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consultations are short, and that patients inimical forces so that we can all see them healthcare systems struggle to afford.
Stockdale, the American admiral, captured consultation is one of the purest examples the Hanoi Hilton between 1965 and 1973.12 RESOURCE SCARCITY
love our neighbour as we love ourselves.
Performed badly the consultation can be a money has to be found for it. The British venue for rejection, misery and complaint.
‘This is a very important lesson. You must never confuse faith that you will consultation was well described in The prevail in the end — which you can Future General Practitioner.1 This book has set the frame for general practice learning discipline to confront the most brutal facts of your current reality, whatever rising to the challenge of unmet need.16 As treating the patient, rather than explaining why I am acting as an agent of irrational the brutal facts of our current reality. The positive side of the consultation has been celebrated by many authors.5–8 The TIME SCARCITY
Sir Clifford Allbutt notoriously described conflict between meeting the needs of the general practice as, ‘perfunctory medicine individual in front of me against the overall performed by perfunctory men.’ Like all health budget of an area even sharper.17,18 relationship between doctor and patient.9–11 gross caricatures it has an element of truth There is an irreconcilable role confusion in it. One example will suffice. A patient between the role of GPs as the gatekeeper of the college motto, Cum scientia caritas has already had 12 minutes of a 10 minute slot. I point this out to her. She is offended INADEQUACY
work and its achievements. I want to thank time.’ ‘Yes,’ I reply, ‘and he also always Fear of inadequacy is huge in medicine.19 consultation style and therefore helping me improve it. I would love to spend the rest of between meeting every need of the patient that says, ‘GPs do not diagnose or treat the next patient and those of the doctor to need to say that I find the conditions in which I practise do not allow me to fully the minute not meeting this lady’s needs deploy my abilities. I have a grief that there failure, eating disorders, and cancer.
are forces arising that threaten to damage time and resource limited service this is the the practice of medicine. If unchecked they kind of sharp time constraint necessary to activity. If our practice is as bad as these will nullify the great professional drive to experts imply should we really be allowed both the givers and recipients of medical each and every consultation. If we fail to British Journal of General Practice, March 2006 To some extent of course as GPs we are.
What we offer is a quick, mostly accurate ILLEGITIMATE ENDS
assessment of the patient and then call in ‘You must diagnose depression and affective disorders more frequently … everyone. There is always a knowing/doing they get other gains from the sick role.
but … (3 years later) … you are gap20,21 and we will all let someone down at So rather than observing the terms of the prescribing too many antidepressants.’ their area of expertise than non-specialists.
What is galling is the misguided attempt to with us is actually very small indeed. The waits for appointments will go up if we go vision of general practice. Philosophically to too many meetings are just one example this is known as the error of mistaking a claimants being told to ‘get a note from your doctor’ is a sad reflection of how LOSS OF TOLERANCE AND
Engineers have ‘tolerances.’ Physicists PASSIVE AND ACTIVE
describe their ‘approximations.’ GPs are AGGRESSION
politicians would back us as we do this.
the health service at some stage of their rarely have the specificity of a diagnosis careers.33–37 The active version is direct from a radiologist or histopathologist. It requires a different mindset to work with need to face this fact. The political drive wouldn’t want to rock the apple cart would as the ‘risk sink’ for the NHS. We absorb you?’ The correct response is, ‘the apples INDECISIVE MANAGEMENT
facilities. We do so reasonably accurately, practitioners is not conducive to free and serious from less serious cases and refer EXCESS OF EXPECTATIONS
like a theological institution.29 Although consequences for us as well the patient.
results. In the NHS we do the opposite, we will no longer accept our approximations as being sufficient, then general practice and our ‘management of uncertainty’ will fail.
not to manage.’31,32 The result of this British Journal of General Practice, March 2006 such a strategy is a recipe for disaster. A cash limited, time limited service can never higher level the whole process is damaging the country needs to be able to live with of apparently (and originally) confidential medical information to outside parties.
Maintaining confidentiality is impossible in Sheriff’s officer put it, ‘courts have all the these circumstances.50–53 To pretend that fail to get their expectations met they tend LOSS OF CONTINUITY
inevitable both by patients and doctors as MEDIA MISREPRESENTATION
general practice used to be its pattern of doctor–patient consultations. Taken with investigations’ and ‘an organisation with a includes doctors, a map of reality but it is hospitals it leaves a risk that patients end ‘dangerous and deadly.’ Most of us are The fact that a patient can use the threat of a complaint as a means towards getting trying to provide a reasonable service, to multiple morbidities at risk of ill planned The great strength of general practice is aim of the consultation is not for one side ‘Who sets the frame will set the game’ and with the media it is the editor who has problems and if we lose this strength many community will suffer.48 Also the costs of exactly how and why this done.54 We could Peters49 points out that in blue collar jobs hidden as ‘taking extra caution.’ However it labour by 98.5% over the last 100 years.
is driving extra referrals and investigations.
He predicts that professional jobs could be It is hindering good medicine and pushing broken down into parts and become ‘blue premise that the aim of general practice is collarised’ in the future. There is a risk in this that what can be counted will be what relationships with patients. I see this as is measured, and that that which is difficult LITIGATION
being good for both patients and doctors. I to count will be deleted from the record.
Consultation skills are difficult to count and that sort of thing.’ Sir Lancelot Spratt’s doctor–patient relationship is currently so may not appear on the official record. doctors think about going to court for any LOSS OF CONFIDENTIALITY
reason. Lord Denning put it thus, ‘an action general practice consulting room. Most of for negligence against a doctor is for him allowing doctor and patient to trust each unto a dagger. His professional reputation other so that full details of the context of a hospital doctor–patient interactions.
is as dear to him as his body, perhaps more patient’s symptoms can be appreciated.
survive and even flourish then we need to information around the NHS is beginning to take precedence over the patient’s rights to litigation against themselves. The rise in around the doctor-patient relationship. We negligence actions against doctors may be need to make this relationship central to British Journal of General Practice, March 2006 ‘You have a very difficult job to do 13. Stott NCH, Davis RH. The exceptional potential in each primary care consultation. Journal of the Royal doctor, and my job is to make it easier College of General Practitioners 1979; 29: 20–205.
40. Turnberg L. To err is human: learning from mistakes.
14. Davies P. Proper work for a doctor. Hoolet 2001; 31.
Clin Med 2001; 1: 264–265.
41. Smillie J. Accept the injustice and deal with the reality. BMA news review 2004; 1 May.
many years ago and it is doubtful that he 15. Lowe R. Financing health care in Britain since 1939. 42. Jain A, Ogden J. General practitioners’ experiences of History and Policy Papers, No 8 (online collection).
would even get a job now thinking like that.
patients’ complaints: qualitative study. BMJ 1999; 318: 1596–1599.
43. Anonymous. Deadly mistakes [editorial]. Times 2004; exist to support in turn the doctor–patient 16. Chisholm J. Viagra, a botched test case for rationing.
13 Aug: 25.
BMJ 1999; 318: 273–274.
44. Holden P. Medicine is suffering from a serious 17. Newdick C, Danbury CM. The effect on patients’ complaint BMA News review 2003; 19 Jul.
rights of private commissioning of NHS services.
BMJ 2006; 332: 126.
45. Jenkins S. Playing the blame game. Times 2004; 8 Oct:
consultation, the central event in medicine 18. Smith J, Dixon J, Mays M, et al. Practice based commissioning: applying the research evidence. BMJ 46. Roberts D. GP accountability overkill. 2004.
medical care reduced. This is bad both for 33; 2005: 1397–1399.
19. Davidoff F. Shame: the elephant in the room. BMJ 2003; 324: 623–624.
47. Davies P. The non-principal phenomenon: a threat to continuity of care and patient enablement? followed from the thinking represented in The Future General Practitioner is coming 48. RCGP Health Inequalities Standing Group. Hard lives: improving the health of people with multiple problems. London: RCGP, 2003.
renegotiate and rewrite its understanding 49. Peters T. Re-Imagine! business excellence in a disriptive 22. Haslam D. ‘Schools and hospitals’ for ‘education and age. London: Dorling-Kindersley, 2003.
and contract with both itself, and the public health’. BMJ 2003; 326: 234-235.
50. Davies P. Who are we kidding on confidentiality? 23. Farrell L. The cornerstone of malingering. GP Hoolet 2004; 41: 11.
Magazine 2004; 28 Aug.
Peter Davies
24. Dalrymple T. Why I am feeling queasy about 51. Walterspiel JN. The privacy of patient records. N Engl constantly signing sickness notes. Times 2004 ; 11
J Med 2001; 345: 1576–1577.
52. Welch CA. Sacred secrets — the privacy of medical 25. Nilsson B, Heath I. Patients, doctors and sickness 1. Royal College of General Practitioners. The Future benefit. BMJ 2003; 327: 1057.
General Practitioner: learning and teaching. London: 53. Willis JA. Between you and me … Br J Gen Pract Royal College of General Practitioners, 1972.
26. Jenkinson, S. A brief history of time off work. 2004; 54: 488.
2. National Office of Summative Assessment.
54. Morgan, P. The insider: the private diaries of a 27. Davies P. Sick note syndrome needs to be cured. GP scandalous decade. London: Ebury Press, 2005.
Magazine 2004; 9 Feb: 27.
3. GMC. Good medical practice. 2001. 28. Malik S. A Very British sickness. New Statesman 2005; 10 Jan: 27–29.
4. RCGP/GMC. Good medical practice for general 29. Neuberger J. The NHS as a theological institution.
BMJ 1999; 319: 1588–1589.
30. Braithwaite J. Axioms for governing health systems.
5. Neighbour R. The inner consultation. London: Kluwer BMJ 2005; 330: 1032.
31. Gillon R, Higgs R, Boyd K, et al. Wanted: a social 6. Willis J. Friends in low places. Oxford: Radcliffe contract for the practice of medicine. BMJ 2001; 323:
7. Dowrick C. Beyond depression. Oxford: Oxford 32. Sergeant, H. Managing not to manage, management in the NHS. Centre for Policy Studies, 2003; London.
8. Innes AD, Campion PD, Griffiths FE. Complex 33. Dalrymple T. The social sickness that has turned consultations and the ‘edge of chaos.’ Britain’s hospitals into war zones. Times 2004; 3 Jun.
34. Winrow J. Protect our teachers. Halifax Evening 9. Pereira-Gray, D Evans, P Sweeney, et al. Towards a Courier 2003; 6 Aug.
35. Kmietowicz Z. Half of UK doctors experience violence or abuse from patients. BMJ 2003; 327: 889.
10. Hjortdahl P. Continuity of care. In: Oxford textbook of 36. Paice E, Aitken M, Houghton A, Firth-Cozens J.
primary medical care, Chapter 7.6. Oxford: Oxford Bullying among doctors in training: cross sectional questionnaire survey. BMJ 2004; 329: 658–659.
11. Heath I, Sweeney K. Medical generalists: connecting 37. Middlemiss P. UK Patients most abusive in Europe the map and the territory. BMJ 2005; 331:
GP Magazine 2006; 20 Jan: 3,15.
38. McEwen WJ. Married to the brand. Why consumers 12. Collins J. The Stockdale paradox. In: Good to great.
bond with some brands for life. Gallup Press, New London: Random House Business Books, 2001: 39. Davies GF. Anatomy of a complaint. BMJ 1994; 308:
British Journal of General Practice, March 2006


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