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Experts in our patients

Coalface tales

James Booth

Tuesday, 12 February 2019

AdobeStock_39976862_GP.jpgWe’ve a new GP just started at my practice – an excellent one, I might add, if she reads this – and watching her get used to the place over the last several weeks has brought something home to me. It’s something that I think is the great privilege of general practice, the core skill that our model of working allows us to develop, and the one thing that literally can’t be trained into us.

I’ve spent nearly 12 years here now, and given that I do upwards of 8 sessions a week, that’s turned into quite a few contacts. I’ve also been the only partner for the last year, and whilst my practice is growing, we’re still pretty small. It’s taken a new GP to start, though, to really make me appreciate that, this means I know our practice list pretty well by now.

There’s nothing medical I can tell Paula that she doesn’t know, but what’s characterised our conversations over lunch and coffee has been that I know who’s related to who, who has a mother who had bowel cancer, who has a family history of dementia that worries them, which child has an older sibling whose presentation made us fear neglect a few years ago. I know which elderly man near us has the Legion d’Honneur to commemorate his service on D-day. I know the couple who, over 40 years ago, had Arnold Schwarzenegger as a lodger for a few months. I know which lady is a doyenne of the local Catholic church, and which man spent much of his young and middle years in prison. 

It’s happened by increments, this, but it hadn’t really been since a new colleague stepped in full time that I have realised now that it’s an unusual surgery in which I don’t know nine out of the ten patients pretty well. I’ve had the chance to reflect how it has become normal not to take a full history, but to pick up threads that I’d dropped a few months before. I’d taken for granted that I often look after an extended, complex web of relatives and friends. 

Last month, this enabled me to participate in the care of a patient in a way that simply wouldn’t have been possible without this. M is a middle-aged lady with a learning disability, brittle diabetes, and a host of complex social vulnerabilities which I won’t be more specific about for fear of identifying her. She’s part of a large, multi-generational traveller family my practice has looked after for years. Barely a fortnight has ever gone by without some sort of contact with one or more of them in the last decade. M has been increasingly frail this past year, and has had multiple brief admissions followed by failed discharges when she’s been unable to cope out of hospital. The last time she was an inpatient, I rang the ward and asked them if I could be involved with the plan before she came home, and so it happened that I ended up with the rest of the MDT working this out. I hadn’t been aware of how challenging she had been as an inpatient, and how resistant she’d been to some of her care. The ward team didn’t know the state of her home, where I’d visited on many occasions, nor the precarious circumstances of her tenancy owing to police action against another family member. I knew which family member was probably being realistic about the help they could offer, and which one wasn’t. I knew that she and her partner can barely read, but don’t tell anyone. We’ve kept her out of hospital now for longer than we’ve managed in well over a year now; whilst I don’t underestimate the impact of her excellent inpatient care, I think part of that is down to the fact that her plan was tailored to her much more specifically this time.

In my child safeguarding role, one of the things that case reviews bring home is the importance of professional memory about cases. The ability of a professional to know what has gone before not just with a patient, but with those around them is absolutely crucial in complex cases. I’m aware of a local case in which a midwife safeguarded a child when she recognised the man who walked into the room during a post-natal home visit. A hugely important source of advice and experience for me at the start of my time as a GP looking after children was our now retired health visitor, who’d worked in our area since before I was born and knew everyone.

A generation ago, all of primary care was like this. I think it’s sometimes easy to forget that alongside our role as generalists, the thing we specialise in is our patients. In the MDT last month, there was an expert in her diabetes, an expert in her rehabilitation, an expert in her surgical management…and an expert in her, and none of us could do a full job without the other. It’s quite easy – and often correct – to be cynical about the rather twee image of the old-style GP, serving a chocolate-box village like a medical James Herriot, but at the heart of that rather over-idealised memory there was a core value that I think we are sometimes in danger of forgetting. Each new reform, each new initiative seems to take us further away from this. Could anything be more anathema to this kind of practice than GP At Hand and the ilk? It’s utterly unquantifiable, that ability to become a fixture in a community, and to use that to inform the care of your patients, but as we move into a future defined by ever larger practices, and the homogenisation of primary care through regulation and a changing workforce, it’s ever more important to recognise and attempt to guard it.

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James Booth

James qualified from UCL in 2002 and has been a GP partner in Chelmsford since 2006. He is also the named GP for Safeguarding Children locally. All views expressed are his own.
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