Do we need GPs?
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6589 (Published 01 November 2013) Cite this as: BMJ 2013;347:f6589All rapid responses
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In his defence of the generalist's gatekeeping, Des says 'Trust, reassurance, and misdirection are our greatest therapeutic interventions'. This worries me. Any homeopath, or other quack, could perform this function.
Ramakant Sharma offers an incisive, detached extensively historic critique of our self-serving delusional attachment as NHS GPs..
But he mentions two unresolved issues - Continuity of care and extra resource utilization - upon which the USA has nothing to teach us.
Continuity of care went out of the window with advent of shift work ( New GMS GP contract ) - true. But the Minister is trying to row back..
Resource utilization or "use of technology when it is not needed".
Ramakand states "There is no evidence that presence of GPs lead to better utilization, it is just an effect you see due to delaying the care needed by the patient", and that is where I believe , at least in my own case, he is plain wrong.
I teach my students/trainees that the most valuable resource a GP has is his brain. Without our judicious efficient and evidence-based interventions, diagnosing and treating 90% of presentations without referral, I fear the queues at A&E for CT/MR Scanning will rapidly reach American proportions. But the pressures on a GP's judgement from all sides may push us deeper into that mire anyway..
Competing interests: I am still an NHS GP
The response from the Communications Director at Diabetes UK following the critique of the campagn to increase understanding of diabetes is interesting: "We needed strong imagery to try to address this (poor understanding of risk) and we did not decide to use this sort of imagery lightly. It was developed through focus groups of people with Type 2 diabetes, who told us that highlighting the emotional impact of the condition on people’s families is the best way to make people think seriously about their own risk. We then tested this approach in quantitative market research and the results of this clearly showed that this was the sort of approach that most resonated".
This non-evidence based approach is all to prevalent in health education. Fear messaging does not work to address risk understanding or, the core issue, that management of diabetes does not usually include the wider psychological impact on the individual. Furthermore it raises the question whether focus group 'research' is bad research. Good qualitative methods pose and answer research questions, focus groups are often poor quality qualitative research dressed up.
GPs recognise the wider management needs of people with diabetes but all too often do little about it. Let's have more debate on why they don't address key issues in patient managment.
Competing interests: No competing interests
The hard-pressed general practitioner would be greatly assisted in his gatekeeping role if all patients were issued with copies of the correspondence (such as discharge summaries and clinic letters) from secondary and tertiary care which is traditionally sent only to the general practitioner. Typically the correspondence includes a "road map" which outlines the strategy for future management, including subsequent referral to other subspecialties. Patients need to be, quite literally, "on the same page" as the general practitioner on such matters so that decision-making can be shared in the event of a requirement to depart from the "road map". Some hospitals already participate in this sharing of information, which patients find profoundly empowering, and which is also perceived to signify respect for the patient. It is high time this became universal practice in the NHS.
Competing interests: No competing interests
Yes we need GPs. No we don't do enough to recruit we expect people to join GP without investing early as other specialities evidently as laid out by Thomas Lemon below.
Receptionists should not be involved in gate keeping to access, they should not be triaging in any way whatsoever, I believe, as they lack suitable medical training.
Thomas Lemon is correct, as long as health care is centrally taxed, GPs are needed.
Oscar Jolobe raises some interesting points, particularly regarding geriatrics being the other blind spot. I think its relevant that GPs don't rotate through geriatrics. Perhaps as geriatrics is becoming rapidly more popular with trainees as a speciality this will change.
Competing interests: Retired GP, previously involved in Med Ed
Answer is No.
Dr. Spence has raised a very thoughtful question, probably too late. To look deeper, we need to look at the history of general practice and evolution of medical knowledge.
Prior to 1800s, there were healers who would give you medicine or may do a little surgery. In UK, there were general practitioners and barber surgeons who can assume each other’s role. Until the late 1800’s, many of the general practitioners in both England and the United States were trained as apprentices. However, in the late 1800’s many of the general practitioners obtained university training. In the early 1900’s, with the development of university centers for educating physicians, almost all of the general practitioners, in the United States, were university trained. In the 1930’s, more than 80 percent of practicing physicians in the United States were general practitioners1.
Medical practice in early 20th century was performed by a single person, GP who will provide all the services.
Medical knowledge since then has increased leaps and bounds over the decades leading to development of several specialties. For example, the term ophthalmology was coined after Hermann von Helmholtz invented the ophthalmoscope in 1851. Over the years, due to expansion of the knowledge of medical science, it was not physically or mentally possible for one person to learn or practice everything medical science has to offer. Initially, after medical school, you could become a GP after the internship. Later on, some rotations in hospital were introduced (Depending on country). In many countries, you can still practice as a doctor (aka GP) after finishing internship. Emergence of specialists took away more and more of the treatments a GP can provide. Now the GP has (as rightly pointed by Dr. Spence) become a gate keeper to the health system. GPs are often expected to diagnose every disease early without support of technology. Failure to do so(which will be the case many times), they are labeled as failed doctors: the thick, the lazy, and the useless. In fact, tasks performed by a GP (triage, filling forms and preventive care) can be provided by a trained high school student (or a nurse for that matter). Making a GP (an intelligent person who has invested years in learning medicine) do things which a high school graduate can do is unethical and mis-utilization of resources. Similarly, there is no place for a hospital generalist. These highly trained individuals can be utilized to do things for which we are training nurse practitioners (nurse anesthetists, nurse endoscopists).
Few of the responders here talk about two issues, Continuity of care and extra resource utilization.
Continuity of care went out of the window with advent of shift work, population increase and duty hour restrictions (all right policies). It is not physically possible for one person to provide care 24/7 to the population he/she is serving.
Second issue raised is of resource utilization or use of technology when it is not needed. There is no evidence that presence of GPs lead to better utilization, it is just an effect you see due to delaying the care needed by the patient.
References
1. http://www.history-ofgeneralpractice.org/
2. Reiser S. (1978): Medicine and the reign of technology. (Cambridge: Cambridge University Press)
Competing interests: No competing interests
Geriatric medicine might well be the other "blind spot" in UK primary care, given the fact that rotation through geriatric medicine in not yet the norm for doctors who wish to take up general practice as a career. In the context of the predicted increase in the number of elderly people in many Western countries (including the UK) "good care for frail older people should be part of mainstream clinical practice"(1). Accordingly, it is unconscionable that "achievement for 14 of 16 quality indicators suitable for vulnerable older people was lower for residents of care homes than for those living in the community..."(2). What is more, "Residents in care homes were more likely to be excluded by doctors from QOF (Quality and Outcomes Framework) targets(2). This sorry state of affairs is compounded by the fact that, in one study, "age, independent of comorbidity, presentation, and patients' wishes, directly influenced decision making about, [for example], angina investigation and treatment by half of the doctors in the primary care and secondary care sample"(3). Accordingly, what we need is a primary care healthcare workforce which is well grounded in the complexity and nuances of disease presentation and management in old age, and that this should amount to a recognition that medical practice in the developed countries is, in essence, a vital ingredient of mainstream clinical practice.
References
(1) Parker S., Conroy S
Poor inpatient care for older people
BMJ 2011;342:612
(2)Shah SM., Carey IM., Harris T., DeWilde S., Cook DG
Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system:retrospective study
BMJ 2011;342:587-
(3) Harries C., Forrest D., Harvey N., McClelland A., Bowling A
Which doctors are influenced by a patient's age? a multi-method study of angina treatment in general practice, cardiology and gerontology
Qual Saf Health care 2007;16:23-27
Competing interests: No competing interests
Thanks to compulsory internship in medicine, the assertion is probably largely true that most doctors are highly equipped to become competent generalists (in general internal medicine) by the time they enter general practice. The same is not necessarily true of competence in paediatrics, given the fact that, according to one estimate, only 37% of general practitioners have previous experience of hospital paediatrics post qualification. By contrast, "in Sweden first access and some outpatient care for children is provided by general practitioners trained in paediatrics working closely with paediatricians and children's nurses in local health centres"(1). No wonder all cause mortality in children aged 0-14 is, on average, worse in the UK than in a number of European countries(1). This is the blind spot in UK primary care.
References
Wolfe I., Cass H., Thompson MJ et al. How can we improve child health services? BMJ 2011;342:901-4
Competing interests: No competing interests
In “Do We Need GPs” (BMJ 2013;347:f6589), Des Spence describes our Type 2 diabetes awareness campaign as “hysterical, tear stained, and intellectual schmaltz” and suggests that we did not give “any consideration of the harm it might do”.
This is unfair. Dr Spence may not like the adverts and may think they play on fear. But a long-standing problem for Type 2 diabetes is that people do not understand how serious it is and so do not realise why it is so important to try to prevent it if you are high risk or to get diagnosed if you already have it.
We needed strong imagery to try to address this and we did not decide to use this sort of imagery lightly. It was developed through focus groups of people with Type 2 diabetes, who told us that highlighting the emotional impact of the condition on people’s families is the best way to make people think seriously about their own risk. We then tested this approach in quantitative market research and the results of this clearly showed that this was the sort of approach that most resonated.
Above all, the campaign worked. There was a significant increase in public understanding of the seriousness of Type 2 diabetes and, crucially, more than 30,000 people took action by taking an online risk assessment, as well as many others getting their risk assessed at pharmacies and GP surgeries.
By identifying people at high risk, the campaign can make a real difference by being the start of a process of people making the kind of healthy lifestyle changes that can help prevent it. It will also identify some of the estimated 850,000 people with undiagnosed Type 2 diabetes and so improve their chances of good health outcomes by ensuring they can start getting the support and medication they need to effectively manage their condition.
Competing interests: I work for Diabetes UK
Although it may be true that, in many cases, general practitioners are "gate keepers to a myriad of complex bureaucracy through which patients must guide themselves...", the reality, in some cases, is that the ultimate gatekeeper is the practice receptionist, given the fact that patients have neither telephone nor online direct access to their doctor. In a multi-partner practice, for example, it is the receptionist who decides which doctor will review the patient who gives only 2-3 days notice that he or she has experienced a change in his symptoms. In the event that the latter signifies a subtle evolution in the natural history of a disease with atypical presentation, review by a different doctor each time there is a change in symptomatology might well delay arrival at the final diagnosis and, hence, a potential delay in referral (if necessary) to secondary care.
Accordingly, although the purpose of gate keeping might be to stem the flow of [patient] traffic to secondary care, this does not necessarily translate into a favourable outcome for the individual patient caught up in that flow of traffic. We must also not lose sight of the fact that the doctor-patient relationship, at its best, generates an opportunity for the patient to "bond" with the doctor under whom he or she is registered, and it also generates a once in a lifetime opportunity to fine tune one's diagnostic skills through the medium of experiential learning.
Competing interests: No competing interests
Re: Do we need GPs?
Judging by the approval ratings for some of the rapid responses, some aspects of primary care practice would not be popular topics for future discussion. Definitely "off the agenda" is the gatekeeping role of the receptionist in those practices where the patient has neither direct telephonic or "on line" access to the doctor under whom he or she is registered. Also "off the agenda" is the role of post qualification hospital experience either in paediatrics or in geriatrics for doctors planning a career in general practice
Competing interests: No competing interests