Ben Hoban is a GP in Exeter
GPs do very little nowadays that could be described as routine. Practice nurses, Healthcare Assistants, midwives and pharmacists have been looking after this side of patient care for a long time, and more recently, Mental Health and Wellbeing Practitioners, First Contact Physiotherapists, Nurse Practitioners, paramedics and Advanced Care Practitioners have been managing some of the more acute and non-routine care in general practice too. Given the shortage of doctors, this seems both reasonable and practical, and frees up GPs to deal with what’s left. Let’s be honest here: our clinical work nowadays is governed far more by guidelines of some kind or other than used to be the case, and our core strength probably hasn’t ever been the ability to follow rules.
Where does this leave us, then? Can we still argue that it’s right for us to manage everything from tonsillitis to terminal care personally in order to nurture the doctor-patient relationship, or should we focus on those elements of care that are too complex or poorly defined to fit within the portfolio of our colleagues? Can we still reasonably describe ourselves as generalists, doing a bit of everything, or are we on the road to re-branding ourselves as specialists in primary care?
Can we still reasonably describe ourselves as generalists, doing a bit of everything, or are we on the road to re-branding ourselves as specialists in primary care?
A hummingbird is a specialist, highly adapted to hover in front of a flower and extract nectar from it. It does this extremely effectively, and looks amazing doing it, but is limited to a very specific setting in which its adaptations will work. A fox, by contrast, is very much the generalist, at home in a variety of settings, and particularly able to exploit the opportunities which our modern urban environment offers an omnivorous species. Foxes are liminal, scruffy chancers sneaking around among the dustbins under cover of dark.
GPs are liminal too, practising on the threshold between the medical and the everyday. We rarely dazzle with our clinical acumen. Rather, we help our patients to negotiate the gloomy landscape of ill health and make good decisions when there are no perfect ones, sharing with them the uncertainty of the world outside the guidelines. There is much well-intentioned guesswork, and experience is measured in lessons learned from our mistakes. By and large, patients are looking for someone they can trust to do their best, rather than a wizard with all the answers.
We will never be specialists in the sense of either the hummingbird or our colleagues in secondary care. Our strength lies not in being able to do one thing perfectly, but in doing many things effectively in the grey zones of medicine. Physicians deal in physic and surgeons work with their hands, * but the GP’s role is a function of the inability of either branch of the profession to meet patients’ needs in isolation. And yet, despite our obligate generalism, we still act as consultants in the sense that other professionals within the practice team consult and refer patients to us.
Resilience is not just about personal toughness, but about adapting as a profession to changing circumstances, and foxes are survivors.
If a re-branding is in order, how about Consulting Primary Care Generalists? As the role of non-medical clinicians in our practices continues to grow, we are well-placed to lead, oversee and support colleagues whose scope of practice is more closely bounded by protocols, while they see the majority of patients and involve us as needed. This would mean abandoning any aspiration to personal continuity of GP care, but to put it bluntly, something’s got to give. Even if we double medical school places tomorrow, can we really wait another decade for the new recruits to arrive at the coalface?
The current realities may mean that rather than holding on for an increase in our numbers to maintain the status quo, we consider instead what might be the optimal role for a smaller number of highly skilled doctors working alongside colleagues from a variety of professional backgrounds. In this context, it would make sense to lengthen GP training, while aligning the training of non-medical clinicians more closely with general practice. Resilience is not just about personal toughness, but about adapting as a profession to changing circumstances, and foxes are survivors.
Physic is an archaic term for medicine. Surgeon is derived from chirurgeon, which is itself derived from the Greek words cheir, meaning a hand, and ergon, meaning work: hence, someone who works with their hands.