Reflections of Father Christmas’s GPBMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c6782 (Published 10 December 2010) Cite this as: BMJ 2010;341:c6782
- Quentin Shaw, general practitioner principal
- Correspondence to:
- Accepted 15 November 2010
A recent article accused Father Christmas of being a poor health role model for children, and “a public health pariah.”1 By implication, the authors criticise the quality of his healthcare, a criticism that I find hard to take, as his general practitioner⇓.
Guidance from the General Medical Council recommends that doctors should not disclose confidential patient information, even to rectify false assertions made by the patient or others in the press.2 There may be occasions, however, when disclosure “in the public interest” is appropriate. On this basis, with the informed consent of the patient, and after discussion with respected colleagues and my defence union, I would like to set the record straight.
Father Christmas (FC) registered as a patient with Stirchley Medical Practice in 1991, using the name Nicholas S Claus. His relationship with GPs and staff has been, for much of the past 20 years, somewhat tense, but despite his repeated threats to leave our list, we have managed to maintain engagement with him.
He has not been the easiest of patients to deal with. Despite our policy of encouraging patients to consult a named “usual GP,” he seeks care impetuously, electing to consult medical students, registrars, or other young doctors, rather than wait for a booked appointment with his own GP. Such behaviour is often adopted by patients who want to avoid being confronted about their unhealthy lifestyle⇓.
Younger practitioners are often perceived as more likely to comply with the patient’s agenda, and many juniors have proved to be very gullible when he has been booked into their surgeries. Records show that he has consulted dozens of students and registrars over the years. These consultations have provided background material for tutorials on subjects such as the angry patient, the demanding patient, and the ethical dilemmas of receiving gifts. Hopefully those students and young doctors have been educated by the experience.
Our first opportunity to genuinely help FC came when a reindeer bite became septic in 1993. An inspired microbiologist at our local laboratory (Princess Royal Hospital, Telford) identified Streptococcus rudolfus in a specimen consisting largely of tinsel. Prompt treatment saved Christmas and established our therapeutic relationship with him. Perhaps as a consequence of this increase in trust, he accepted the single brief intervention that stopped him smoking in 1994. This has probably been the greatest impact we have had on his health.
Through the 1990s, the changing nature of his job became a major stress. Increasing marketisation and consumerisation of public services meant that the demands on him rose steeply: he was less often appreciated as a voluntary benefactor and more often seen as a public servant, to be incentivised by targets. His young clients (a word he hates) were encouraged by politicians to think that they were entitled to his visits, without themselves accepting any responsibility for their previous behaviour.3
Increasing affluence meant increasing physical challenges in his work, as presents became larger and heavier.4 This has resulted in repeated musculoskeletal problems and chronic back pain. He lives under constant political threat of losing his monopoly and being opened up to private competition. Unregulated imposters cherrypick the easier parts of his job. His profit margins have been squeezed, and he has been forced to adopt modern employment practices for his workers, using short term contracts and foreign locums⇓.
Increasing regulation has impinged on his own traditional working practices.5 6 7 8 The European Working Time Directive has severely disrupted continuity of his junior elf rota,9 and elves don’t seem to want to work as hard as they used to. In many cases, he has only managed to continue his activities by virtue of being self employed and thus exempt from legislation. The consequence has been that he has worked harder to compensate for the protections offered to his juniors and his animals. At the same time, he is not getting any younger, and he continues to work in his late 80s because of pension insecurity.
It will be no surprise, then, that his physical and mental health have suffered. He has, at times, been heavily dependent on alcohol and addicted to sweet, fat-rich foods. A shift towards a more managerial role and more computer based work has resulted in further weight gain, lipid disorder, hypertension, and diabetes. For some years he became more irritable, and even less likely to accept lifestyle advice. An attempt to use a motivational interviewing approach in 2001 met with the response “Bah humbug,” and he walked out of the consultation.
His marriage has been under severe strain. One of my more empathetic colleagues, while exploring the context of his depressed mood, elicited a problem with sexual dysfunction, when FC disclosed that he only comes once a year (T Underwood, personal communication, 2004). Sympathetic treatment has resulted in a vast improvement, despite him failing once again to comply with lifestyle advice.
Throughout our 20 years, I have been humbled by his determination to continue providing a public service that he believes in, at the expense of his own health. We have found ourselves protecting him from himself, insisting on him accepting “fit notes,”10 giving him drugs for his various health problems and providing brief supportive psychotherapy. We have begun to identify the effect of his primary relationship to his health, and tried to protect him from some of Mrs Christmas’s more unreasonable demands, while supporting him in a zero tolerance approach to her domestic violence (S Kumar and S Ughovwa, personal communication, 2009).
Because of the seasonal and unsocial nature of his occupation, we have made special “easy access” arrangements for him to book appointments ahead, at times to suit him. If he cannot get through the appointments system, he knows he can speak to a GP. There have been fewer tantrums at the front desk, and fewer letters of complaint.
One of the great unsung benefits of universal NHS registration is that everyone, no matter how eccentric their lifestyle, has a GP. GPs are moral relativists, disinclined to be judgmental, and sanguine about self destructive behaviour. Politicians, other professionals, and the greater public may criticise us for not forcing everyone to adopt a healthy lifestyle, but we have to take the long view. We work to a time scale of decades and have to develop relationships with challenging patients gradually.
Only when we fully understand the circumstances of their life and health beliefs do we stand any chance of negotiating the more difficult behavioural changes. Whether we succeed or not, we maintain an unconditional positive regard for our patients, no matter what their body mass index, and no matter what they have just said or done at the reception desk. With FC the first challenge was simply to keep him coming to the GP and not storming off. After that we had to gain his confidence and respect. Only now, after 20 years, is he engaging with the healthy change message.
Of course, we have a long way to go, but I remain confident that his health will continue to improve. I now look forward to our appointments, perhaps because we have both mellowed over the years. Like him, I am getting older, but one of the great strengths of group practice is that younger and more able GPs will take over his care when I retire. Children and parents everywhere should be reassured.
And our medical practice will continue to be enlivened by his surprise visits to gullible young students and registrars.
Cite this as: BMJ 2010;341:c6782
Competing interests: The author has completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; not externally peer reviewed.