I have just spent a day in a GP’s surgery. I was not detaining her with any complicated medical complaint of my own. I was shadowing her as a journalist.
Some weeks ago I wrote a column for the Times whose headline (though not my choice) brutally summarised my argument: that general practitioners were becoming glorified receptionists for the specialist medical services offered by the NHS; that patients should be able to save time and money by going straight to a specialist if they were sure of their problem; and that GPs, though hard-working, were often busy with counselling that a less expensively trained and less well paid nurse practitioner or medical assistant could provide.
As you can imagine, the column attracted much comment, some of it sympathetic but much of it hostile, from GPs who felt variously that I had misrepresented, misunderstood, overlooked or underestimated what they did. A few invited me to sit with them in their surgeries and see for myself. I accepted two of these invitations, one from a doctor in a rural practice and one from a doctor whose surgery served a mixed but generally poor locality in a big English provincial city.
I have yet to spend my rural GP-day, but have shadowed the city doctor. Her patients were asked beforehand if they minded an observer being present: only one did, and I stayed out. Otherwise I sat quietly in the corner of a cheerful but cramped little surgery, taking notes and trying to be invisible.
In what I now write I must take care not only that you, the reader, should be unable to identify any real individual, but that not even the patients themselves should be able to do so; so I shall conceal, transpose and jumble; but every observation I make will be from a note I did record, about someone I did see.
The experience did not seem to me either to confirm or rebut the column I had written. It was simply very, very interesting. It was also strangely and intensely moving. All human life was there.
The doctor was in at 7 a.m., preparing and dealing with her mostly electronic equivalent of paperwork. I joined her at 7.30. Her first patient was due just before 8; we did two or three hours of appointments; she then spent an hour more on e-paperwork, and after that introduced me to a little panel of patients she had assembled, leaving me alone to quiz them for half an hour. A short lunch was followed by an introduction to her systems for follow-up, referral, research and for keeping abreast of medical science. Then the two of us went out on her rounds, visiting patients too frail to come in. I (by then physically and emotionally exhausted) left her in the late afternoon with an hour or two’s work still to do.
You quickly realise that a great proportion of a doctor’s time is spent on a pretty small proportion of the patients on her list, and that a substantial number of them have family or psychological problems. I was deeply impressed that this particular doctor seemed so well acquainted with her patients’ personal histories; she proved her assertion that mere medical expertise would be an insufficient resource when it came to diagnosing and treating many human beings. This must be among the strongest arguments for general practice; but the impression I drew from those I spoke to was that there was rather less of this than there used to be, and that our hero (or heroine) wasn’t ‘like all those other doctors that don’t know you from Adam and just want to bundle you out of their surgeries as quickly as possible’.
I was deeply struck by how great a part stress, anxiety and depression seemed to play in the apparently medical conditions of those we saw. My GP host shared with me (I suspect) a slight and always kindly disinclination to stick fancy names on things, like ‘ADHD’, but you saw how much pressure a GP must be under to pluck a pathology from the air, prescribe sedatives and write sick notes.
I’d go as far as to say that physical infirmity was the main problem only in a minority of those we saw. Where it was, I’d estimate that respiratory and heart problems, in most cases exacerbated or even caused by smoking, were the single most recurrent (and distressing) ailment. The second commonest ‘reason’ for infirmity was, frankly, advanced age. I’m afraid to say, and will restrict myself to saying, that some of these patients were getting very little out of life.
There were only a couple of ‘referrals’ to specialists. I do now take the GPs’ point that rather than being simply portals for specialist medical services, they can also be much-needed screens. Conscientious as she was (she left no stone unturned and never hurried anyone from the surgery), it appeared to be a part of this family doctor’s work sometimes to persuade a patient that they didn’t rather than that they did need referral to a consultant.
What I did not see much of (and one day is hardly sufficient to generalise) was, in the fullest sense, diagnosis. This was not because my host GP was unable or unwilling to pronounce a diagnosis, but because in most cases there wasn’t much of a mystery about what the problem was. One or two of the patients showed themselves quite internet-savvy and had boned up on their condition in a (generally) useful way. Much use was made of blood-pressure testing and the stethoscope, but not with results that seemed to surprise or explain. There was no ‘aha! So this is what’s wrong with you!’ moment.
And so often during my day’s observation I thought that the patient was just very lonely, or seeking reassurance. Our two visits, both to isolated and very frail people, fair cut me up. You realised that a doctor’s visit may be one of the few visits that some patients are likely to receive from anyone at all. More than once I was fighting back tears.
‘Nothing’s ever going to get better, doctor, is it?’ said one old lady with a suddenly candid glance. She was not asking for a reply.