nhs.uk/explore-by-career/wider-healthcare-team/careers-in-the-wider-healthcare-team/clinical-support-staff/physician-associate/

5.     BMJ Careers. Physician assistants: friends or foes to doctors. http://careers.bmj.com/careers/advice/view-article.html?id=20008022