Monday, 7 January 2013

Farewell full time general practice part 2!

I'm now into my second week of reduced hours. So far so good, but I suspect it's not going to be easy for sometime. I've accumulated a fair number of patients throughout my 30 years and I suspect it will take them a while to take their custom elsewhere if I'm not available. Thus I'm expecting my remaining three days per week to be rather full.

Reviewing some more changes from when I first started, I must now get into the dreaded 'evidenced based medicine'. This represents the application of reliable clinical trial information to the everyday practice of medicine. Sounds good, but...

1. In 1983 I wasn't encumbered by the extraordinary myriad of clinical guidelines. Now it seems that every situation I'm confronted with in general practice has a guideline which I must  adhere to or have very compelling reasons for deviating from.  My concern with the practice of medicine in this way is that it becomes very 'guideline focused', a sort of tick-box affair, and fails to recognise the sheer variety of individuals in their particular social, emotional, spiritual,  physical, relational (and other axes) context. And it is these very contexts which an experienced GP carries in his/her head, oftentimes without even realising it, and which influences the choices of treatment, or none, recommended.

2. Thus in 2013 if a patient of mine is admitted to hospital having had a heart attack, he will be discharged on at last 4 drugs, all of which can bring their own problems individually, and who can say what effects will occur in their interactions Thus each subsequent consultation becomes much more complicated.

3. In my early days in practice there were far fewer associations to worry about. Thus we know now that if a patient has say rheumatoid arthritis or diabetes, he is at greater rest of coronary heart disease. The two conditions act as compounding factors.  We are much more alert to the needs of children and increasingly adults, whose well-being needs to be safeguarded. Screening has brought it's own problems with the increasing burden of over-diagnosis, and we are much more alert to the place of family history in certain cancers. And all to say that a GP's life is so much more complicated.

4. One pleasing change is the loss of what was previously known as 24 hour responsibility of care. Now many GPs go home at the end of their working day and no longer have to take calls from home and stagger out of bed at unwelcome hours. The out of hours care is provided by various local organisations, largely staffed by local GPs who work a shift pattern, and who are paid for that extra work.  I have mixed feelings about it since there's no doubt with the demands of a typical working day being much greater than when I started, the thought of continuing on through the evening and night-only to be followed by the next working day-is truly unthinkable. Nevertheless something has been lost.

5. Being on call at night for one's own practice (and perhaps for a neighbouring practice as well), did lead in time to a certain familiarity with the clientele. And certainly to a decent knowledge of  the geography of the patch. There was also a sense of continuity since either one would brief the on-call doctor of what may happen, or there would be a discussion the following morning of what had happened.  Its hard to get that with the current system, although at least there is a fax each morning with details of what has transpired through the night with our patients.

6. One major change is the massive increase in night time calls for a doctor (and a similar increase in A+E attendances).  It seems we are just more intolerant of waiting, or to put it another way, we are just impatient.  Exacerbating that, we have lost the ability to check with mum or granny what we should do before calling for help. With job mobility and increasing family breakdown, the connections are often just not there.

So is health care better now? Hmm...

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A message from the other side

No, not that side! But thank God got through surgery ok yesterday. And thanks to all for love support and prayer.