Friday, 23 May 2014

GP or Social worker? A historical perspective

Guest post by Bastiaan Kole

My father and grandfather were both country GPs (from 1924 to 1996). They knew patients and their extended families very well, had supported them through major life events, palliated them and delivered three generations of their babies.

People had no sense of entitlement and were not unreasonably demanding. In that setting (in a far less complicated world), they sometimes found reason to support people in all facets of their lives. They were taken seriously, respected and even had some success on the odd occasion when they did.

I, as any other GP or indeed any decent human being, listen with empathy and try to support people going through difficult life events, but never give them the illusion that we should by the first port of call or indeed can really help.

I have seen a lot of unhealthy co-dependency that started with “compassionate listening”. One often wonders who gets more out of it: the patient or the self-congratulatory doctor with a sense of purpose. It is invariably very time consuming as these problems can never be discussed in ten minutes and there is clearly some self-delusion, as what can be achieved is in reality very little. It does, however, take resources away from other patients and places an additional burden on colleagues.

In the seventies, GPs’ medical abilities were often ridiculed by specialists. GP training was in its infancy: requirement of completion of vocational training for general practice before a doctor could become a GP principal was only fully implemented in 19821. The extent of what could actually medically be done outside a hospital setting was much more limited. This, combined with the Zeitgeist of sociology, shifted emphasis in General Practice (as promulgated by the fledgling RCGP) to focussing on psychosocial causation of illness. The pendulum has defied gravity ever since.

Trying to make up in the consultation room for hefty social care and welfare cuts is exactly what David Cameron intended with his flawed 'Big Society' agenda2. Health is directly related to income and living standards3, which a healthcare service cannot influence. To take on the responsibility as a profession for fixing government failings is, to say the least, unrealistic or worse: a waste of time and resources, leading to medicalisation of unhappiness.

It will not end there, because it never does. Why indeed not police illegal migrants for the greater good4? Why not monitor radicalisation to possibly save countless lives5? Why not provide relationship counselling6? Why not monitor gambling habits7? Why not offer financial advice8? And what about making up for failings caused by underfunding of secondary care? The list is endless.

Idealism can lead to positive changes but often lacks realistic goals and pragmatism. Doctors who have clear views on the limits of their profession, will use resources responsibly, so that care for all their patients can be backed up by evidence-based healthcare interventions. Repeatedly accusing these doctors of “lacking compassion” is never going to lead to better care or better outcomes.

Such idealism will cause people, more and more, to regard their GP as a “life coach”, a role for which we are not trained, funded or equipped. I am sure the majority of GP's did not envisage such a role when they chose the profession.

It is neither viable nor responsible for GPs to act as social worker and life coach, nor to replace traditional support networks, in times of steeply rising demand and decrease in funding. The time has come for the BMA and RCGP to help the profession survive, by clearly redefining our roles as medical doctors and not pander to politicians’ continuous demands and point scoring.

References

1 Field S. The story of general practice postgraduate training and education. In: Lakhani M, editor. A celebration of general practice. Radcliffe Medical Press; 2003: p120
3Marmot MG, Bell R. Action on health disparities in the United States: commission on social determinants of health. JAMA 2009;301:1169–71. doi:10.1001/jama.2009.363
6 Swinford S. Midwives, GPs and registrars to help tackle family breakdown. The Daily Telegraph 23 March 2014
7 Sanju G, Gerada C. Problem gamblers in primary care: can GPs do more? Br J Gen Pract 2011;61:248–9. doi:10.3399/bjgp11X567027
8 Graham, G. Patients should get financial advice at GP surgery, watchdog says The Daily Telegraph. 28 April 2014

5 comments:

Dr Gandalf said...

A reasoned and timely post. #1careRevolution

Tim Senior said...

Thanks for an interesting post. I have some sympathy for this view, as I often don't feel like I've been taught all the extra things we are asked to do as GPs. It would be lovely if it was a more pure medicine. I'm not sure this is the case, though, and think if we try to work purely as the doctors we were taught to be in (hospital based) medical school, then we are actually choosing to be ineffective.
If you look at a pendulum and it appears to be defying gravity, it may be worth another look!
Sociology may be beyond ouur comfort zone, but it does remind us that we operate in a social context. It doesn't really matter what we think we're there to do. Patients will choose to come and see us when they are or believe themselves to be unwell. Much of the time this is not a result of disease, and ours is the only specialty that knows how to navigate safely through this. Often we come to the cause of health problems seen in our consultation as being something non-medical. They can't afford their prescriptiom, they don't have a safe house, the fridge needs maintenance. I'm not suggesting GPs should do the repairs (that would be a disaster in my case!) but that our medical care in those circumstances is a waste of time and money if the patient is not able to carry out changes.
This post focuses purely on a consultaiton between an individual GP and an individual patient. In the service I work in we do have a financial counsellor. We also have a community kitchen, mens's group, mums and bubs group etc. It's not all our responsibility as a GP, but often, if we are doing our job well, we are the first port of call - a friendly, trustworthy, listening ear who is not a relative and will keep secrets.
We are also powerful. We may not feel it, but we are given special secret powers by society (that sociology again!)We are allowed to certify whether people are truly sick enough to be off work, whether their housing is causing health problems. A phone call from us will often get more done than one from the patient. Collectively, our colleges and unions are routinely in conversations with politicians, unlike our patients.
It means there is a role for us as advocates - to make the changes that affect our patients' health and make our medical car less effective, and to advocate for services beyond out consulting room to help deal with these for our own patients.
Some further reading:
Our definition of health makes a difference: http://blogs.crikey.com.au/croakey/2013/02/13/as-we-move-towards-constitutional-recognition-what-can-we-learn-from-indigenous-understandings-of-health-heaps-suggests-one-gp
And the views of GPs and a College on these issues in Oz: http://www.biomedcentral.com/1741-7015/5/23

John Cosgrove said...

Thank you for this counterpoint, Tim. As I asked you on Twitter, is our acceptance of these "special secret powers" helpful or disempowering for our communities?

Samir Dawlatly said...

http://samirdawlatly.wordpress.com/2014/05/25/being-a-gp-more-than-a-doctor/

some thoughts written before reading Tim's response...

Dr Tim McMinn said...

The role of the current GP is brought further into definition by the current dispute over pay. GPs are well paid ... to be GPs. We receive no funding nor resources to be social workers, housing officers, counsellors, priests, hospital liaison,citizen advice bureau officers, hospital administrators marriage counsellors etc all roles that have become part of our daily work. We, free at the point of contact, are the last resort for the public for all the services and resources being diminished by cuts elsewhere.
These added unfunded roles are the reason why we no longer have the ability to be accessible nor have the resources to do the job we are trained to do as well as we could.