consultations are short, and that patients
inimical forces so that we can all see them
healthcare systems struggle to afford.
Stockdale, the American admiral, captured
consultation is one of the purest examples
the Hanoi Hilton between 1965 and 1973.12
love our neighbour as we love ourselves.
Performed badly the consultation can be a
money has to be found for it. The British
venue for rejection, misery and complaint. ‘This is a very important lesson. Youmust never confuse faith that you will
consultation was well described in Theprevail in the end — which you canFuture General Practitioner.1 This book has
set the frame for general practice learning
discipline to confront the most brutalfacts of your current reality, whatever
rising to the challenge of unmet need.16 As
treating the patient, rather than explaining
why I am acting as an agent of irrational
the brutal facts of our current reality.
The positive side of the consultation has
been celebrated by many authors.5–8 The
Sir Clifford Allbutt notoriously described
conflict between meeting the needs of the
general practice as, ‘perfunctory medicine
individual in front of me against the overall
performed by perfunctory men.’ Like all
health budget of an area even sharper.17,18
relationship between doctor and patient.9–11
gross caricatures it has an element of truth
There is an irreconcilable role confusion
in it. One example will suffice. A patient
between the role of GPs as the gatekeeper
of the college motto, Cum scientia caritas
has already had 12 minutes of a 10 minute
slot. I point this out to her. She is offended
work and its achievements. I want to thank
time.’ ‘Yes,’ I reply, ‘and he also always
Fear of inadequacy is huge in medicine.19
consultation style and therefore helping me
improve it. I would love to spend the rest of
between meeting every need of the patient
that says, ‘GPs do not diagnose or treat
the next patient and those of the doctor to
need to say that I find the conditions in
which I practise do not allow me to fully
the minute not meeting this lady’s needs
deploy my abilities. I have a grief that there
failure, eating disorders, and cancer.
are forces arising that threaten to damage
time and resource limited service this is the
the practice of medicine. If unchecked they
kind of sharp time constraint necessary to
activity. If our practice is as bad as these
will nullify the great professional drive to
experts imply should we really be allowed
both the givers and recipients of medical
each and every consultation. If we fail to
British Journal of General Practice, March 2006
To some extent of course as GPs we are. MISUSE OF MEDICINE TO
What we offer is a quick, mostly accurate
assessment of the patient and then call in
‘You must diagnose depression andaffective disorders more frequently …
everyone. There is always a knowing/doing
they get other gains from the sick role. but … (3 years later) … you are
gap20,21 and we will all let someone down at
So rather than observing the terms of the
prescribing too many antidepressants.’
their area of expertise than non-specialists.
What is galling is the misguided attempt to
with us is actually very small indeed. The
waits for appointments will go up if we go
vision of general practice. Philosophically
to too many meetings are just one example
this is known as the error of mistaking a
claimants being told to ‘get a note from
your doctor’ is a sad reflection of how
LOSS OF TOLERANCE AND
Engineers have ‘tolerances.’ Physicists
PASSIVE AND ACTIVE
describe their ‘approximations.’ GPs are
politicians would back us as we do this.
the health service at some stage of their
rarely have the specificity of a diagnosis
careers.33–37 The active version is direct
from a radiologist or histopathologist. It
requires a different mindset to work with
need to face this fact. The political drive
wouldn’t want to rock the apple cart would
as the ‘risk sink’ for the NHS. We absorb
you?’ The correct response is, ‘the apples
facilities. We do so reasonably accurately,
practitioners is not conducive to free and
serious from less serious cases and refer
EXCESS OF EXPECTATIONS
like a theological institution.29 Although
consequences for us as well the patient.
results. In the NHS we do the opposite, we
will no longer accept our approximations as
being sufficient, then general practice and
our ‘management of uncertainty’ will fail.
not to manage.’31,32 The result of this
British Journal of General Practice, March 2006
such a strategy is a recipe for disaster. A
cash limited, time limited service can never
higher level the whole process is damaging
the country needs to be able to live with
of apparently (and originally) confidential
medical information to outside parties. COMPLAINTS
Maintaining confidentiality is impossible in
Sheriff’s officer put it, ‘courts have all the
these circumstances.50–53 To pretend that
fail to get their expectations met they tend
LOSS OF CONTINUITY
inevitable both by patients and doctors as
general practice used to be its pattern of
doctor–patient consultations. Taken with
investigations’ and ‘an organisation with a
includes doctors, a map of reality but it is
hospitals it leaves a risk that patients end
‘dangerous and deadly.’ Most of us are
The fact that a patient can use the threat
of a complaint as a means towards getting
trying to provide a reasonable service, to
multiple morbidities at risk of ill planned
The great strength of general practice is
aim of the consultation is not for one side
‘Who sets the frame will set the game’
and with the media it is the editor who has
problems and if we lose this strength many
community will suffer.48 Also the costs of
exactly how and why this done.54 We could
Peters49 points out that in blue collar jobs
hidden as ‘taking extra caution.’ However it
labour by 98.5% over the last 100 years.
is driving extra referrals and investigations. CONCLUSION
He predicts that professional jobs could be
It is hindering good medicine and pushing
broken down into parts and become ‘blue
premise that the aim of general practice is
collarised’ in the future. There is a risk in
this that what can be counted will be what
relationships with patients. I see this as
is measured, and that that which is difficult
being good for both patients and doctors. I
to count will be deleted from the record.
Consultation skills are difficult to count and
that sort of thing.’ Sir Lancelot Spratt’s
doctor–patient relationship is currently
so may not appear on the official record.
doctors think about going to court for any
LOSS OF CONFIDENTIALITY
reason. Lord Denning put it thus, ‘an action
general practice consulting room. Most of
for negligence against a doctor is for him
allowing doctor and patient to trust each
unto a dagger. His professional reputation
other so that full details of the context of a
hospital doctor–patient interactions.
is as dear to him as his body, perhaps more
patient’s symptoms can be appreciated.
survive and even flourish then we need to
information around the NHS is beginning to
take precedence over the patient’s rights to
litigation against themselves. The rise in
around the doctor-patient relationship. We
negligence actions against doctors may be
need to make this relationship central to
British Journal of General Practice, March 2006‘You have a very difficult job to do
13. Stott NCH, Davis RH. The exceptional potential in
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41. Smillie J. Accept the injustice and deal with the
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many years ago and it is doubtful that he
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