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Frequently Unasked Questions FUQs

Questioning Primary Care or Frequently unasked questions in general practice

This is a bank of FUQ which will develop as the questions don’t get asked.

1. What is special about being a family doctor?
2. Why be a generalist?
3. Can GPs really do everything?
4. How do you listen to patients?
5. What should you do when you get stuck in your clinical care?
6. Is continuity of care useful?
7. Do you need a GP to make a diagnosis?
8. Why are diseases treated differently in primary care?
9. Why do we spend so much time in organisational change or Why do I feel like screaming?
10. Aren’t most problems in primary care trivial or self limiting?
11. How difficult can it be to manage self limiting illnesses?
12. How long will it take to make me a wise doctor?
13. How do I ask better questions, and get good answers?
14. What are the key questions in managing clinical care?
15. How can I be the leader?
16. How do I change myself and others?
17. How do I ensure a patient takes the medication I advise?
18. How do I know when I am getting too stressed?
19. How do I make sure changes become improvements?
20. How do I survive complaints?
21. Why is it important to have bad doctors?
22. What is the Perfect General Practice?
23. How should do GPs plan their day?
24. Why GPs do not always implement guideline?
25. How do I develop my career, and not get stuck in a rut?
26. How can I manage bureaucrats, politicians and academics who don’t understand general practice?
27. How can I avoid working in a dysfunctional team?
28. If I am the learner why are you asking the questions?
29. Is the difference between primary care and secondary care, just more knowledge?
30. Why be person centred?
31. Do GPs look after communities or patients?
32. What is quality in primary care?
33. What should I do in a crisis?
34. What is the purpose of becoming an old GP?
35. When is the right time to do something?
36 When should I really take a break?
37. Who is in charge in general practice?
38. Why don’t I manage patients better, more like a specialist?
39. How can I rate education experiences?
40. Why are diseases treated differently in primary care?
41. Why be a coordinator of care?
42. What do dissatisfied patients do?
43. Is general practice an art or a science?
44. Why do patients become frequent attenders?
45. How do we change our patients?
46. How do adults change their behaviour?
47. How do I avoid having to do the work myself?
48. What is the Art of Medicine?
49. What are the four principles of family medicine?
50. How trusted are GPs?
51. What causes health scares and panics?

1. What is special about being a family doctor?

If a hospital bed is a parked taxi with the meter running (Groucho Marx), is general practice a bus queue in the rain?

There are differences between being a Family doctor, General Practitioner, a Primary Care doctor and a specialist. Does it matter?

Some definitions

Primary care is the setting within a health care system, usually in the patient’s own community, in which the first contact with a health professional occurs (excluding major trauma).

Specialist is a physician from whatever discipline who has undergone a period of higher postgraduate training.

Primary care physician is a physician from whatever discipline working in a primary care setting.

Secondary care physician a physician who has undergone a period of higher postgraduate training in an organ/disease based discipline, and who works predominately in that discipline in a hospital setting.

General practitioner and family doctor. in Britain these are synonyms, used to describe those doctors who have undergone postgraduate training in general practice. in other parts of the world, general practitioner may mean a doctor without any postgraduate specialist training.

General practice / family medicine is an academic and scientific discipline, with its own educational content, research, evidence base and clinical activity, and a clinical specialty orientated to primary care.

What is special about the being a family doctor. There is a special dimension to the way that you understand the patients problems and how to manage those problems. You may understand cause, cure and care better.

Over 50% encounters are family orientated in some way, and family problems are discussed in about 25% of encounters . There are six main ways family contacts inform and affect the encounter. In many ways you treat the family not just the patient

Knowledge about a family can

help you understand the patient’s disease, illness and health
help you identify the source of the patients disease
focus your attention on the health and illness of other family members
demonstrate the family concern for your patients health
involve the family as a care resource and care collaborator
prompt family members to receive unscheduled care

In hospital the diseases stay the same but the patients and families change, in general practice the patients and families stay the same but their diseases change.

2. Why be a generalist?

No human being is constituted to know the truth, the whole truth, and nothing but the truth; and even the best of men must be content with fragments, with partial glimpses, never the full fruition.
Sir William Osler

General Practice ‘is normally the point of first medical contact within the health care system, providing open and unlimited access to its users, dealing with all health problems regardless of the age, sex, or any other characteristic of the person concerned.’ From the European Definition of General Practice/Family Medicine

GPs deal with unsorted problems. This ranges from listening but doing very little, to listening very little but doing a lot. GPs are often a clearing house for problems, where patients can bring their worries to a reasonably user friendly service. Clinicians who follow guidelines can help the management of specific problems, but a GP’s real work starts when the guideline ends and it’s not clear what to do next. The challenge is to get to the important point of the encounter quickly. This can be exciting and overwhelming. A patient may present very worried about some perceived illness, and within a few minutes you may be able to either diagnose and treat the problem and send the patient home happy and reassured.

GPs know a bit about everything which doesn’t sound very special until you realise most other doctors don’t have the same breadth of knowledge. Only GPs seem to understand how all of the health care system fits together. I have heard careers advice given to medical students that said ‘don’t do general practice, you don’t have to know anything in depth, its too easy you’ll be bored’ and other advice ‘don’t do general practice, you have to know something about everything, its will be too difficult for you to do it well’.

With the range of problems, and the range of patients, and the opportunities to practice medicine with breadth and varying depth over a 30 year career, what could be better than being a generalist?

3. Can GPs really do everything?

If the only tool you have is a hammer, you tend to see every problem as a nail.
Abraham Maslow

General Practice ‘deals with health problems in their physical, psychological, social, cultural and existential dimensions’. The discipline has to recognise all these dimensions simultaneously, and to give appropriate weight to each. Illness behaviour and patterns of disease are varied by many of these issues and much unhappiness is caused by interventions which do not address the root cause of the problem for the patient. From the European Definition of General Practice/Family Medicine:

Coping (or appearing to cope) with everything is an essential part of being a GP. In the predictable part of work you deal with familiar problems in contexts that are familiar. Organisations like the NHS improve effectiveness within this predictable work by sharing best practice (e.g. sharing clinical guidelines, or sharing the results of evidence based medicine). If the problem or the context is unfamiliar then best practice transferred from your predictable work may be unworkable or even a disaster. Distressed patients are common, and most doctors have experienced consultations when the patient ends up more distressed. The reason for the distress can be complex and might seem unfathomable. The only realistic strategy is learning to cope effectively with uncertainty. The unfamiliar is a different emotional experience, characterised by feelings of exposure, unsureness about competence and confidence and the need for courage, imagination, taking responsibility and initiative. Above all the unfamiliar is the realm of learning in which you become more focused on developing wisdom. In reality there is always a mix between the unfamiliar and the familiar and with increasing experience a gradual move towards the familiar.

You can classify your usual way of working using four assessments based on your skill level and personal philosophy (ref 1). Do you have basic or advanced skills, and do you have a simple or complex approach to problems? You can usually assess yourself by recognising what sort of patient you are comfortable with, and what sort of feedback you get from patients, staff and other doctors about your performance. Depending on your approach you will tend to fit one of four distinct profiles The basic simple profile is ‘the mechanic’. You have basic skills, dispense medications and direct advice. Your encounters are problem-focused, and at times you can seem abrupt, ignorant of emotional distress and not patient centred. The basic complex profile is ‘the counsellor’. You are bio-psychosocially orientated with basic skills and you offer advice. You explore the patients backgrounds, concerns and spiritual dimensions of illness in a patient centred fashion. The more advanced simple profile is ‘the investigator’. You are bio-medically focused but when the occasion warrants you have a repertoire of detective skills that allows you to sense patient cues of emotional distress that shed light on the patients condition. Finally the more advanced complex profile is ‘the healer’. You use the full breadth of bio-psycho-social skills taking into account cultural and existential dimension and integrate most aspects of care seamlessly. You appear comfortable with different patients in different situations. When you know your style, if you want to change it to treat the person, not the just the disease you will need consultation skills advice. This can be a difficult process but rewarding to cope with difficult consultations better.

Reference 1: Robinson, W.D., Prest, L.A., Susman, J.L., and others. (2001, October). "Technician, friend, detective, and healer: Family physicians' responses to emotional distress" (HS08776). Journal of Family Practice 50 (10), pp. 864-870. www.ahrq.gov

4. How do you listen to patients?

Wisdom is the reward you get for a lifetime of listening when you'd have preferred to talk.
Doug Larson

General Practice ‘has a unique consultation process, which establishes a relationship over time, through effective communication between doctor and patient’. From the European Definition of General Practice/Family Medicine

The essence of the consultation is to provide the cues for yourself and the patient. A consultation with a new patient at its simplest should include the following

1. Welcome the patient
Ask: How are you? What can I do for you today?
Let the patient speak without interruption for the 90 seconds it takes to tell the story

2.Clarify the problem
Ask how does this affect you? At work, at home, at school? Find out why it’s a problem

3. Check for worries and expectations
Ask: What worried you? What did you think this was? What did you want me to do?

4. Take a history, exclude serious illnesses.

5. Examine the patient
Explain what you are doing and why you are doing it.

6. Formulate a plan
Say: Having examined you I think it is ……………. and there are some choices about what we do next.

7. Predict what should happen next.
This is what I think will happen next. This is what you should do next.

8. Have a backup plan
If this does not go as predicted this is what you should do.

Finally how do you know if the consultation has gone on too long, its when the patient starts checking the time.

5. What should you do when you get stuck in your clinical care?

Nothing is impossible for the man who doesn't have to do it himself.
"Weiler's Law"

General Practice ‘promotes health and well being both by appropriate and effective intervention. Interventions must be appropriate, effective and based on sound evidence whenever possible. Intervention when none is required may cause harm, and wastes valuable health care resources’. From the European Definition of General Practice/Family Medicine

Traditionally GPs have a relationship with their patients over many years. For a generation GPs have been taught skills to improve their empathy and effectiveness in consultations. Now GPs have to advise stricter control in chronic diseases like diabetes. There is a conflict between having a long term relationship, that is empathic, and getting patients to make major changes in their way of life. The transtheoretical theory of change suggests in relation to any behaviour change that patients are at different stages e.g. precontemplation, contemplation, planning, action, maintenance, termination and use different process to move from one stage to the next.

Hammerfest is a small town in northern Norway and everyone knows everyone else too well. A GP in Hammerfest says they have no time for euphemistic consultations. In England we tell an obese patient he has a body mass index of 36, in the Hammerfest consultation he is told he is disgustingly fat. A study to assess the effect of additional training of practice nurses and general practitioners in patient centred care on the lifestyle and psychological and physiological status of patients with newly diagnosed type 2 diabetes demonstrated better communication with the doctors, greater treatment satisfaction and well-being. However body mass index was higher, triglyceride concentrations were higher and knowledge scores lower. There was no significant difference in lifestyle and glycaemic control. The trained practitioners seemed to give greater attention to the consultation process rather than to preventative care (reference 1). In contrast there are stories that when doctors who have no continuity with the patient (eg locums, GPs in other parts of the country, or hospital doctors) give the patient feedback on their lifestyle, the patients remember the feedback and say it made a difference.

Dr Caresalot counselled one of her patients (Mr Heartsink) weekly for many years without ever making much progress. Dr Caresalot takes a much needed and well earned six month sabbatical to study how to improve her counselling skills so that she can give a better service within the 10-20 minutes appointments that she can actually provide for patients in her practice. Upon her return to her practice she is surprised that Mr Heartsink no longer comes to see her. A year passes and finally Mr Heartsink comes to the doctor. They exchange greetings, Mr Heartsink is well except for a physical problem, shingles. They talk and eventually Dr Caresalot asks why happened that made Mr Heartsink not seek medical attention weekly. Mr Heartsink explains that the when Dr Caresalot was away he came to see the locum Dr Getalife, and the locum had listened to Mr Heartsinks usual list of worries and complaints and told him 'Pull yourself together', and so he had, and only wished someone had said this years ago. So perhaps we now need two sorts of doctors the caring and empathic that helps patients through change, and a more honest and blunt doctor that gives the patients the truth about their self destructive behaviour and prompts the patient into changing their way of life. An example of an intervention could be that we target the poorly controlled diabetes patients, from our current knowledge decide what is the most important lifestyle intervention (diet, better tablet adherence, more exercise, switch to insulin) and send the patient an invitation to see our specialist in the management of poorly controlled diabetes Dr Hammerfest. Dr Hammerfest who is not in a long term relationship with the patient gives the patient the truth about the risks to health and very clear instructions about what the patient must do to reduce the risks to their health. The usual GP & team then provide ongoing support for the lifestyle change. The good news is that this is a relatively easy intervention, one consultation per patient, and can be applied to many practices. This style of intervention is already happening with practice nurses running chronic disease management programmes that check a patients treatment against a guideline.

Reference 1: Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. Kinmonth AL, Woodcock A, Griffin S, Spiegal, Campbell MJ. BMJ 1998;317: 1202-8.

6. Is continuity of care useful?

Experience is that marvellous thing that enables you to recognise a mistake when you make it again.
Franklin P. Jones

General Practice ‘is responsible for the provision of longitudinal continuity of care as determined by the needs of the patient’. From the European Definition of General Practice/Family Medicine

Primary care is a result of the historical processes that formed general practice and the current pressure and rewards to change care. The history of general practice is that it was a cheap service that valued the personal GP as the usual provider of primary care, but could not guarantee either a fast or quality assured service. The current NHS costs more and favours faster access to any competent clinician. There is no pressure or reward to encourage GPs to provide personal continuity of care. For patients one definition of personal continuity of care is that it exists when 80% of contacts by a patient with their GP are with the same GP. The health benefits for the patient of a system that ensures continuity of care are uncertain (ref 1). There is some evidence that continuity improves uptake of preventative care, adherences to treatments, satisfaction and perhaps health status. There is conflicting evidence in chronic diseases. Advice on diabetic control may be less strict, but there may be improvement in diabetic care. Male, younger patients and those with more mechanical type problems perceive continuity as less important. Patients who have conditions with a psychosocial aspect value continuity more. Other research in the US suggests that whilst patients indicated that continuity of care was important to them, they were unwilling to spend much additional personal time or money to maintain continuity with their current GP. Nevertheless, an important subset of older and more vulnerable patients reported being more willing to pay to maintain continuity. In an undefined way it seems that more experienced patients recognise continuity or a personal relationship as an important part of the process of care. For GPs, the responsibility for the continuing care of specific patients may be important, because it makes it clear that the GP does not have the same continuing responsibility for all the other patients. It’s hard for any GP to feel responsible for all the patients in a large practice with more than few thousand patients. It’s easier to relate to a more manageable smaller list of patients who are known very well. When you recognise the name on a list as a real person, with whom you already have a relationship and whose problems you know something about it, it easier to feel committed to improving that person’s care. My practice has 13,500 patients and 12 GPs. We have roughly 450 patients with diabetes and have been auditing our care of diabetes for 20 years. In the course of our audits we produce lists of the names of patients whose care seems suboptimal. Now we audit many more chronic conditions and do it more frequently. Patients often have many co-morbidities and the same patients names appear on more and more of these lists. These lists become unmanageable if the names on them have little meaning to most of the GPs. The GPs struggle with the care of these patients unless either the name is recognised and the patient is known as a person, or the GP has a personal responsibility for the named patients and continuity of care. When the patient is known as a person it becomes easier to plan the most appropriate and best care possible for that person. GPs may have ongoing long term contact with their patients and their families for a wide range of problems over many years, and the contact and care continues even when their medical treatment has ‘failed’ or has little to offer. Continuity of care helps make the doctor and patient develop the relations hip that sustains them when life is difficult.

Different types and definitions of continuity of care can also include

Longitudinal. How much or for how long the patient has seen the same provider
Relationship/personal. The relationship with the provider is assessed in some way
Team. As longitudinal but with a group or team of care providers either in primary or secondary care
Geographic. Care is given/received in person on one site
Cross boundary. Typically hospital/specialist outreach to primary care.
Regimen/comprehensive. Reference to a common and usually comprehensive treatment programme indicating a multi-skilled team or teams.
Flexible. Care adjusts seamlessly and interactively as the individual patient’s needs evolve over time
Information/records. Includes computer links and shared records and where outreach is not interactive.
Interactive remote care including consultation by telephone, real-time computer, email.
Experienced continuity from the patient’s viewpoint.

Ref 1 Towards a theory of continuity of care. Denis Pereira Gray, Philip Evans, Kieran Sweeney, Pamela Lings, David Seamark, Clare Seamark, Michael Dixon, and Nicholas Bradley. J R Soc Med 2003 96: 160-166.

7. Do you need a GP to make a diagnosis?

See - I told you I was ill.
Epitaph of a hypochondriac (also on Spike Milligan’s gravestone)

General Practice ‘manages illness which presents in an undifferentiated way at an early stage in its development, which may require urgent intervention’. The patient often comes at the onset of symptoms, and it is difficult to make a diagnosis at this early stage. This manner of presentation means that important decisions for patients have to be taken on the basis of limited information and the predictive value of clinical examination and tests is less certain. Even if the signs of a particular disease are generally well known, this does not apply for the early signs, which are often non-specific and common to a lot of diseases. Risk management under these circumstances is a key feature of the discipline. Having excluded an immediately serious outcome, the decision may well be to await further developments and review later. The result of a single consultation often stays on the level of one or several symptoms, sometimes an idea of a disease, rarely a full diagnosis. From the European Definition of General Practice/Family Medicine

Most patients know, suspect or fear a diagnosis. They usually reveal it if you listen to the patient and let them tell their story and share their own diagnosis. Most patients rehearse what they are going to say, it usually lasts only 30 seconds to 2 minutes and its worth the time. If you think they have left out an important piece of information like the diagnosis then ask them ‘what do think the cause of problem is?’ Most new patients with symptoms of diabetes have already checked their urine or blood sugar using a friends testing kit. You only need to make a diagnosis when the patient can’t give you it, you need to witness and confirm the patients own diagnosis.

8. Why are diseases treated differently in primary care?

It is much more important to know what sort of patient has a disease than what sort of disease a patient has.
Sir William Osler

GP ‘has a specific decision making process determined by the prevalence and incidence of illness in the community’. Problems are presented to family doctors in the community in a very different way from the presentations in secondary care. The prevalence and incidence of illnesses is different from that which appears in a hospital setting and serious disease presents less frequently in general practice than in hospital because there is no prior selection. This requires a specific probability based decision-making process which is informed by a knowledge of patients and the community. The predictive value, positive or negative of a clinical sign or of a diagnostic test has a different weight in family medicine compared to the hospital setting . Frequently family doctors have to reassure those with anxieties about illness having first determined that such illness is not present. From the European Definition of General Practice/Family Medicine

The populations served are very different in general practice and hospital medicine This is an obvious but forgotten difference that can cause inappropriate management of patients and the muddled teaching of students. Primary care sees a more general mix of patients who present early in their symptomatology. Hospitals specialists should only see the patients who have already been selected for referral by their GPs. For instance if a patient presents to a GP with a headache, the GP knows that most patients with a headache have self limiting illness and do not need to be investigated. Only a very few patients will have serious pathology. In general the GP can assume that most patients are normal, be able to reassure and treat most patients, but be vigilant to identify the 1% of patients who have unusual headache that might need referral for further investigation. By contrast a neurologist’s clinic is full of the 1% with unusual headaches that have been referred, and the neurologist knows that a high proportion of patients will have an important abnormality so each patient must be assumed to have a serious pathology and investigated. Primary and secondary care work well together when each understands the prevalence of illness in its patient population, its role in the management of illness, and only the appropriate patients are referred to hospital care. The worst scenarios are when this becomes muddled and primary care assumes everyone with a headache needs investigation or referral, or when secondary care assumes that everyone with a headache is normal and doesn’t need investigation. This muddle is continued if secondary care specialists don’t acknowledge the differences in the patient population in primary care, teach primary care subjects and mistakenly advocate secondary care management for these primary care populations. This may cause GPs to refer more patients to hospitals. The balance between primary care and secondary care is traditionally preserved by the GP gatekeeper role. GPs control who is referred to secondary care. The balance is easily upset if GPs are advised to refer patients more often to hospitals or if hospital specialists (or GPs with a special interest) work in a primary care setting. If the average GP usually refers 4 out of every 100 patients to secondary care, but increases referrals to 5 out of every 100 patients, whilst it has very little impact on the daily work of the GP, hospitals have to cope with a 25% increase in their referrals. And a vicious circle develops where the distinctive differences between primary care and secondary care are eroded. Patients suffer with unnecessary investigations and referrals, and the NHS struggles to cope with the workload.

Never assume that there is someone else in charge who knows what they are doing, always know what you are doing, and that it’s likely to benefit not harm the patient.

9. Why do we spend so much time in organisational change or Why do I feel like screaming?

Like death and taxes in life, meddling (or change without improvement ) in the health services is inevitable. Its does not take long in the life of any GP to get a sense of déjà vu, and recognise that the latest batch of reorganisations or reconfigurations are remodels of previously discredited changes.

Why does this happen? The politicians believe that you can’t take the politics out of health so they have to initiate changes to reflect their latest spin on ‘how to run a health service and win votes’. Despite their best intentions the politicians don’t understand the health or management problems, so we end up with policy that can be described as ‘specifically vague’. Once you know this description you start to recognise it everywhere in policy and planning statements. Worthy and wordy but without any real meaning. The careers of NHS managers and administrators depend on translating this policy into action. There are so many loose ends that sooner or later the whole thing unravels until the politicians discover a new solution, and the cycle of change starts again. At times it feels like a three card trick, with the only participants who seem to win are those in on the trick to fool the rest of us. Do you play the game and risk making a fool of yourself or stay out of the game but worry that your pocket will be picked.

10. Aren’t most problems in primary care trivial or self limiting?

Trivial and self limiting illnesses are not difficult problems. Good GPs know that patients may present with a simple illness but often have an underlying worry about their health that needs to be identified and addressed. Good GPs use the opportunity that trivial and self limiting illnesses allow for advising patients on healthy lifestyles and opportunistic health screening opportunities

11. How difficult can it be to manage self limiting illnesses?

It’s easy to manage self limiting illnesses.

12. How long will it take to make me a wise doctor?

Nine times out of ten, in the arts as in life, there is actually no truth to be discovered; there is only error to be exposed.
H. L. Mencken

It will take less time if you are aware that absolute wisdom is unachievable, you just get smarter than you were yesterday because you learn from your experiences. Arguably the more mistakes you have made the wiser you will be!

13. How do I ask better questions, and get good answers?

http://www.bristolgpsolutions.org.uk/j3.htm

14. What are the key questions in managing clinical care?

General Practice ‘manages simultaneously both acute and chronic health problems of individual patients’. Family medicine must deal with all of the health care problems of the individual patient. It cannot limit itself to the management of the presenting illness alone, and often the doctor will have to manage multiple problems. The patient often consults for several complaints, the number increasing with age. The simultaneous response to several demands renders necessary a hierarchical management of the problems which takes account of both the patient's and the doctor's priorities.
From the European Definition of General Practice/Family Medicine

GPs often manage the acute and chronic health problems of individual patients and their families over a long period of time. The usual clinical questions are

What is the reason for the consultation
When should I request a test
What does this report mean, how do I interpret it
What do I do about a result
What is the treatment
When do I refer
When should I review

If you want to ask a good clinical question, then the question should be directly relevant to the problem at hand. The question should be phrased to make searching for a precise answer easier. The question must focus on the four parts

The problem being addressed
The intervention or exposure being considered
The comparison intervention or exposure (when relevant)
The clinical outcomes of interest

Most questions arise from 6 aspects of clinical work

Clinical evidence: How to gather clinical findings properly and interpret them soundly
Diagnosis: How to select and interpret diagnostic tests
Prognosis: How to anticipate the patient’s likely course
Therapy: How to select treatments that do more harm than good
Prevention: How to screen and reduce the risk for disease
Education: How to teach yourself, the patient and the family what is needed

15. How can I be the leader?

The secret of life is honesty and fair dealing. If you can fake that, you've got it made.
Groucho Marx

You can’t build a reputation on what you are going to do.
Henry Ford

It helps if someone wants to follow you. They are more likely to follow you if you have charisma, power or money. None of these will make you an effective leader. If you don’t have charisma power or money then you have to build a history of success in what you do.

It helps if you know what you are trying to achieve. Improvement knowledge can get you started http://www.bristolgpsolutions.org.uk/a4.htm.

16. How do I change myself and others?

http://www.uri.edu/research/cprc/TTM/detailedoverview.htm

17. How do I ensure a patient takes the medication I advise?

Compliance or adherence?

Often we are surprised when the information we dispense fails to have the effect we expect. Patients may openly reject the advice we offer, or pretend to accept advice but ignore it, or later stop the treatment for rational or perhaps irrational reasons. These patients become labelled as poor compliars, or in newer less prejudicial language non-adherers.

A rule of thumb is that the patient’s adherence to a recommended treatment is equal to the patient’s preference plus the treatment’s relevance multiplied by its perceived effectiveness divided by the sum of the effort required to adher and the adverse side effects. Elpmek’s treatment formula.

The usual important questions for drug treatments are

What are the benefits of treatment versus the risks of treatment

What is the correct dose of the drug for the patient

Which one is the best drug of a particular class to use (eg statin for hypercholesterolaemia).

A patient on multiple therapy complains of a problem, could it be due to one of their drugs or be an interaction or a coincidence.

18. How do I know when I am getting too stressed?

How do you know you are stressed. We usually discover our limits by exceeding them, and then recovering. You may not know you are doing too much and getting too stressed until after you have exceeded your own safety limits. Before you get stressed if you can predict early warning signs with other people like family and work colleagues and agree how they will be able to tell you, you might save yourself.

http://www.bristolgpsolutions.org.uk/b4.htm

19. How do I make sure changes become improvements?

http://www.bristolgpsolutions.org.uk/a4.htm

20. How do I survive complaints?

A clear conscience is usually the result of a bad memory.
Anon

Never get into fights with ugly people, they have nothing to lose.
The law of reality.

When we remember we are all mad, the mysteries disappear and life stands explained.
Mark Twain

Don't go around saying the world owes you a living. The world owes you nothing. It was here first.
Mark Twain

If you feel you’ve made a terrible mistake, and you feel like giving up, don’t. Its terrible when things go wrong, it’s worse if you feel you were partly to blame. Nothing makes you feel better about it. Its ruins your day, your week, your year and you will never forget it.

You will continue to make mistakes. We all make mistakes. All you can do is learn from each mistake, and avoid making the same mistake again. When you do make a mistake, acknowledge it, do whatever you need to do to get it ‘off your chest’ and then realise you will continue to feel terrible until time has passed. Comfort others when they make their mistakes.

It’s a well trodden path and every doctor has been on the path. Its what makes us want to do better, the knowledge that we are important because we are the ones that are in charge, we are responsible, we are to blame.

Don Berwick is an expert on this and regularly writes, and says it better than other people can (www.bmj.com)
BMJ 2001;322:247-248 ( 3 February )
Not again! Preventing errors lies in redesign not exhortation
BMJ 1999;319:136-137 ( 17 July )
Reducing errors in medicine .It's time to take this more seriously

21. Why is it important to have bad doctors?

This assumes that what we are really saying is why is it important to have people who are not the best doctors?

I met a GP who I rate as competent but not one of the best doctors around who was whinging about the proposed revalidation of doctors. He said ‘When I look around I don’t see any bad doctors anymore’ I realised that if I can’t look arounds and indentify a bad ‘doctor’ then I am probably the bad doctor. Bad doctors are necessary to make the rest of us feel better.

22. What is the Perfect General Practice?

There are no perfect practices, only imperfect practices. Some are more imperfect than others.

http://www.bristolgpsolutions.org.uk/a1.htm

23. How should do GPs plan their day?

How do you make God laugh? Tell him your plans.

24. Why GPs do not always implement guideline?

No human being is constituted to know the truth, the whole truth, and nothing but the truth; and even the best of men must be content with fragments, with partial glimpses, never the full fruition.
Sir William Osler

Never be afraid to try something new. Remember, amateurs built the ark, professionals built the Titanic.
Anon

What to do when you’re stuck in your clinical care. Clinical Inertia is the Failure of clinicians to initiate or intensify therapy when indicated

They may recognise problem but fail to act due to at least three problems

they overestimate the care they provide e.g. frequency of foot examinatiopns
they se soft reasons to avoid intensification of therapy (i.e. believe that problem starting to get better)
they may lack education training or practice organisation needed to achieve therapeutic goals

Shaughnessey’s equation is that the usefulness of any source of information is equal to its relevance multiplied by its validity divided by the work required to extract the information. This formula makes sense to most of us who search on a daily basis for new and useful information.

Family physicians are told to implement guidelines, diagnose and treat patients in specific ways, and eliminate inappropriate variation in practice. Family practices as systems that self-organize, reveal emergent behaviour, and co-evolve. Successful practices are ones that minimize errors, make good sense of what is happening, and effectively improvise to make everything work together.

Inflexible standardization is often poorly responsive to the needs of different practices' diverse agents (clinicians, patients, and office staff) and to the almost constant situations of uncertainty, contextual uniqueness, and surprise that occur in practices. The complex real world encourages all family practice staff members to become knowledgeable about practice guidelines and evidence-based practice and use the core skills they gain to implement flexible, locally meaningful systems to provide good care.

The conventional view that promotes guidelines is that the best way to improve care is to eliminate variation. An alternative view suggests that efforts to change and enhance family practice should be focused on improving care as a whole and on developing the skills of relationship-centered care. Policymakers should acknowledge the potential benefits of some kinds of practice variation and to support its healthy evolution. These conclusions are based on lengthy observations of 18 Nebraska family practices, which demonstrated that some practice variations are appropriate.

Miller, W.L., McDaniel, R.B., Crabtree, B.F., and Stange, K.C. (2001, October). "Practice jazz: Understanding variation in family practices using complexity science" (HS08776), Journal of Family Practice 50(10), pp. 872-878.

25. How do I develop my career, and not get stuck in a rut?

What’s the difference between a rut and a grave, just depth. The most important thing is to have a plan. One year, 5 year, or 10 year, have a plan of what you want to achieve or where you want to be. The NHS appraisal system gives you an opportunity to make a rut avoiding plan each year.

26. How can I manage bureaucrats, politicians and academics who don’t understand general practice?

The show stopping questions are to ask them ‘What are you trying to achieve?’ and ‘How will you know you have been successful?’ You may not get an answer, but at least you will confirm they don’t really know what they are doing.

27. How can I avoid working in a dysfunctional team?

You can’t. All teams are dysfunctional but some are more dysfunctional than others. The important issue is recognise that the team is dysfunctional, identify the main cause and limit the dysfunction.

28. If I am the learner why are you asking the questions?

Live as if your were to die tomorrow. Learn as if you were to live forever.
Gandhi

The important thing is never to stop questioning.
Albert Einstein

You’re not learning if you’re not asking the questions, so if someone else is asking the questions think about what is happening. Manage your efforts when you are trying to be a learner, and make sure you are learning about solutions to your problems, that you can ask questions and get them answered and that you valuable time is not wasted by others.

29. Is the difference between primary care and secondary care, just more knowledge?

See FUQ #40 Why are diseases treated differently in primary care?

30. Why be person centred?

Everyone is different, but some are more different than others, and that’s why a GP’s job is so interesting.

General Practice ‘develops a person-centred approach, orientated to the individual, his/her family, and their community’. From the European Definition of General Practice/Family Medicine

The most important question to ask anyone is ‘How are you?’ Effective communication with a patient is related to your understanding and respect of that patient. You can learn so much by paying attention to the person. A home visit to an elderly patient define shows what you can learn about a patient, just by ringing the doorbell. Is there a doorbell, (is the house well maintained), what’s the door like, can you hear the bell ring, does it work, how long does it take to answer the door (is the resident deaf, immobile, in the toilet), who answers the bell (does the patient have a carer?), what state is the answerer in (in day or night clothes, clean), what does the house look like inside the door.

Most GPs change their consulting styles according to factors in and around the consultation. Each GP might have a tendency to be more or less patient centred but all change their styles when needed. One view of this is that it is the clash of 2 stories the patients and the GPs. The GP changes style when rushed, or dealing with a serious illness (that the GPs story), the patients story changes with life circumstances. The patient’s real life does not have a plot, but it is a common human experience to construct meaning from otherwise seemingly disparate life events.

31. Do GPs look after communities or patients?

General Practice ‘has a specific responsibility for the health of the community’.

The discipline recognises that it has a responsibility both to the individual patient and to the wider community in dealing with health care issues. On occasions this will produce a tension and can lead to conflicts of interest, which must be appropriately managed. From the European Definition of General Practice/Family Medicine

GPs become very specialist after a few years working in the same place, they become specialists about the individual, families, house, streets and services in their area. This is a unique tacit knowledge that informs their daily work. After 20 years a local GP becomes a repository of knowledge about the community.

32. What is quality in primary care?

If the service is high quality it will have to address all aspects of what makes a quality service. These are that

There is easy ACCESS to the service
The BEST Treatments are available
The CUSTOMERS are satisfied with the service
There is a DEPTH of care available
It is EFFICIENT & EFFECTIVE
It is FAIR to all

33. What should I do in a crisis?

Don’t panic, there is always a crisis. If you are unaware of a crisis then it probably means you haven’t been paying enough attention.

34. What is the purpose of becoming an old GP?

It's frustrating when you know all the answers but nobody bothers to ask you the questions.

Wisdom comes with age, but sometimes age comes alone.

All the other options apart from ageing are worse, so read Aging Well: Surprising Guideposts to a Happier Life from the Landmark Harvard Study of Adult Development by George E. Vaillant This is the story of the real lives of 3 cohorts of American men and women (in longitudinal research studies) that start in the early part of the 20th century and with regular interviews chronicles their progress through health and illness, happiness and misery, work and retirement and gives the reader tips on what can keep you healthy and happy throughout life. Read it and learn from their mistakes

At the start of my career I ran a study day and one of the sessions was on career planning and four GPs reflected on their experiences in the first 10 years of practice, the second ten years, the third ten years and after. I remember some bits of advice, particulary the GP who said that in the first ten years in practice he didn’t have enough time for his children, but in the second ten years his children didn’t have enough time for him.

35. When is the right time to do something?

There is usually no right time, only times that are less wrong. You will probably always be wrong. You will either do it too early or too late. The good news is that if you know you will always be wrong you can relax and just get on with life.

36 When should I really take a break?

Plan a break at least once every three months, and try to have at least 2 breaks planned in advance. If you don’t do this then when you are busy you will forget to take a break and suddenly wake one morning desperately needing a break which can’t take because everyone else is having a break!

If you can, plan a sabbatical. There are three joys to sabbaticals, planning it, taking it and remembering it. A sabbatical provides many benefits. If you decide to return to your previous job you will feel more like a volunteer rather than a conscript and enjoy your job more. A sabbatical gives you an exit strategy from all the extra jobs you accumulated prior to the sabbatical, someone else can take over those jobs.

37. Who is in charge in general practice?

No one is in charge, just people hoping that nothing terrible will happen whilst they seem to be in charge.

38. Why don’t I manage patients better, more like a specialist?

See FUQ #40 Why are diseases treated differently in primary care?

39. How can I rate education experiences?

Try these star ratings

No star: Not worthy of further discussion

1 star: This is only of interest to someone who has a special interest in this subject, It may be either obscure or difficult to comprehend.

2 stars: I liked it but it might be too obscure or badly presented for others

3 stars: This is either very relevant or very well presented

4 stars: This is relevant and well presented

5 stars: This may not be relevant to your life, but it is so well presented it is an example of the best quality, easy to use, and of interest to anyone who wants to aspire to the highest standards of learning.

40. Why are diseases treated differently in primary care?

In hospitals the diseases stay the same and the patients change but, in general practice the people stay the same and it’s their diseases that change.

The populations served are very different in general practice and hospital medicine This is an obvious but forgotten difference that can cause inappropriate management of patients and the muddled teaching of students. Primary care sees a more general mix of patients who present early in their symptomatology. Hospitals specialists should only see the patients who have already been selected for referral by their GPs. For instance if a patient presents to a GP with a headache, the GP knows that most patients with a headache have self limiting illness and do not need to be investigated. Only a very few patients will have serious pathology. In general the GP can assume that most patients are normal, be able to reassure and treat most patients, but be vigilant to identify the 1% of patients who have unusual headache that might need referral for further investigation. By contrast a neurologist’s clinic is full of the 1% with unusual headaches that have been referred, and the neurologist knows that a high proportion of patients will have an important abnormality so each patient must be assumed to have a serious pathology and investigated. Primary and secondary care work well together when each understands the prevalence of illness in its patient population, its role in the management of illness, and only the appropriate patients are referred to hospital care. The worst scenarios are when this becomes and primary care assumes everyone with a headache needs investigation or referral, or when secondary care assumes that everyone with a headache is normal and doesn’t need investigation. This muddle is continued if secondary care specialists don’t acknowledge the differences in the patient population in primary care, teach primary care subjects and mistakenly advocate secondary care management for these primary care populations. This may cause GPs to refer more patients to hospitals. The balance between primary care and secondary care is traditionally preserved by the GP gatekeeper role. GPs control who is referred to secondary care. The balance is easily upset if GPs are advised to refer patients more often to hospitals or if hospital specialists (or GPs with a special interest) work in a primary care setting. If the average GP usually refers 4 out of every 100 patients to secondary care, but increases referrals to 5 out of every 100 patients, whilst it has very little impact on the daily work of the GP, hospitals have to cope with a 25% increase in their referrals and a vicious circle develops where the distinctive differences between primary care and secondary care are eroded. Patients suffer with unnecessary investigations and referrals, and the NHS struggles to cope with the workload. Always consider if what you are doing is likely to benefit not harm the patient. Its best to never assume that there is someone else in charge who knows what they are doing, always know what you are doing.

41. Why be a coordinator of care?

General Practice ‘makes efficient use of health care resources through co-ordinating care, working with other professionals in the primary care setting, and by managing the interface with other specialities taking an advocacy role for the patient when needed’. From the European Definition of General Practice/Family Medicine

Someone has to be in charge, feel and be responsible. Traditionally this has been the GP. In the changing NHS it is less clear what the role of the GP will be. For most patients it may be that they have the responsibility to be the coordinator of their own care, and GPs will only have a role providing the services that are provided by some other specialist doctor or nurse. GPs can choose to be coordinators of care for patients who want them to be, but the role may be undermined by the changes,

42. What do dissatisfied patients do?

It is impossible to make all patients satisfied all the time, so you will always have some dissatisfied patients

Patients dissatisfied with their usual source of care may visit A&E departments, and OOH services

Patients who are dissatisfied with or have trouble-accessing their usual doctor are more likely to go to A&E or OOH service for a non-urgent visit. Reasons include dissatisfaction with usual GP 22% or GP’s staff, lack of confidence in GP’s ability 4, difficulty scheduling an appointment 8%, difficulty reaching GP by phone 9% and waiting more than an hour despite having an appointment 6%.

Usual Source of care and non-urgent emergency department use. Sarver, Cydulka R, Baker D 9/02 Academic Emergency medicine 9 p916-923

43. Is general practice an art or a science?

What is necessary to change a person is to change his awareness of himself.
Abraham Maslow.

If you steal from one author, it’s plagiarism; if you steal from many, it’s research.
Wilson Mizner

Technology is unstoppable but it is delayable

Do we use wisdom, knowledge, information or data?

The usefulness of any source of information is equal to its relevance multiplied by its validity divided by the work required to extract the information. This formula makes sense to most of us who search on a daily basis for new and useful information. What happens after we share this information with our patients? Shaughnessey’s equation

Slawson DC, Shaughnessy A, Bennett JH. Becoming a medical information master: feeling good about not knowing everything. Journal of Family Practice 1994 38 505-513

Interventions must be appropriate, effective and based on sound evidence whenever possible. Intervention when none is required may cause harm, and wastes valuable health care resources.

44. Why do patients become frequent attenders?

Good Health is the slowest possible rate at which one can die.
Anon

Pain is inevitable, misery is optional

Frequent attenders either make at least 25 visits in the previous 2 years or attend at least once in every season of a year (a four season patient). The patient may present with simple or complex problems, single or multiple problems and have different reasons for attending that include anxiety, advice, examination, diagnosis, prognosis, treatment, prevention, education, investigation, results, interpretation, referral, and review

Always try to understand what the problem is likely to be and why the patient wants to see you.

Simple reasons are

The frustrated patient who is frustrated with the system (eg they are trying to get an appointment for outpatient or an earlier operation)
The injured patient who has a series of unconnected acute medical problems (eg an acute foot injury)
The regular treatment patient who has chronic medical problems which includes a ritual visit for ongoing care (for example injections for chronic LBP)

Or they attend for more complex reasons

The detailed list patient (doctor & patient negotiate on medical solutions to multiple problems)
The disengaged patient. The patient attends but does not engage with the doctor, does not understand the medical advice the doctor is giving and does not plan to follow it.
The dissonant patient. The patient is confused about the doctors plan and is not sure it will help the current problem
The difficult or Heartsink. The patient has multiple problems but is not satisfied with anything the doctor suggests; the emotionally taxed doctor gets little satisfaction and much grief in return.

Frequent attenders are more likely to be older, divorced, or widowed, in lower socioeconomic groups and have multiple physical and pyscho social ills and vague physical symptoms with no obvious aetiology. Many frequent attenders seemed to have developed an intricate and harmonious realtionship with the doctor office staff and nurses in the practice, Visits often include friendly chatting and humour among patients staff and doctors

45. How do we change our patients?

You can’t make someone change, you can only change yourself and how you react to them, then they might change

Readiness to change is related to patients confidence that he/she can change and its relevant importance

The T to T ratio, when the patient has more tattoos than teeth health promotion is unlikely to be effective.

Lifestyle changes are not popular with patients

Only the wisest and stupidest of men never change.
Confucius

The more work the patient does the smarter a doctor I am

See FUQ #46

46. How do adults change their behaviour?

The transformational theory of change encompasses the diverse theories of change and psychotherapy and recognises that an individual goes through stages of change (precontemplation, contemplation, preparation, action, maintenance and termination) and uses different change process at different stages of change ( e.g consciousness raising, social liberation, emotional arousal, self revelation, commitment, reward, countering, environmental control and helping relationships)

See http://www.uri.edu/research/cprc/TTM/detailedoverview.htm

47. How do I avoid having to do the work myself?

Nothing is impossible for the man who doesn’t have to do it himself.
Weilers Law

Why delegate? The usual excuses for not delegating are listed below, but if you want to be a better delegater just assume the opposite is true

I can do it better myself.
I don't know if I can trust someone else to do it.
He isn't qualified to do it.
She avoids any added responsibilities.
I don’t want to spend time showing someone else how to do it.
There is no one to delegate to.
He already has enough to do.
I don't want to give up this task because I like doing it.
I'm the only person who knows how to do this.
He made a mess last time, so I'm not giving him anything else to do.

What to delegate? Don't delegate what you should eliminate.

Delegate routine activities, even though you don't want to:
Delegate things that aren't part of your core competency.
Some things are too important to delegate e.g. performance and discipline reviews

How to delegate? Have a plan to delegate.

Invest short term time in training to gain a long term increase in productivity.
Others may end up doing a better job than you can or finding new ways to complete a task.
Delegate, don't abdicate. Someone else can do the task, but you're still responsible for the completion of it, and for managing the delegation process.
Make sure the standards and the outcome are clear. What needs to be done, when should it be finished and to what degree of quality or detail?
Delegate the objective, not the procedure. Outline the desired results, not the methodology.
Ask people to provide progress reports. Set interim deadlines to see how things are going.
Delegate to the right person. Don't always give tasks to the strongest, most experienced or first available person.
Spread delegation around and give people new experiences as part of their training.
Obtain feedback from employees to ensure they feel they're being treated appropriately. A simple "How's it going with that new project?" might be all that's needed.
Be sure to delegate the authority along with the responsibility. Don't make people come back to you for too many minor approvals.
Trust people to do well and don't look over their shoulders or check up with them along the way, unless they ask.
Be prepared to trade short term errors for long term results.
When you finish giving instructions, the last thing to ask is, "What else do you need to get started?" They'll tell you.
Give praise and feedback at the end of the project, and additional responsibilities.

48. What is the Art of Medicine?

All of medicine minus evidence based medicine.

49. What are the four principles of family medicine?

The College of Family Physicians of Canada believe they are that

Patient-physician relationships are central to the role of family physicians
Family physicians are skilled clinicians
Family physicians are a resource to a defined community
Family physicians are adaptable professionals http://www.cfpc.ca/cfp/2006/Oct/vol52-oct-editorial-2.asp

50. How trusted are GPs?

A YouGov poll in 2007 shows that whilst GPs are the most trusted (i.e. are trusted a great deal or a fair amount) profession. The percentage have decreased from 93% in 2003 to 89% in 2006 and 89% in 2007 http://www.yougov.com/archives/pdf/Trust070427.pdf

51. What causes health scares and panics?

Scared to Death by Christopher Booker & Richard North 2007 details many of the scare stories in the past few decades when the hysteria of government, professions, media and public has overwhelmed the facts about a threat and caused a bogus scare. The attributes of a scare story seem to be

1. A real problem increases, becomes exaggerated, or any tolerance of it becomes unacceptable
2. The problem is linked to a threat.
3. The threat appears universal i.e. anyone might be exposed to it
4. There is uncertainty. The problem or threat may be newly discovered or complex, so there is speculation about the causes and consequences.
5. The threat seems scientifically plausible
6. The threat is promoted by the media. The threat becomes a scare
7. The government acknowledges the scare. The scare becomes a crisis
8. If the scare is bogus, the evidence accumulates to show the facts have been misread. The scare is revealed as a fake.

If you have a suggestion for a better answer to any of the questions or additional unasked questions email contact@bristolgpsolutions.org.uk

Terry Kemple is responsible for this page. It was last updated and will be reviewed by 1/01/08.