Following on from twitter discussion.
I am a GP; I qualified in 1994. I spend two or three hours a week reading and learning new things about evidence and medical practice. I encounter at least one problem daily that I think I should go and find out more about. I have passed lots of exams, have letters after my name, am often asked to give talks about medical things, I teach students, and I would still never think of calling myself an ‘expert’.
Part of this is the nature of general practice – some people say ‘expert generalist’; I just say GP. ’Expert’ to me implies that I am better than others; my dictionary says ‘having a thorough knowledge’. Of medicine, I don’t know if that is realistic. There is danger in presuming that one’s knowledge is complete; and arrogant danger in assuming that I know everything. I try my best. Sometimes I get things wrong; we all do; my hope is that I own up, make best amends, and use that experience usefully. Because I know that I don’t know everything, I know that I need to check back, think, talk to colleagues. I am a working GP, same as other GPs, trying to do my best with what’s available.
I am on my patients’ side. That is to say; my automatic default is that I am advocating for the person who is my patient. This will mean that I do my best to get a helpful diagnosis, sometimes to avoid diagnosis, to share uncertainty, to discuss the limits of medicine or the dilemmas we face. This will also mean that I will sometimes decline to do things which are harmful or dishonest; such as extended prescriptions for dangerous and unneeded medication, or sign sick lines which I can’t justify.
Often, this is not just a 10 minute appointment. More often, it’s a relationship over time. So a decision might, on reflection, change; more information might be later gathered; further issues might appear to be explored or ignored. I am on my patients’ side. Whose else could I be on?
The rise of the ‘expert’ patient changes this.
For decades, patients have organised themselves into groups where information can be shared, support and knowledge offered, and where they have been able to request health professionals address their concerns or wants of discussion. I am aware of many, usually small, charities and patient groups who have fulfilled these needs locally and extremely well. The agenda has been created and designed by patients, they have been in control, and they have been able to talk and directly influence healthcare staff. Not all patients have wanted to be involved centrally or peripherally with other people who have similar illnesses. Some people have wanted to be told by their doctors what they should do; some people want to examine each decision possible in minute detail.
That’s all fine. It’s more than fine – I should be adaptable enough to maintain basic standards of informed consent while ensuring that people get the right amount of information. It’s my job, it’s what I love, it’s what I still feel I have a vocation to do.
But when I read the text of the ‘expert patient‘ programme, I am filled with dismay. It offers people the chance to ‘take control of your health’ in a six week course. I am not sure that anyone can really offer an intervention promising control over our health. This course, rather than being run by people with the same condition (so unlike the support from a charity or group for say MS or diabetes) is run by people with any of many long term conditions, and is run to a Department of Health protocol. There is no teaching of things that might be useful, for example, how to interpret media claims about ‘breakthroughs’, and much of the teaching – for example, relaxation skills – are often being run already for free by local services. The inference from the DoH is of health consumerism, where people as patients should be able to push harder for and consumerism only really works if there is to be shopping around. So we have one aim
greater flexibility and choice in accessing services, for example through the nurse-led telephone service (NHS Direct), Walk-in Centres and the NHS website;
Hilda Bastian puts it very well
“Who will be left sitting and waiting, with little time left for them, while others are getting all their questions answered, and getting double medical advice for each decision? Whether you look at it from the point of view of the have-nots, the timid, or an overburdened practitioner, my fear is that some of this might not be fair.”
In other words; the least articulate, the least demanding, and possibly the most vulnerable will end up worse off.
I am worried, deeply worried, that the consumerism masquerading as ‘expertise’ is really only there to make patients into customers. Customers can choose and shop around and demand; they can also be fired by businesspeople who see them as drains on time and resources. (We have seen this already; some GPs, in the post-NHS Act have ‘let go’ patients in nursing homes because of high workload to financial reward). A professional relationship is something different; a duty of care; and primarily, of course, of making the care of my patient my first concern – and advocating for that person to the best of my ability.
If we really wanted to get closer to that – and why is can often seem to some people (some of whom have replied on twitter) that doctors are not on the patients side – it is necessary to look at the influences on the consultation. Doctors are seen by the government to offer quality based on ticking lots of boxes; smears, blood pressures, advice to stop smoking. If you are pretty well and don’t have a lot of health care needs, it might be easy to fit these in. (Whether it is right is another matter.) But if you are ill, if you have issues you want to discuss, if you need to be listened to: these needs are competing with the need of the practice to demonstrate ‘quality’ ticking of boxes. The patient’s agenda looses out. It’s almost criminal. It has threatened professionalism. I think it has broached it. It distresses me.
More than ever, urgently, as the NHS Bill comes home to roost, we need patients and doctors on the same side. We need to make sure that our shared priorities – not the GP contracts’ – are the ones we listen to. We do not need to be made enemies, playing pointless games of who has the greater ability to be ‘expert’. Patients need to help doctors regain their professionalism in the face of government pressures – the contract, choose and book, the electronic patient record – which detract from what we it is that the patient really wants to talk about.
More than ever, we need doctors and patients to be on the same side.