GPs are much more than gatekeepers
BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2751 (Published 18 May 2016) Cite this as: BMJ 2016;353:i2751
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Sir,
The metaphor of “gatekeeper” to describe the GP’s role it is not a disaster. The disaster is that suggesting a very limited vision of family doctor. Metaphors of interpreter and trainer are also good, but also very limited (1).
Metaphors enable us to understand something that is unknown in terms of its familiarity. For this reason, they are used frequently in all sciences that adopt common words to name complex realities. The metaphors are analogue devices, used to illuminate reality. Metaphors can simplify expert knowledge, not by ignoring or reducing the inherent complexity, but by providing a point of entry for its comprehension. They are a means of generating ideas, promoting creativity, and constructing concepts and theories. Thinking based on metaphors and comparisons is a way of transforming a concept into something that is so suggestive, interesting, and surprising, that it reaches people more easily (2, 3).
The conceptual elements and skills that promote the mastery of family medicine, such as contextual knowledge, continuity of care, the clinical interview, comprehensiveness, coordination, and so on, are often difficult to explain and to understand. The family doctor is the general practitioner who assumes professional responsibility for attention to the whole patient, not selecting according to undifferentiated problems, and who has committed himself to the person independent of age, sex, disease, organs or corporal systems. The clinical specialty of family medicine focuses on the patient. It is based on evidence, centered on the family, and orientated to the problem. Family physicians acquire and maintain a wide range of skills that depend on the needs of the patients and the communities they serve. The scope of their practice is not defined by diagnoses or procedures, but by human needs. Family physicians do not treat diseases; they take care of people. The nodal points in the life cycle of the family, such as birth, severe illness, and end of life, deserve special attention. Family physicians are experts in the management of common problems, recognizing the important diseases, discovering hidden conditions, and managing acute and chronic diseases (4-7).
These concepts can be explained through others metaphors, plus gatekeeper, interpreter and trainer. Thus, among other, the family doctor can be presented as the “genie in aladdin’s lamp”, as a “drinker of chinese tea”, a “classic painter”, an “explorer on a desert island”, as a “bass”, a “plug”, a “photographer”, an “historian”, a “person eating spaghetti or cherries”, a “cat”, a “civil engineer”, a “catalyst”, a “meteorologist”, a “detective”, a “fisherman rather than a hunter”, a “sculptor”, a “sea turtle”, a “golfer”, a “filter coffee”, a “diver”, a “poet”, a “billiards player”, “Sancho Panza”, a “mother who picks up her baby”, and a “nuts and bolts mechanism” (8).
The value of family medicine lies in its distinctiveness from academic medicine: it is a unique discipline that defines itself in terms of relations, especially those between the doctor and patient. Family physicians tend to think in terms of individual patients rather than of abstractions and generalizations and family medicine is based more on the metaphor of an organism rather than that of mechanistic biology.
REFERENCES
1.-Whitaker P. GPs are much more than gatekeepers. BMJ 2016;353:i2751. http://www.bmj.com/content/353/bmj.i2751?etoc
2.-Sontag S. Illness as metaphor. Aids and its metaphors. London: Penguin Books, 1991.
3.-Reisfield GM, Wilson GR. Use of Metaphor in the Discourse on Cancer. Journal of Clinical Oncology. http://jco.ascopubs.org/content/22/19/4024.full
4.-Phillips WR, Haynes DG. The domain of family practice: scope, role, and function. Fam Med. 2001;33(4):273-7. http://www.ncbi.nlm.nih.gov/pubmed/11322520
5.-AAFP. “Family Medicine, Definition of.” http://www.aafp.org/online/en/home/policy/policies/f/fammeddef.html.
6.-AAFP. “Family Medicine, Scope and Philosophical Statement.” http://www.aafp.org/online/en/home/policy/policies/f/scopephil.html.
7.-Operational Definitions of Attributes of Primary Health Care: Consensus Among Canadian Experts. Annals of Family Medicine 5:336-344 (2007).
http://www.annfammed.org/cgi/content/full/5/4/336
8.- Turabian JL, Perez-Franco B. The Family Doctors: Images and Metaphors of the Family Doctor to Learn Family Medicine. New York. Nova Publishers; 2016. https://www.novapublishers.com/catalog/product_info.php?products_id=58346
Competing interests: No competing interests
Sir,
Phil Whitaker (BMJ 2016;353:i2948) outlines the great strength of general practice, what we are good at, generalist and friend. Since the 1950s we have been a major part of British everyday life. However, as healthcare gets more complex, and people live longer but not fitter, as expectations of health and care rightly escalate, maybe primary care, like secondary care, needs to move on.
The doubling or tripling of consultant numbers represents a sub-sub-specialisation. Maybe we need to step up. GPs are rubbish at picking up cancer early. We support our heart sink patients with no evidence to justify this work, and miss their new symptoms. We follow people up and befriend them, no evidence, not part of NHS core work.
What are we good at? Young families? Arguably health visitors with an extended role, backed up by a GP, could be better. Teenage angst? We are hopeless, adolescent psychologist would do so much better. Minor illness and injury among young and middle aged adults? They want a drop in, 8-8, 6 day a week hub on their commuting route. Chronic disease, disability, self management? Patients want an expert that knows them. Their consultant supported by their specialist nurse. Our diabetic nurse is so good, backed up by us for a once or twice a day two minute discussion.
The frail elderly need a community based multi-disciplinary team, which hopefully CCGs will be forming over the next 4 years.
Insurance companies in America, Switzerland and health management in Australia show that primary care organisations, asking clients to forgo choice for evidence based efficiency, are as effective as general practice at gate keeping but better at efficiency, with improved outcomes. This is the model Simon Stephens is steering us towards, with the double huge benefit of abolishing the wasted costs of the primary-secondary internal market. He acknowledges there is no money to make this change in a painless, orderly way.
We need to change. But we personally have large amounts of money invested in an out-moded, no longer wanted, model of care. The pathway of change for us skilled, valued, old dinosaurs is not at all certain.
Yours,
Sarah Evans (GP)
Milton House
Berkhamsted
Competing interests: No competing interests
Dr Copeman cites an interesting paper that provides evidence to support the value that patients put on continuity of care. However, I'm not sure he's right to say the British NHS provides 'low levels of continuity of care (in large group practices)'. Size of practice does not automatically correlate with abililty to provide continuity - that's a function of how a practice, of whatever size, is organised. And I believe NHS general practice still provides good continuity - albeit declining over the past decade from a high level because of contractual changes that have incentivised access and convenience over continuity.
The finding that patients of doctors paid by item of service were significantly more satisfied than patients of salaried practitioners is under-explored in the cited study. One plausible explanation is that the incentive to 'do' things (and thereby generate income for doctors paid item of service) creates for the patient a sense of satisfaction because their care appears active and interventionist. A doctor whose income is independent of activity may feel more able to use inactivity both to clarify diagnosis and allow illness to self-limit. A better measure of the difference between these two remuneration models might be overall health outcomes, rather than patients' sense of satisfaction with the management undertaken.
Competing interests: No competing interests
The importance of continuity of care for patient satisfaction in general practice was shown by a Scandinavian study published in the BMJ in 1992 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1881840/pdf/bmj00073-0037.pdf . The same study showed that patients had 40% higher satisfaction if doctors were paid on a fee-for-service basis, rather than by salary. Crucially, patients studied were not aware how their doctors were paid - indicating that this finding was unlikely to be due to bias. So, almost 25 years later, why does the UK NHS run a system of general practice that has low levels of continuity of care (in large group practices) and virtually no fee-for-service care?
Competing interests: No competing interests
Dr Arnold correctly guesses I'm male, but I probably wouldn't be described as a full-time GP: I work 7 sessions per week (3 full days in practice, 1 evening out-of-hours) and write on the other two days. What he mourns the loss of in urban Australian general practice is continuity of care, something that is under threat in the UK, and something that we will regret at leisure if we allow it to be completely eroded here, too.
There appears to be a prevailing political orthodoxy (at least in the English NHS) that access and convenience are the only things of worth, and my article is one contribution to the contrary view in the debate - a restatement of what is so good, and worth protecting, about traditional British general practice.
Clearly continuity of care was readily achieved with personal lists and 24 hour responsibility, but that is not the world in which we now live. I don't believe that part-time working (for either female or male GPs) precludes continuity. My own practice of 4 GPs (one full-time and three part-time, operating a group list) achieves good continuity of care for our patients, while also allowing sustainable work-life balance for the doctors.
Each practice is different, and different solutions will apply. What is essential is a regulatory framework that rewards continuity in primary care at least as much as it promotes access and convenience. That has been sorely missing for the past 12 years or so in England, and urgently needs addressing if we are turn off the path Dr Arnold describes (and which, I do recognise, is already affecting general practice quite significantly in many parts of our country).
Competing interests: No competing interests
If only! I am guessing that Dr Whitaker is a full-time GP and a part-time writer. Also that Phil is a male name, not female.
His description of GP is what I knew and practised in Sydney a few decades ago.
I cannot comment about GP in the UK, but in urban Australia this form of practice has all but disappeared. Instead, an urban Aussie, if asked who "their GP" is, is likely to say that they don't have one. They go to the multi-doctor practice and see whichever doctor is available.
Australian urban GP has dropped the ball as far as continuing care, especially of patients with serious chronic illness, is concerned. Most urban GPs are part-timers (most of these being female), and almost none are available after-hours or on weekends. Despite signing an affidavit (to obtain higher payment – fee-for-service) that they provide care after-hours, their telephone answering machines refer their patients to the nearest public hospital or provide a phone number for a 'stranger-doctor' who has no access to the patient's medical records.
Australia continues to produce more women doctors (including two of my daughters) than men. As men cannot produce and nurture babies, there is little chance that Dr Whitaker's ideal will again be seen in urban Australia. If his ideal is, in fact, being widely practised in the UK, all I can say is "You lucky Pommies!"
Competing interests: No competing interests
Author's reply
Dr Evans describes a version of British general practice that I don't recognise (either as a practising GP or as a trainer of the next generation) with GPs variously 'rubbish' and 'hopeless' at different aspects of our caseload. She notes the trend to super-specialisation in secondary care, and suggests precisely the wrong prescription for primary care: that this area of the NHS, too, should fragment into disconnected sub-specialties. We actually need a strong generalist counterbalance to preserve holistic and cost-effective care, and GPs are the profession to provide it. Dr Evans doesn't say who 'no longer want[s]' the kind of care we provide, but I'm sure it isn't the majority of our patients. Whoever it is, we need to engage with them and explain assertively why the GP is the indispensable heart of a cost-effective, holistic health service.
Dr Turabian articulates beautifully some of the core aspects of great family medicine - the very things that make us so effective and valued, and which are virtually impossible to quantify (and hence 'evidence' as per Dr Evans) in our present-day reductionism-obsessed culture. Dr Evans thinks we are dinosaurs. I prefer Dr Turabian's notion of the family doctor as elephant - a strong, graceful animal, interconnected with the others in its herd, possessed of longevity and wisdom, usually to be found moving deliberately and slowly, but capable of the most robust turn of speed and decisive action when circumstances require.
Competing interests: No competing interests