My weekly run with a GP friend has become a breathless
litany of the ways in which she feels she and her practice are failing
patients. Last week, she resigned after
almost twenty years as a GP partner in a deprived part of London. She left with regret – still loving the doctor-ing,
but no longer feeling she can do it properly.
How to shoehorn the various problems of an asylum seeker with secondary
syphilis and compound health problems into a ten minute consultation? Or a woman with depression and crippling
arthritis caring for her husband with advanced dementia?
This has become topical with recent focus on the purpose and
future of general practice, from the Kings Fund’s conference last month to
words from the outgoing RCGP chair last week.
Similar debates have been had about the need to strengthen the general
physician role to provide person-centred care in hospital.
At the risk of sounding like a romantic, there is something
special about the general practitioner role and its place in British
society. A seminal work is John Berger’s
moving, lyrical (almost mystical) short account, A Fortunate Man, shadowing a
country doctor in 1950s rural England, accompanied by haunting photographs http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463119/. I remember hearing the late, lamented Kieran
Sweeney describe a key role of the general practitioner to `bear witness’ to
life (and death) events, as well as more technical forms of treatment. In this vein, Iona Heath’s monograph from
nearly twenty years ago is still worth reading for thoughtful reflections on
what she calls the mystery of general practice
http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/The_Mystery_of_General_Practice.pdf. I like her description of the GP’s role in
helping the patient to make sense of illness – the search for meaning being
something which doesn’t fit well with performance metrics.
Many have been influenced by the great US clinician/writer
(and now TEDx speaker), Rita Charon, who helped to develop the field of
`narrative medicine’ that honours the stories people (patients) tell and how to
listen http://jama.jamanetwork.com/article.aspx?articleid=194300. A good
doctor should have `the capacity for attention and the power of
representation’. In her book, she starts
with the great case story of Luz, who she dismisses as a time-waster before
understanding the reality of her underlying problems in an act of `clinical imagination’.
In this country, the torch has been carried by many others,
including Trish Greenhalgh’s work on storytelling and its place in the clinical
consultation http://www.bmj.com//content/318/7175/48.1. That many of these leading thinkers are women
is perhaps no coincidence. Evidence this
month from Karen Bloor’s team in York shows that women clinicians spend longer
on each patient consultation (2.24 minutes to be precise)with a more `relationship-building’
style http://hsr.sagepub.com/content/18/4/242.abstract
So there is good understanding of the power of narrative and
interpretation in clinical encounters. Medical
and nursing education is now more focused on improving communication with
patients, using ever more sophisticated role-playing,
simulation and interactive teaching of `softer skills'. But there is
often little time to truly `honour the stories of illness’ in a system under
strain.
I was thinking of all this as my frail, elderly father goes
in and out of hospital (currently over a week waiting in a busy medical care
assessment unit until a bed comes free) with a host of complex, overlapping
problems. No one seems to have time to
ask him how he is and what has changed.
And it is difficult to understand who, if anyone, is holding the
ring. So how can we bring the best of
a female-styled Dr Finlay into the twenty first century?
Also posted on BMJ blogs 14 October 2013 - http://blogs.bmj.com/bmj/2013/10/15/tara-lamont-a-female-dr-finlay-for-the-21st-century
Also posted on BMJ blogs 14 October 2013 - http://blogs.bmj.com/bmj/2013/10/15/tara-lamont-a-female-dr-finlay-for-the-21st-century
