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.