Advocacy, and what GPs do.

Interesting twitter discussion about what GPs do, and who is whose advocate.

Muir Grey thinks “the patient is the principal some not all need an advocate” , and that “because of ‘information asymmetry’.. it is often difficult for the citizen to act like a principal.”

I am confused and dismayed by the logic that then, patients become customers – being unable/unwilling to trust their doctor to act in their best interests, and that information “asymmetry” is a bad thing.

To be clear:

I think that clinical research should be made freely available to patients and doctors

I think doctors should be highly trained in how to assess, relate and consider evidence

I think patients should expect their doctors to be competent in knowledge, and willing to find out stuff they don’t know

And doctors will want to share this information with patients.

There will be patients who will want to find out everything about their condition and how to manage it. That’s fine, yes. However in real life, people have lots of priorites. They may not, for many reasons, wish to or be able to or want to become as deeply engaged as that. This should not mean that the patient becomes disadvantaged. This is especially important because some conditions pre-dispose people to not being able to seek and evaluate evidence properly, or even stand up for themselves. And this can be difficult at the best of times.

The problem that some commentators in this discussion have had is around the word ‘advocacy’. I use it to mean that I will act in the patients’ best interests. So if I can print out some useful stuff, or recommend a website, or suggest that a very expensive privately available treatment is in fact evidence free and not recommended, that’s what I will do. General practice is not all about diagnosing and treating – it’s about living with conditions, or uncertainty about conditions, or negotiating around problems. It’s about weighing things up, about wondering if a mental health condition needs a different approach, it’s about deciding how much hospital diagnostics are necessary, given, perhaps, that you wouldn’t, for whatever reason, want much treatment. I can’t imagine being a GP without this role.

In the NHS, in delivery of professional care, my first duty is to the patient. I’m delighted if my patient wants to learn about a condition and make decisions about it – but I will still want to make sure that they are the decisions that he or she means to make. That ‘s the same as for anyone else, regardless of how high or low their motivation or enthusiasm. My concern is that in market-driven medicine, the professional priorities we currently have will be consumed by a management structure that places protocols and guidelines, tickboxes and flowcharts, above the importance of the individual and their priorities.

There is lots of evidence that continuity of care and longer appointments with GPs results in better health outcomes. I suspect this is because good general practice is  difficult to do well, and gets better the better resourced it is. As Muir says, ” the  GP morning surgery is one of the intellectual marvels of medicine.” The bigger question is of how doctors and patients work together to achieve better outcomes for everyone. I don’t think the answer involves private sector competition, online rating sites for patients to rate doctors, or arguments about who has ‘principal’ in the consultation. I do think the answer lies in what good general practice means, and I think we will find it in those rich, tangled, complex ten – or twelve – or fourteen – minute appointments.

5 Responses to “Advocacy, and what GPs do.”

  1. Susan September 18, 2011 at 10:00 pm #

    I agree: as a layperson, I want to respect the Doctor for judgement as to what to do as well as medical knowledge, skill, links with specialists, advice, willingness to discuss the issues, understanding of me as a person, manners and sympathy, even though I have Science degree and a professional qualification of my own. I am likely to be willing to do as recommended, to co-operate symbiotically with such a Doctor. I do not like waving things I have found on the internet at the Doctor but I may use information gained that way to support discussion. The only things I could think of saying to the Doctor who would not communicate with us over my husband’s mother and who asked why we weren’t just going with the flow, accepting what he had done “We are not from here, we don’t know you and I have a professional qualification”, which seemed daft but was true and to the point. Many people are upset by Doctors and Nurses but bite their tongue: two people have told me that in recent days. Honesty and clarity are also important: at least tell families if/ when you can’t speak to them and why, don’t just fob them off.
    If the Doctor-Patient relationship could be strengthened, things would begin to improve. I don’t really see much in the pending Bill to help that, quite the opposite. Both Doctors and patients seem to be pawns in a game organised to benefit shareholders/ company directors. GP is different to the pharmaceutical industry because it directly involves people and their very precious health. We need enthusiastic Doctors who we can trust, not Doctors under pressure for whatever reason, the effects of the Bill or anything else. Nothing the Government has said so far is encouraging or inspiring. How can we encourage better Doctors? We don”t want Doctors who are in it as a business; it should be a vocation. We need Doctors who are special people who can cope with new life and end of life and give us confidence through the difficulties health can cause. I had to admire an old Yorkshire Doctor who advised someone in my husband’s family who had poor lungs to take Benylin to clear his lungs, probably not conventional in the amounts taken yet it worked for quite a long time in the absence of any other treatment. I would like to be able to choose a good Doctor, not one who will laugh at me as has happened (although perhaps I encouraged it with an unusual query) and with the right one, have room for optimism in spite of the Bill not because of it. As it is, sadly good Doctors are not as easy to find as all that. Maybe I am easily impressed but a good Doctor has a passion for it. If a good Doctor is not around, then I will have to rely on myself, family and friends as far as I can see.

  2. muir September 19, 2011 at 1:44 pm #

    as wittgenstein said most arguments arise from failure to agree on the meaning of the terms in us – here is Margaret’s ‘
    The problem that some commentators in this discussion have had is around the word ‘advocacy’. I use it to mean that I will act in the patients’ best interests.’
    here is the shorter OED
    ‘one who pleads intercedes or speaks for another ‘
    one could say a referral to hospital is an intercession but i would interpret advocacy as , for example, being willing to attend an appeal that a patient was making following refusal of treatment, or attending a complaint investigation in the local hospital


  3. Mark Struthers September 22, 2011 at 10:07 am #

    I went to my GP – the first time for years – for help with chronic anxiety and depression. She wanted me to have a cholesterol test. What was that all about? What has a cholesterol level got to do with the price of fish?

  4. Verite Reily Collins September 29, 2011 at 8:17 am #

    We Patients often do need advocates, although many don’t realise this.
    But in today’s complex medical care, with patients on numerous strong drugs, a ten minute appointment is not enough to explore the best treatment.

    Your comment on Jane Maher’s interview re GPs and cancer patients had many good points, but I suspect Prof. Maher based her comments on the ‘average’ GP’s care for cancer patients.

    I have written to Macmillan asking why can’t we have a round-table discussion with yourself, Prof. Maher, some patients (me included) and the head of Macmillan GPs. This way we could set up guidelines as to how patients can access GPs who understand their condition.

    |If you are interested, do call me on 020 7351 4434

  5. Elizabeth (Aust) September 30, 2011 at 9:35 pm #

    Very interesting…yet in cancer screening many/most doctors here just stick to the program, collect target payments and, for example, recommend pap testing for sexually active women in the target population – that includes 18 year old women (GPs may even test younger women) – they must know this is harmful for no benefit…and in the States they include women not yet sexually active from age 21 – doctors appear to mindlessly stick to the program rather than put their patient’s health first.
    Some may think it’s safer to follow the program – defensive medicine – in the unlikely event a woman worked out she had a potentially harmful test she couldn’t benefit from or was harmed as a result of over-treatment and took legal action, the doctor could hide behind the program.

    Then we have the power of these programs. Helen Zorbas, the head of Breast Screen was on the “News” recently – she mentioned a Swedish study that showed women having mammograms had 30% less mortality from breast cancer over the long term. She then urged women to have their mammograms – they should feel confident and reassured by this research.
    Some women think Breast Screen is a health group, in fact they’re a political body charged with the responsibility of protecting the program, not women….and that means achieving the govt-set target of 70% of women aged 50-69.
    Ms Zorbas did not mention that a more recent study shows the fall in the death rate from breast cancer is about better treatments, not screening.
    This sort of selective reporting of research is dishonest, unethical and terribly unfair. Yet not one Aussie doctor has challenged Ms Zorbas or alerted women to the later study. (to my knowledge and I’ve been looking and listening!)
    In the UK this latest research has prompted Prof Baum to call for the scrapping of the UK program and I read that Prof Baum and others are taking legal action against the NHS. The latest study was briefly mentioned in the papers here – most women would have missed it…in most cases a pro-screener has the last word anyway.
    I’ve found as an informed woman, GPs back off fairly quickly – I believe more women could hold their ground in the consult room if they had the information they needed – in many cases women feel overwhelmed or intimidated by the doctor or feel it’s inappropriate to be challenging the doctor – they have the medical degree after all.
    I feel our doctors have sold out on us – they have allowed the Govt to get in between and compromise the doctor-patient relationship.