hoolet issue 40 

Spring 2004

Chris Johnstone Intro.
First lets kill the bureaucrats
Of Knees and Knickers
Tales of a Grandfather - What Goes Around Comes Around
Practice Accreditation Symposium
The Future General Practitioner MRCGP
Did You Know??
Scottish Clinical Information Management in Primary Care - SCIMP
New - EPASS
Whats New?
Freedom of Information
Up General Practice!!
The Diary of a Traveller - A view back from the Dark Side
Review - Trawler
6th Wonca
Christmas Night on Call
Not Cricket

Doing What You Are Told

By Chris Johnstone
Contact the author by e-mail at christopher.johnstone@ntlworld.com

I sat down with my Registrar yesterday to watch some videos. Rather than the latest pirated Hollywood blockbuster or something from Sweden sir, we watched the nitty gritty of general practice. Patients and doctors sitting knee to knee, talking, communicating, sharing and healing. I never tire of watching consultation videos, all human life is there and nothing is more interesting. I agree that some may be boring and there are many where I am glad I am not the doctor involved. Usually they are short stories with beginnings shrouded in mystery. Sometimes they are simplistic with a stated problem, a simple fix and a thankful ending. In others the patients are less straight forward with their presentation, hiding their problem away, sometimes consciously and often subconsciously. Unravelling and clarifying their story can be simple, but clues to hidden depths are often littered through the consultation. These are more obvious when observing a video dispassionately with a rewind button. As the story unfolds, observing the patient and doctor coming to a common understanding is a great pleasure. Its what we do and I love it.

We have used videos as an educational tool for along time and once Registrars get over the their initial apprehension most of them enjoy video tutorials. However the video has been highjacked by the assessors and now each time we sit down for a tutorial we have to set the ground rules; real life or exam. In the first, we discuss life in all its glory and in the second we tick off the boxes for assessment. The first is fun and the second a drudge, necessary, but a drudge. But I think that setting the ground rules is very important in how we perceive the video. If it is always seen as assessment it is never enjoyed. So saying at the start of the tutorial whether this is real and therefore matters or just for an exam puts it in context. It does not make it any more enjoyable, but it prevents the video being lost in the summative morass.

I repeat this when teaching about audit. Audit is a brilliant, fun educational tool and you can get some great graphs out of it. Honest. Again however if it is seen as purely as a pass/fail exercise, it loses its charm and becomes a painful chore. Therefore I clearly differentiate between audit for life enhancing education and that which is required for the powers that be to label us competent.

I found myself doing the same thing with the new contract. I looked at the quality points scheme and decided that I would have to tick the boxes and set up systems as required just to get the points. And we all know what points make. It has little to do with the real general practice, the personal contact, the long term relationship, the healing milieu. So in my mind I had set up a barrier between my general practice and the contractual bureaucratic needs. I would earn the money, but it would not get in the way of me practising the sort of medicine which I believe to be the essence of good general practice.

It was my partners who pointed out to me that the contract was not all bad, in fact a lot of the new contract quality points were for things that I have espoused myself and have even tried to help practices achieve voluntarily through audit and our LHCC. I believe we should treat diabetics according to the guidelines, I do think asthmatics should get annual reviews. Most, not all, of the quality indicators are sensible and will improve the health of our patients if we implement them and even more if we reach the targets. So why wasn’t I doing it already. My personal audits show that although I know the best way to treat many diseases, a lot of my patients were not best treated. I had a slightly laissez-faire attitude towards BP readings, HbA1cs and cholesterol. My patients were happy, why upset them by adding another hypertensive or increasing their statin. They were happy, symptom free and so was I.

Already in our practice we have set up a variety of recall systems and can show improvements in some of our clinical measures. If the new contract can achieve this it cannot all be bad. I think my antipathy towards the contract came from being told what to do rather than choosing to it myself. I knew what to do, but I needed the contract to actually make me do it and I resented it. I will still practice my type of medicine, but with maybe a slightly larger nod towards EBM.

As I write this, two weeks before the end of March, I still do not know how much our practice will earn next year. I do not know how much a quality point is worth, nor what will happen to my PGEA. My wife, a lawyer, cannot believe I/we voted for a contract without knowing how much I would earn. I voted yes because I trusted our negotiators and knew that the old contract was no longer workable. So despite all its problems, I hope the new contract will deliver, patients will get treated better, I will still be able to practice as I want. There might even be a bit of money in it too.

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