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CONS IN THE CONSULTING ROOM:
WHY YOU CANNOT MAKE PROGRESS WITHOUT AN ENEMY

By Peter Davies
Contact the author by e-mail at Alisonlea@aol.com

To be for something, you also have to be against something. General Practice has suffered for too long by not defining what it is against, and by allowing too many others to see us as being “for them.” The very plasticity of general practice has tempted others to misuse our speciality, its social capital of trust and its services to ends that are not of our or our patient's choosing. If we are to make progress as a speciality we need to define far more clearly than we have done before both what we are against and what we are really for.

The confusion between reactive practice and being the front line of public health is embedded in our new contract. The QOF does not sit easily alongside the need to deal with large numbers of patients quickly. Are GPs doctors who deal with patients and their symptoms? Or are we (should we be) the front line of preventative and public health medicine? Our failure to define ourselves clearly leaves us with both these roles and with the problem of trying to balance them in each consultation.

We were discussing these issues in December and decided that hoolet needed some enemies if it was to be for something. So I thought I would help sharpen the focus by bringing some targets into sight.

These targets all describe cons, things that are against something, or things that are not quite as they seem. They are all apparently noble, but the gap between nobility of intent, and institutional embodiment is huge in all these areas. Most are sacred cows, with somewhat dirty udders.

Confidentiality
I examined this concept in hoolet 41. Briefly I do not think we provide a truly confidential service any more, and further I think that to practise modern team based medicine we cannot be a confidential service. Benjamin Franklin said “Three may keep a secret, if two of them are dead.” Our teams and networks are larger than three and I am glad that most of the people working in them are alive.

Control
We are enjoined to pretend that we are in control of the patient's journey through a system of pathways that if they were roads would be described as no entry, danger of falling, diverted, under construction, and similar. Abandon hope all ye who enter this labyrinth, and pray that GPs, hospital secretaries, and ambulances will talk to each other sensibly. Could choose and book become the cones hotline of this government?

Continuity
This is supposedly a key part of general practice, the speciality which prides itself on providing “primary, ongoing and continuing care” to patients. Yet the NHS is putting all its money into walk in centres and NHS24 and seems to have not noticed that GP turnover is rising rapidly. General Practice was once one of the lowest turnover professions. Now it is common to find that GPs have changed practice several times. If we really value continuity we need to support the GP principals far more both individually and systematically to provide this. An endless series of locums is not continuous care yet this is what many patients are receiving.

Consent
The myth that life is predictable and orderly, and that if it is not launching a tidal wave of writs and guidelines will make it so. Raymond Tallis destroys the naivety of the notion of “informed consent” in his book Hippocratic Oaths.

Consultation
This suggests dialogue, but how often do we hear patients saying they would like more time with their doctor? Anyone ever thought that perhaps the doctors might also enjoy a bit more time with the patients?

“Next please” is an adaptation to scarcity, not great medicine.

Constraints
We are "cabined, cribbed confined" by so many things. Fear is the root of most of these constraints and at present the government, the Health Boards, the doctors and the patients are all fearful. Not a good place to start from if we want to develop a great health service. However I think a fig leaf of a health service is quite sufficient for our political masters.

Conformity
The refuge of the fearful in any generation. Are you one against whom the authorities can find no complaint?

Contradictions
Understanding that the NHS has great expectations does not mean that it will give you great resources with which to meet these. The basis of doublethink and widespread in today's NHS. Known also as the double bind and liable to generate organisational schizophrenia, but don't worry you'll soon love Big Brother Reid.

Conflict
Understanding the hopes fears and expectations of a diazepam addict will not help you get them out of the room any quicker! Some expectations of service are illegitimate and need to be labelled as such very quickly.

Congratulations
More often noticed by their absence in this audit rather than plaudit society.

In general practice we are the centre of multiple conflicting impulses in our patients, in ourselves and in our regulators and paymasters. There seems to be no golden mean that would balance out these impulses and so as GPs we feel buffeted by forces from many directions simultaneously.

We are taking a pummelling and if we are to achieve satisfactory careers in future we need to build strong walls that will protect us from these forces. We need to stop the slings and arrows of outraged patients and administrators from getting to us.

The GPs surgery is not his castle, yet we need to regroup in a defensible redoubt and begin a counter attack to re-establish our niche in the medical landscape. The alternative is that we are attacked from all sides, dismembered and destroyed by the march of conniving weasels who use forked tongue phrases about “caring for others” whilst really meaning “do it our way, or else.”

Other hoolet online articles by Peter Davies can be found at:
hoolet edition 48 - Three Theories
hoolet edition 46 - Whinging
hoolet edition 44 - Cons In The Consulting Room
hoolet edition 41 - Who are we kidding on confidentiality?
hoolet edition 40 - First, let's kill the bureaucrats
hoolet edition 38 - Waking up from the medical matrix: Reality and its representation in medicine
hoolet edition 36 - Festina lente
hoolet edition 35 - Determinants or Prerequisites?
hoolet edition 34 - Propulsion Systems in Medicine
hoolet edition 32 - Time to give MRCGP away?
hoolet edition 31 - Proper work for a doctor
hoolet edition 30 - The Intruder
hoolet edition 29 - Edging towards the truth: Does it make any sense at all?
hoolet edition 28 - Thoughts from the Dark Forest
hoolet edition 27 - The Vision Splendid

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.