Giles Dawnay is a recently qualified GP and writer from Herefordshire. Visit his website at www.gilesdawnay.com and find him on Twitter: @gilesdawnay This essay came second in the 2021 Kieran Sweeney Prize
‘Everything we see has its roots in the unseen world’ (Hafiz)
I sit here in my sterile, Covid aware and razor sharp linear room as the last patient of the day departs. He floated out with an air of satisfaction, all his medications gone though one by one. He can update his list with some new dosages and cross others off. ‘Mission accomplished,’ I suspect for him. But for me, I’m ashamed to say, I now sit under the silent rumblings of my seemingly endless avalanche of Docman tasks with a degree of frustration. Did he really need to come? I ask myself. Surely I could have done all of that in 5 minutes on the phone? But perhaps, most importantly, why does this annoy me?
The GP landscape has changed considerably in the last 18 months. Covid has forced a rapid mass reorganisation of the way we practice in a way that could scarcely have been believed as Big Ben and Jools Holland played us in on New Year’s Eve 2020. Somehow the sacred physical space of doctor and patient was completely overhauled to the medium of telephone and video. The healing hands were put away and the noise limiting headsets put on. And we, the clinicians adapted and became used to it.
Yet now, after a seemingly concerted and targeted effort by the government and media, the patients are coming back again face-to-face. And so we must readapt, re-remember how to consult and examine in one go, and re-motivate ourselves to find the energy to welcome those occasional patients into our clinical space who we strongly feel do not need to be here.
What does this most recent turn of events say about the public, what does it say us, and what does it say about the future in which we are heading?
There are so many forces at play that surround and create any given consultation in the GP consulting room. The expectations and vulnerability the patient, the workload on the doctor at the time the interaction takes place, the political forces that guide the time and money that can be invested into that meeting, the cultural view of what being healthy means and who is responsible, and ultimately the relationship between the two human beings (or more) who hold that space together. This is a multifaceted intersection of both the biophysical and the abstract, the truth and the story, the strong and vulnerable, humanity and efficiency and the ‘do no harm’ to the ‘do something.’
It is the entangled interplay, therefore, of all these vital elements that charts our course for the future and creates the roots of future relationship. To attempt to explore and answer this question will need to look at all these tributaries before tracing our path to the mouth of the surging river and the powerful ocean they will flow out into.
‘All good things arrive unto them that wait–and don’t die in the meantime.’ (Mark Twain)
What the patient wants and what the NHS wants are curiously not always aligned. Perhaps never more evident is the manifestation of this in Primary Care. We’ve all had or overheard that conversation with a colleague about the consultation that we cannot work out whether anything useful was done. Yet the patient still departed seemingly satisfied. From our point of view we couldn’t scratch our conditioned itch of needing to actively do something, yet perhaps, hidden deep in the dark matter of the encounter, far more was done than we realise?
It has often struck me how often I have heard patients talking about ‘my GP’ or ‘my consultant’ in reference to their health.
The title of this question is an interesting one, it asks about the relationship between the patient and ‘their GP.’ In the use of the word ‘their’ there is implied ownership. It has often struck me how often I have heard patients talking about ‘my GP’ or ‘my consultant’ in reference to their health. This could be for one of many things; that the patient perceives the Doctor to be at their service (i.e. their taxes pay our wages), a reference to a sense of continuity that they are well known by the same doctor, or even from a more infantilised approach as we might refer to our own parents with such possessive pronouns.
With ownership comes expectation. With expectation comes the possibility of future resentment if the wanted outcome does not match the reality. The loss of the recent face-to-face appointment seems to have triggered a deep sense of loss of control, hence the desire for it to return. A patient comes to their GP in the hope of being understood and maybe even influence the direction of treatment, but how hard is it to give a full account of oneself if we cannot even share a room with the one who is listening?
Alongside a coherent explanation for their troubles, I believe the patient comes to be both witnessed and dignified by their encounter with their doctor. In a post-religious world where once the priests used to guide their charges through the interpreted word of God, now the same people look to the guardians of science and evidence to make sense of who they are and how to find meaning in their crises. Most, if not all, patients simply want to be given time and recognition from their doctor. Any future system that wants to enhance this relationship must incorporate this or suffer the interminable grumbles and outrages at what is perceived to being denied.
“Medicine cure diseases but only doctors can cure patients.” (Carl Jung)
GP’s are classically the first protective layer of the skin of modern health care, the first line encountered by those who believe they have a problem. 50% of students who leave medical school will likely become a GP at some point. Yet GP’s are rarely spoken highly of in training, instead often belittled by the specialist consultants who have been invited to teach and train hungry young minds. When I told one consultant at medical school my plan to become a GP, he smirked, ‘you’ve given up before you have started.’ We are a cohort who have chosen to rebel against the system of endless guidelines, militaristic hierarchies, rational imperialism and punishing shift patterns. We have chosen the uncertainty and intimacy of the one-on-one consultation. No other eyes, ears and observations but our own.
Yet we are asked to do this in ten minutes, a figure seemingly snatched from thin political air in the 1990’s.
Yet we are asked to do this in ten minutes, a figure seemingly snatched from thin political air in the 1990’s. Speed chess with consequences. 600 seconds is often barely enough time to walk to the waiting room, shepherd the creaking patient in and begin an introduction before the clock has chimed. Let alone should a patient of ours need admitting to the nearest hospital! Of course, this can be done, as it has been since then, but to what cost? Most GPs are now working part time, nearly 40% of GPs are over 50 yet there is an estimated 6000 due to retire early in the next 5 years.1 We chose a speciality that was about the patient story, yet we rarely are able to get past the first trailer.
The temptation is for the practices to merge, become bigger, offer more. Financial and partnership security dilutes the possibility of knowing our patients, consultations become random, picking up the work and thinking from another colleague, asking the patient to tell us their story all over again. Patients are living longer, their health conditions increasingly managed with more complexity. There is the unyielding shadow of the GMC lurking in our medico-legal waiting room.
In the UK there are now just 0.45 fully qualified GPs per 1000 patients in England – down from 0.52 in 2015. There are actually now 1,803 fewer fully qualified FTE GPs today than there were in 2015.2 The numbers are showing that there is only so long anyone can sustain themselves in a job they want to love but are unable to by the sheer volume of complexity, paperwork and fear of making a bad or harmful decision.
The modern GP is now programmed to focus only on an efficient and safe consultation, to create time for their other duties and administration. The utilitarian NHS self-righteously demands it. While justifiably important, what consequence to their ability to be themselves, to express their art of their humanity as well as their science?
‘there is something rotten in the State of Denmark’ (Hamlet, Act I, scene iv (67))
The recent incredible success of discovering and implementing an effective vaccine in under two years against a deadly virus that was previously unknown underlines how much of our capacity to be healthy lies in the hands of our politicians. One of the deeply uncomfortable truths of our ability to be healthy (along with how well we are educated) is that the tools put in place for this come from those in power. They hold the purse strings; they decide how money is to be spent on the society they envision.
The NHS is a modern ugly duckling, a universal socialist ideal embedded in an ever increasingly aggressive individualised and capitalist world. The Conservatives make little attempt to hide their disdain for having to pay for the health of the many, and long for a another system where the bills are taken care of elsewhere. Hashi Mohammed argues that as long as there is a monarchy in the UK (hence a deference to tradition and the status quo) then this country will remain profoundly Tory. If this is the case, then the NHS will be constantly met with political suspicion, disruption and distrust by its political masters.
In simple matters, the more GP’s there are, the more patients can be seen by them. The more money given to the system, the more time can be spent. The relationship between patient and their doctor takes place on an ever shakier platform constructed by those in far off ivory towers. No matter how well any two groups of people might get on, it counts for little if they consistently feel they are passing ships in the night.
‘Speed is irrelevant if you are going in the wrong direction.’ Mahatma Ghandi
Modern Western culture is defined by speed and progress. With Moore’s Law our computers are predicted to double in power every 2 years. Internet is becoming faster and faster and we can order what we want at the click of a button. There is little virtue in patience or doing without, everything and everyone are available almost instantaneously. Each subsequent invention promises the holy grail of speed which will lead to spare time. Yet the enduing irony seems to be that no matter how fast we move there still never seems to be enough time.
In stark contrast the natural world (from which we emerged) seems to reward slow and persistent behaviour. Good health in an ecosystem is seen over the course of many small and unseen decisions, not rapid intervention.
There are two issues here, that patients want instant access to their doctor, and that they want instant healing. A lack of both leads to inevitable frustration and a perceived failing of the system.
There is also the issue of the outsourcing of the patient’s body to the medical profession.
There is also the issue of the outsourcing of the patient’s body to the medical profession. Most patients inhabit a dark space which periodically sends signals of discomfort and pain that the doctor is then requested to interpret. By having an education system that doesn’t place knowledge and stewardship of our bodies as a central theme, then in an ever quickening world that seems built mainly for the able bodied to thrive, access to a doctor becomes vital.
Good health and high speed are uncomfortable bedfellows. The future relationship between patient and their GP will be hugely influenced by how the expectations of what it means to be healthy and whose responsibility it is to be healthy are managed.
‘listening is the highest form of generosity’ (Simone Weil)
Ultimately, when all the narratives, robes and traditions of patient and doctor are stripped away, in the consultation room sit two human beings. Both vulnerable in their own unique ways. When doctoring transcends its rational core and moves into a shared space of humanity with the patient, perhaps here is when the real work is done. If the patient feels that he/she simply sits opposite a technician and bureaucrat, that he is just another number to be worked through then there is little possible in terms of a meaningful encounter. However, if both humans can connect across the invisible chasm that divides them, then we have the beginnings of an abundant relationship.
Pain, and ultimately disease, might be looked at in terms of the build-up of pressure of blocked energy, either in physical, psychological, emotional or spiritual terms. The patient is one who has a blockage and looks to the doctor to help identify and remove it. It could be thought that the difference between a healer and a doctor is that while the doctor removes the blockages as requested, he/she may create new ones through lack of ability to fully witness the individual reality of the patient. The healer, on the other hand, leaves the patient less blocked than when they arrived seeking help.
Efficiency is the nemesis of humanity, the two are inversely proportional. The modern system which can now rely on legitimatising the cull of the face-to-face appointment through telephone and video has the power to make the GP extraordinarily efficient. The possibility to ‘see’ and deal with more patients is genuine. But at what human cost? All true relationships require time and continuity, what future do we look forward to if both are in short supply?
‘Today’s mind is the child of tomorrow’ (Buddhist saying)
In times of crisis the future is very much up for grabs. We find ourselves at a critical juncture as we begin to feel a sense of tentative confidence that there might be a life after COVID. The pandemic has challenged and forced us to let go of many of our assumptions as we have continued to maintain a relationship between patient and GP. How the post pandemic world of health will look is open to debate, no one can claim to know. However, there are certain truths that we must consider if we are to press forward in a way that allows the relationship of patient and their GP to thrive. Unless there is a system built on time and continuity it will continue down a path of fractiousness and dissatisfaction.
It is the patient that wants to be treated, not the disease.
Featured image by Javier Allegue Barros on Unsplash