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:f6589
- Des Spence, general practitioner, Glasgow
Everyone is prejudiced; we merely have different prejudices. There are widely held prejudices against general practitioners (GPs). And, like most prejudices, these are unspoken and denied. But the anonymity of online communities means these views come spilling forth. GPs are the failed doctors: the thick, the lazy, and the useless. Forum members have even suggested that all GPs be sacked, with receptionists simply making appointments with hospital specialists. Generalism means less; everyone wants the expert.⇑
So I perennially find myself promoting or defending generalism (depending on your perspective). There is little appreciation of the levels of patient contact in general practice, with 30 to 40 10 minute appointments a day, and few end in specialist referral. GPs see every condition from every medical specialty, often early, with atypical disease presentation.
GPs realise that our pseudoscientific hospital training has little value in the real world, where there is no certainty—only uncertainty. Generalism is about listening not treating, and understanding that symptoms rarely reflect disease, and that investigation creates only spurious incidental findings. General practice is no place for the obsessive, introspective, and fearful because it will melt their brains. Generalism is a difficult specialty, full of art and craft. Trust, reassurance, and misdirection are our greatest therapeutic interventions. And GPs bear witness first hand to the modern erosion of wellbeing and the iatrogenic calamities of medicalisation, overdiagnosis, and overtreatment.
Most of generalism is rewarding, challenging, diverse, different, and funny. You have useful day to day skills that patients and their families value. But the generalist gatekeeping system is under attack from stupid prescriptive expert guidelines that needlessly increase referrals. Media stories of isolated anecdotes are high in human interest but undermine confidence in a whole system, and simplistic, ill conceived public awareness campaigns play on fears not facts. Consider the current Diabetes UK awareness campaign plastered on city buses.1 This hysterical, tear stained, and intellectual schmaltz appears to me to be without any consideration of the harm it might do.
Of course, hospital consultants feel the same as GPs. The demise of the hospital generalist has seen the constant increase in consultant to consultant referrals, delays in discharge, and overinvestigation and overtreatment. Generalists are the most important economic, medical, and social professional group in healthcare. The good generalist, however fat, is worth his or her weight in health cost savings. The medical world is upside down, but who would ever listen to a simple generalist?
Cite this as: BMJ 2013;347:f6589
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.
Follow Des Spence on Twitter @des_spence1