Memoirs of a 'Good GP'

A GP friend of mine recently told me that there is no longer any reward for being a good GP (General Practitioner).

As I was thinking about what he said I remembered a short story I read years ago about a legendary ship repair man…

A giant ships engine failed and was stranded on a dry dock costing the shipping line more than $100,000 each day it wasn’t at sea.

The shipping company called in all the best ship engine mechanics in the area and one after the other they failed to figure out how to fix the broken engine.

After 3 weeks and spending $40000 on recommended repairs the engine still didn’t work.

Then they remembered a retired engineer who had been fixing ships since he was young. He arrived with a large bag of tools and went to work immediately inspecting the engine very carefully, top to bottom.

Two of the ships owners observed him closely, hopeful for a solution. After thoroughly examining the broken engine he pulled a small hammer out of his bag of tools and gently tapped something. Instantly, the engine roared back to life. He carefully put his hammer away and the engine was fixed!

A week later, the owners received an invoice from the engineer for $10000.

What?! The owners exclaimed. “He hardly did anything..!!!”.

So they wrote to the man; “Please send us an itemised invoice.”

The man sent an invoice that read:

Tapping with a hammer………. $2.00

Knowing where to tap…………. $9,998.00

This story highlights the value of experience, expertise and intuition. There is much more going on in the minds of experts than what we can see.

I realised its true how as GPs we have become completely undervalued by a system that barely rewards our effort, never mind our expertise.

There really is no reward for being a good GP, you’re given the $2.00 and told to be grateful for your privilege. The system scoffs at the audacity to even think about requesting the other $9,998.00.

My goal here isn’t to argue about GP pay, that ship has sailed for me!

However I thought it would be interesting to deconstruct the mind and motivations of the GP from my personal point of view.

I think things will only improve once both parties, patients and GPs fully understand and respect each other.

Communication

GPs are specialists in undifferentiated illness. There is no other specialty where patients can turn up and simply say “I feel unwell” and expect to be fully accommodated. (Unless spending 12+ hours lying in an A+E corridor counts)

For this reason GPs have to possess excellent communication and history taking skills.

All doctors are taught a comprehensive structure to take a patients history in medical school. This is the process of asking questions to collect information from the patient about their problem.

Depending on how the patient answers a diagnosis can be made and managed or specific investigations can be requested to aid in making the diagnosis.

Unfortunately the information collected is only as good as the patient is able to communicate. In the real world outside of medical school simulations, patients often don’t answer questions:

• They don’t know

• They can’t remember

• They start talking about something else completely different

This leaves us struggling to put a diagnosis together and create a solution.

Imagine sitting down to read a book only to find:

• It was riddled with typos

• Massive ink blots blocked out half the pages

• Pages were in the wrong order

• A Goblin appeared out of no where, ate the whole book and then vomited it back up in front of you.

Imagine!!

Before we can even begin to think about the actual problem and identify a solution we have to try and interpret what the problem is first. We have to pick up all the vomit soaked pages, wipe them clean and put them back together in a coherent narrative.

GPs have to do this messy work to put the book back together. Then it can either be stored away or sent off to the specialist with a neat TL:DR summary for them.

Knowledge

The way I see it the purpose of GP training is to become unconsciously competent in our general medical knowledge.

You have to have seen enough of the same puzzles to know how to solve them even when pieces are missing.

Passing exams are one thing, practical experience is another.

I’ve written previously about how doctors are often accused of not listening to patients. Well part of the reason is that we are trying to think about the possible diagnoses, investigations and management at the same time as listening.

Speed is vital if we are to run our clinic on time and avoid attack by irate patients.

As a GP trainee I would be constantly switching back and forth between listening to the patient and thinking about the medical knowledge. I’d be thinking about what they were saying whilst pulling the textbook description of the condition from my mind to compare it.

Its an impossible multi-task that the conscious brain doesn’t have the capacity to do and just leads to missing things.

The solution is to utilise the subconscious mind.

Unconscious competence is having all the medical knowledge stored in our subconscious mind. This way we can listen to the patient fully without having to think about the medical bits.

The difficulty for the GP is that of rare diseases and unusual presentations.

It can take years to see and experience all of them even within one specialty never mind all of them.

So even as a self-proclaimed unconsciously competent GP I still get stumped every so often when my subconscious mind doesn’t contain the information related to rare disease and unusual presentations.

The IceBerg of Knowledge and Communication

Knowledge is the body of the Ice Berg beneath the surface that patients can’t see.

Patients are only aware of our thinking via what we communicate with them verbally and non-verbally.

This is just the tip.

Patients don’t want to sit and listen to a lecture on the pathophysiology of disease and GPs don’t have time to give it.

Conversely patients also only communicate the tip of their own Ice Berg.

Here in lies the problem that occurs in patient GP consultations.

GPs know what information the patient needs to here and how to communicate it in a way that makes sense to the patient.

Patients don’t know what information the GP needs to hear and don’t know how to communicate it.

The information a patient chooses to present in the tip of their IceBerg is often a mishmash of:

• Health Beliefs

• Health Anxiety

• Emotional Hysteria

• Opinions from Friends and Family

As GPs we have to take all this on board before diving down to extract the information we need from the body of their IceBerg:

• Facts

• Dates

• Timing

• Specific Symptoms

The system is historically built on 10 minute consultations in which a GP asks closed questions, the patient answers perfectly, the GP makes a diagnosis and then dictates the management plan to the patient who obediently follows.

It doesn’t quite work that way in the modern world.

Being a ‘Good’ GP

Its not about knowledge, its about being patient-centred in the consultation.

GPs now days are trained to be “patient centred”. This mean the needs, preferences and values of the patient are prioritized throughout the whole interaction.

This is obviously a good thing and leads to better patient satisfaction and outcomes, but at the cost of GP emotional and time resources.

The amplified spread of misinformation via the internet has created a Monster. Patients are hyped up to attack GPs indiscriminately with inappropriate demands and expectations.

This results in 3 different scenarios:

1) The doctor centred GPs basically tell them straight to their face to f off. They exert their dominance and kick them out after 10 minutes. Patients then have more fire power to distribute via the internet.

2) The ‘good’ patient centred GPs spend double the amount of allocated time for each patient employing skills such as:

• Empathy

• Compassion

• Respect

• Understanding

• Effective communication

All to persuade patients to agree to an appropriate management plan that provides them with the best possible care.

3) The lazy GPs crumble under the demands and expectations of patients however inappropriate they are. They give them whatever they want to get them out the door.

And finally the ‘good’ patient centred GPs, get burnt out by prolonged exposure to the emotional drain and intensity of working double time and become either lazy or doctor centred GPs or just leave clinical practice.

The Coroners Judgement

The Coroner is an ever present being in the minds of GPs.

I genuinely care about my patients and do everything I can so they don't come to any harm.

This is why its so frustrating to constantly have to justify my actions so third parties can't blame me if things go wrong.

Every decision. Every word documented. Its all influenced by how things will be interpreted if the patient dies or complains.

Its called defensive medicine and it’s the worst.

In my opinion Defensive medicine is when practice becomes more about the survival of the GP than it does about the best interests of the actual patient.

If you've ever wondered why GPs are sometimes so obsessed with typing notes it because they need to cover themselves.

They may be called to give evidence months or years later if a case goes to coroners court. The notes are all they have to remember the details which determine the fate of their whole medical career.

So you can't really blame a GP for taking meticulous notes. But its yet another drain on our limited time resource.

As if getting through a clinical GP day wasn't hard enough there is still no rest when the responsibility for peoples lives rests soley with you.

After the worst days the anxiety train runs 'what if?' circles round our minds all night.

Eventually with experience we become increasingly numb to this constant state of unease.

We develop the intuition to perform lightning fast risk assessments that tell us when to be meticulous and when we can save a vital few seconds here and there.

Final Thoughts

Times have indeed changed for GPs and for patients.

I’ve come a long way in terms of my mindset since committing to starting a new path outside of GP.

I acknowledge the experiences I’m sharing here paint quite a negative picture, but I want you to know I’m no longer consumed by negativity bias.

I’m out, mentally at least- I simply want to educate about my lived experience in the hope of helping people.

I don’t mean to sound like the past victim of an abusive relationship that has come to terms with my trauma and detached myself from it. But thats kind of how I feel.

We all know the positive aspects of being a ‘Doctor’:

• Saving lives

• Helping People

• Fulfilling your vocation

• Respected professional

• Earning loads of Money?

• Applying medical knowledge

But what about the stuff that isn’t common knowledge? What about the stuff that makes someone walk away after so many years of training?

I’ve tended to avoid writing about my experience as a GP in too much detail for fear of reprisals and judgement.

What I’ve written this week is a tasting menu to guide further writing on the full courses in the future. There is so much more to say about each of the different experiences I’ve talked about this week.

• GP expertise being undervalued

• GPs being cryptographers cracking the code of patient presentation

• GP knowledge and continuous learning

• The IceBerg metaphor of Communication and Knowledge

• Being a ‘Good GP’

• Coroners Judgement and Patient Complaints.

Thats all for now

Lewis

A Good Patient Centred GP

P.S

I would love to hear what you thought of this post and which of the experiences you think I should expand first?

I’ll be back next week with more actionable advice for you on self-improvement, self-discovery and mindset mastery.

Feel free to comment or reach out to me via X or Linked-In.