hoolet issue 46 

Autumn 2005

Chris Johnstone Intro.
M.E. - A Memoir
Peter Davies on Whinging
The Commercial Imperative Assassin
The Commercial Imperative Alternative
Ordinary Angel
Support Groups And New York, New York
Reviews
Peter Murchie Goes Festive
Josie Inwood Pigs out at the EIFF
John Rankin doesn't go to Court
Blair Smith is Text Happy
An inch, an inch...

Teaching To The Converted

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

I like teaching for lots of reasons. I enjoy showing off, patients are much nicer to me when I have a student observing, students obediently laugh at my stale jokes and it is intellectually stimulating. It is particularly stimulating when the innocent voice of the observing final year student quietly asks “And why did you do that?” just as the patient is leaving the room. The patient hesitates at the door and turns back to hear your answer. Your instant reply of “That’s what I always do” dies on your lips as you hear how feeble it sounds. You start to rapidly interrtogate your memory in a desparate attempt to remember why you do treat this type of patient and condition with this remedy. A bit of you thinks, “Because it works.” Better than “That what I always do”, but still pretty feeble. By now your student has leant right towards you and the patient is seated again and is taking of his coat again. Slowly you dredge from the depths of years of experience, the logic and reasoning behind your thoughtless treatment. You recall the lectures and the articles, the discussions with colleagues and the previous trial and error with different doses and combinations. You begin to explain the theory and the practice behind the treatment and the initial anticipation of the patient and student turn to awe and admiration. Then they start snoring and you realise you have been rambling for far too long and are now running thirty minutes late.

I find that the realisation that what I practice has a genuine foundation and is not just making it up as I go along is very satisfying. Normally I do not reflect a lot on what I do, I tend to be too busy. So having a student observing me consulting allows me to consider and justify my behaviour. The other reason why this is possible is that if the student is sitting in I have 15 minute consultations. This is intended to allow discussion of cases, which it does, but it also allows me to review the notes before a patient enters, I can check their BP at leisure, review their repeat prescriptions and even ask them about exercise, or what they hoped to get from the consultation. 15 minutes is such a luxury. I achieve so much more in those extra 5 minutes, including the discussion with the student.

I have consulted at ten minute intervals for many years. I know that some practices still have eight minute appointments. I could not cope with that. However there are a small number of practices consulting at twelve and even fifteen minute intervals. With the new contract, the complexity of polypharmacy and co-morbidity and all the extra paperwork patients walk in with, ten minutes no longer seems enough. We should all consult at fifteen minutes, if not even longer. We would achieve more, patients would be better informed, they would need to attend less, there would be less side-effects from medicines and all our contractual and health promotion needs would be met. So why don’t we?

We would still have the same number of patients and other commitments as well as consulting for an extra hour a day and I no longer have a spare hour in the day. When I began in practice I used to have long lunches, go home and doze or do the crossword, even meet my wife for lunch. No really, honest. Slowly over the years the demands grew, surgeries expanded from two hours to two and a half and now to three hours. Phone calls increased, hospitals became less and less reliable and needed phoning more and more. Paperwork quadrupled. Assessment visits multiplied like rabbits and I am even getting a tension headache typing this this litany of stressors. You can only squeeze so many fluid ounces into a pint pot.

So we are in the situation where we all know longer consultations would benefit both patients and the NHS generally. But we don’t implement them for the simple reason there are not enough hours in the day. We can only offload so much work onto other professionals in the practice. Anyway there is no evidence that offloading reduces GPs’ workload. Employing nurses, phlebotomists and pharmacists may feel that our workload is reduced, but they are not necessarily cost-effective and it is actually cheaper to employ a multi-tasking GP. We need more GPs and lower list sizes.

So we present a very good case to the government for more GPs, especially if they want more work to be transferred to the community. How did they reply to our cogent, reasonable request for more GPs; to cut training numbers and hide their heads in the sands. Why would any sane government behave this way? This is not a rhetorical question. I really cannot understand how the government can refuse to expand general practice in the current climate, let alone ignore future pressures on the workforce. If anyone knows the answer please, please let me know.

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