BJGP Long Read: A valedictory note on my retirement

Claire Stillman is a recently retired GP who spent 30 years in Scottish general practice, the last 20 of which were in Glasgow.

About eight months ago I wrote an emotional, angry rant about why I was leaving general practice. It was in response to a questionnaire from the LMC asking me for reasons why I was going. I never sent it to them; it seemed enough to write everything down and it exhausted my anger. I kept meaning to go back to it but I never did, probably because it was too upsetting when I was in work and then it became irrelevant when I left. My emotion had been expended. Also, I felt that I had said nothing new. There were no blinding insights, other people had said the same things over and over and nothing had changed. It is hard to see how anything can change given the current structure and funding of the NHS. I should say that I took early retirement at the age of 59 following 30 years in General Practice and I might have taken a handful of days of sick leave in that time. I never took any time off for stress.

Here are the reasons I left, or perhaps some of them:

Appointments

The appointment system is not fit for purpose. A GP has to be all things to all people in 10 minutes only and this is untenable. In this time we have to deal with the polypharmacised multiply morbid patient who has several problems to discuss. We have to manage an increasing amount of clinical work transferred from secondary to primary care. We have to deal with the manipulative, the dangerous and the deluded. We have to deal with those with shopping lists of demands, the worried well, those sent by third parties for proof of just about anything. We have to deal with the longwinded, the demented, the unhappy, the angry. We have to deal with the worried parent and the sick child. We have to deal with the medical emergency or those who think it is an emergency. The list goes on. We are accessible to everyone, every single being has the right to walk in to discuss anything; there is no filter, no prior discussion to see whether a trip to a GP is appropriate or suitable.

GPs can be bullied and manipulated by a public who increasingly demand certainty and rights and a bureaucracy that seeks to medicalise social problems. In all this we have no support. We were trained to help others’ suffering, not manage our own. We pay an emotional price for constant availability for everything the world throws at us (and I mean everything), and a professionalism that is never acknowledged or meaningfully supported. We face the relentless expectations of the ten minute appointment, the constantly full waiting rooms, the unacceptable waiting times to be seen and feel constantly punished because we cannot meet them. I can honestly say that in all my time as a GP principle, I can count on one hand the times I did not have a fully booked surgery. Government policy, patient expectation, pressure on our staff mean that we are constantly in the wrong, on the back foot, for not delivering a service that, quite frankly, is impossible to provide. We are supposed to be made of teflon, have no feelings, cope with the relentless daily, monthly, yearly pressure of not delivering the impossibly perfect service that this society believes is their right.

Patient expectations

Expectations by patients have changed over my thirty years in practice. Society has changed; the consumer approach, the belief that everything should have an answer, the inability to accept the uncertainty of life and health; the belief that if something goes wrong someone must be to blame have all increased over time. Expectations increasingly fuelled by the unrealistic claims made on the internet. Also the idea that everyone should have instant access, instant answers, has grown. These expectations are not really compatible with what GPs do, namely manage uncertainty. Because of this GPs have been harried into increasing amounts of patient tests, often with no clear goal in mind and no evidence that it would be useful. On the contrary, tests breed insecurity and more tests, because doctors feel the need to cover themselves, to insure themselves against patients demanding ever more certainty. It is ironic that in an age when the population has never been more healthy or long lived, health uncertainty and anxiety increases. Adding to patient expectations is the medicalisation of human sadness. The belief that a doctor can make grief, sadness, the ordinary difficulties of life better with a pill or therapy seems to have increased steadily over the years.

Lack of resources

GPs are damned if they do and damned if they don’t. We are placed in impossible double binds by chronic NHS underfunding and then blamed for the outcomes. Classic examples are the exploitation of our gate keeping roles by saying we must refer less into secondary care and then blaming us for not diagnosing enough cancers. We are held responsible for not diagnosing the rarest of cancers, which have no characteristic sets of symptoms, and yet demonised or refused by secondary care if we refer patients like these in.

Mental health services were reason enough to leave general practice. The NHS in my area refused to fund or possibly organise an even half functioning service and given society’s propensity for medicalising any adverse human experience we were imprisoned in the ultimate double bind and for us it was a life sentence. Throughout my entire career I was supposed to deal with the mentally distressed in ten minute appointments with no credible back up. The media slammed us for handing out too many antidepressants giving the impression that we had any alternatives. Trust me, we did not. The stark choices for GPs dealing with mental distress ranging from overt psychosis to a little sadness were a prescription for a pill then and there and a bit more than ten minutes (thereby pressurising everyone else in the waiting room), or a referral for a mental health treatment, be it talking therapy or more assessment which might occur within the next 3 to 6 months. The icing on the cake was that despite a GP referral, the mental health service might decide, several weeks later, not to offer any treatment at all. Truly GPs backs are up against the wall when dealing with mental health problems, which on a conservative estimate, take up to 20% of their work. Indeed, there is a psychological component to all disease. Dealing with mental health services throughout my career was the most excruciating and depressing aspect of my job.

Another problem caused by underfunding, which inexorably worsened throughout my time in practice, was waiting times. This has caused the NHS to become cruel in its dealing with suffering patients. I have seen people with severe, debilitating, painful conditions having to wait up to a year to be seen in secondary care. And then they get sent for tests, have to wait months for their results, and then they have to wait further months for follow up in clinics to get the results of said tests. Hospital doctors never make decisions without panels of tests that seem to grow larger by the year. Meanwhile the GP is the only doctor a patient can directly access while waiting for all these events, the walls are very high around secondary care, and we are expected to manage their pain, anxiety and frustration with no power to change anything. As usual, there is no support for the GP managing the patient in this vacuum and the more compassionate the GP, the more likely they are to be broken by this powerlessness in the face of suffering.

Complexity

Patients are becoming increasingly complex. They live longer, are on more medication and often have two, three or even more co-existing conditions. We are expected to deal with their needs in ten minutes, or consider their problems in the little time we have between fire-fighting paperwork and results and managing the practice. Meanwhile secondary care is becoming more specialised with increasing numbers of silos. A patient goes to a hospital clinic where a specialist has the luxury of dealing with one condition only, with all the back up of a hospital department. And it can happen that the decision a specialist makes about the one condition that is their remit will have a knock on effect for the other conditions a patient might have. It is left to the GP to sort it out. A record achieved by one of my patients was that he visited seven different specialties on a regular basis, all of which dealt with one aspect of his care and none of which could come up with an overarching explanation for his symptoms. Needless to say I had ten minutes to deal with all of them. The use of protocols, guidelines and non-doctor vetting of secondary care referrals also lead to GP stress, not to say cruelty to the patient. The silos are getting narrower, secondary care clinicians are more and more empowered to say what they will not deal with . Meanwhile GPs have to deal with their rejections with no support for their suffering patients.

Polypharmacy

This is a real problem in the ten minute appointment. All evidence based medicine derives from studies on single conditions and all medication guidelines come from them. The problem is that very few patients have only one condition. The GP has to juggle co-prescribed medications with their multiplicity of interactions and side effects in each individual, very difficult in a busy surgery with a waiting room full of patients expecting to be seen on time. Ironically when the community pharmacists started to be involved in the Scottish NHS new contract, they stated they would need thirty minutes per patient. And a pharmacist would only be dealing with medications while the GP has to deal with the actual patient’s agenda, which may be something else entirely. Prescribing outwith the consultation has also become more onerous over the last few years as drug shortages and the increasing prescribing demands of secondary care have to be managed.

Poorly understood conditions/somatisation/chronic pain

Some of the hardest patients to deal with, the most time consuming and emotionally draining, are the ones that don’t fit into neat diagnostic boxes, yet constantly present with suffering and demand answers. These patients are not recognised by, and certainly not treated by secondary care. For example, those people with chronic pain for which we actually have no effective medication. Synthetic opiates, the only treatment out there, do not work and turn them into addicts. Any attempts at psychological reframing of their conditions are seriously resisted by the patients, and to be frank, the medical establishment.

The Cartesian dualism that bedevils our concepts of illness means that patients and many doctors think that the ultimate insult is to suggest that their suffering is ‘all in their head’ and for some strange reason does not then exist. Unfortunately GPs are faced with a number of patients who manifest their life distress with physical symptoms, call it somatisation for want of a better term, for whom existing medicine has no treatment and who become bitterly entrenched in their illness behaviour as they feel less and less cared for. The ‘fibromyalgics’, the chronically fatigued, for whom there is no realistic therapy and for which GPs have no training or support. I am not surprised that so many of them turn to snake oil salesman and quacks who at least provide them with attention before exploiting their vulnerabilities.

Outsourcing of secondary care work

Over the years, general practice has been subjected to a form of ‘mission creep’ with secondary care demanding that we increasingly do work that was originally done in hospital medicine. While it may seem reasonable that GPs manage new atrial fibrillation or perform near patient testing, this is added to our already increasing workload. There seems to be a belief that GP is elastic can continuously absorb extra work indefinitely. There is only so much work that we can take before we break.

Housebound patients

While home visit rates have gone down, housebound patients are becoming increasingly complex so that visits can resemble ward rounds in a geriatric hospital. Patients are often on medications and have conditions that need frequent monitoring and repeat visits that we are not resourced to manage. Latterly, I became increasingly concerned about our cohort of usually elderly, frail housebound patients on complex, potentially dangerous treatment regimes who were poorly managed in the community. General practice as it stands is just not equipped to deal with these people.

Conclusion

I think the chief thing to emphasise is that GPs stand alone, and are chronically under resourced. We may work in group practices and have our administration staff, but once the door is closed, it is just the GP and the patient in the room together. And in real time we have no support, indeed we have no formal support networks at all on the ground. There is no-one to catch us as we fall, we have no protection from the ire of the public, anger that is usually caused by a system that fails to deliver what has been promised. We stand and fall by the decisions we make in ten minutes and if things go wrong, the full weight of public and professional opprobrium lands on our heads. There is no safety net, no cavalry coming over the hill to relieve us.

Now, I have retired and I do not miss any of it. I was well thought of by my patients and staff to judge by the feedback I have received over the years and the overwhelming number of cards and presents I received when I retired. I also got on with and liked my partners. Yet a powerful emotion I associate with my time in general practice was one of failure. I had failed to deliver a good service and so now I am just relieved to be free of it. However, what does bother me is that I had a wealth of knowledge and skills, accumulated over lifetime, which I will never use again.

And what does strike me is that perhaps my profession could benefit from my and my peers’ experience. I could perhaps mentor younger GPs, newly practising partners, and provide them with the support I never had. I can read a face, interpret its subtle movements, be aware of another’s suffering. I can listen actively and frame peoples’ stories empathetically and positively. I can pull out the essential points in a narrative, summarise a conversation, help someone form a plan for the future. I can listen. Yet there is no place for me now in my profession, general practice has lost my skills and those of all my retired peers completely. I feel that this is a shame as we are a resource that could be utilised for the good of the profession.

As for the future of general practice, I do not trust the Scottish NHS and the health boards to deliver the supposed new Scottish GP contract. They mouth platitudes but follow their own agendas rather than those of general practice, they have not trusted GPs to execute the changes and allocated funds seem to have dissipated in a plethora of talking shops and committees. It seems that the further you remove practitioners, the people who actually do the work, from decisions about how the work is done, the less successful the outcome. Unfortunately, GPs have been so busy actually doing their jobs, they have not had the time or emotional energy to fight for a new contract that works for them. I have little hope that the new contract will result in better experiences for patients or their doctors.

However, it can be argued that innovation, out of the box thinking comes from those without an interest in the system, so let’s throw the problem of how to run an NHS out there. Let all and sundry chew on it, because I don’t expect those within the system to come up with any answers. Lets hope someone has thought of something before the inevitable happens to me and I become a patient.