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At the heart of general practice since 1960

Election fever

Three GPs share their approach to a practice problem

Is it all getting a bit too much for you?

Case history

You have joined a practice that operates 10-minute appointments. Six months have passed and you are finding it hard to cover both the medicine and the Q&O demands in the time available.

This is because you seem to attract people who take a long time to sort out. You don't mind seeing these patients who need lengthy gynaecological or psychiatric consultations. In fact you find it rewarding, and the patients tell you how much they appreciate having a doctor who listens to them.

Unfortunately this makes you late getting out to do your visits, the paperwork is piling up and you are starting to feel stressed.

One day the senior partner asks you in private whether you think

you are coping with the job.

Dr Rodger Charlton

'Every really successful practice partnership has

a different mix of skills'

I still recall my trainer emphasising the importance of giving patients the time they need. No wonder the first two years as a new GP are perhaps the most stressful as there are a lot of patients to get to know in 10-minute intervals or less.

Also the new GP needs to learn the local NHS system, gain clinical confidence, strive to optimise time management and cope with the latest wave of new contract bureaucracy. I am pleased that the senior partner is showing concern, but is this genuine concern for the new partner or because the work is not being done 'efficiently'?

Having been a GP for 17 years I think the position of senior partner is neither democratic

nor helpful. It is a relic from a bygone era. All partners should be equal and should remember how they too were stressed at the beginning of their careers. They should support their new partner from day one.

Some newly-appointed partners feel they are constantly being judged by the senior partners as they anxiously wait for satisfactory confirmation of their 'mutual assessment' period. This in itself causes stress. I feel great sympathy for this new partner. Every successful partnership has a different mix of skills. This doctor happens to have an interest in gynaecology and psychiatric consultations.

The idea of a division of labour purely in terms of patient numbers and consultation duration is never very helpful. General practice is about getting the best out of each partner, about playing to their strengths. How this is best done is constantly changing as the balances in relation to work change, eg through the new contract.

Individual contributions to the team need to be acknowledged and appreciated. A happy partnership is both efficient and rewarding to work in with contented and satisfied patients where the contributions of different individuals are valued.

Rodger Charlton is a GP in Hampton-in-Arden, Solihull, and director of GP undergraduate medical education, Warwick Medical School

Dr Iain Mclean

'Put simply, can you do the job? Can you manage all that a GP has to manage?'

To quote Dirty Harry 'You've got to ask yourself one question...'. In this doctor's case the question is ­ can I do the job or not. There is an absolute requirement for GPs to manage ­ manage consultations and surgeries, manage practice staff, manage colleagues and business and manage the increasing army of bureaucrats. It looks as if this doctor is failing to do any this.

Consultations are overrunning, there is a failure to manage visits and paperwork properly, and the doctor's health and well-being are suffering as a result. Healthy relations with colleagues appear to be absent, with the senior partner's rhetorical question implying that the new doctor is failing.

If this doctor is determined to succeed in the practice, a workable action plan must be presented. Perhaps the practice could be persuaded to have a medically qualified counsellor to support patients wishing long consultations. As this is unlikely, the following action is appropriate.

Direction should be given to chatty patients. One of the strengths of general practice is the review of patients. If someone has a list of problems make it clear that you can only deal with the most pressing and the patient can come back to discuss the others another day.

Visits should be shared equally among the available partners. If necessary, workload should be removed from the doctor doing visits.

Paperwork should also be equably shared. There is no excuse for not completing it even if it has to be done out of hours.

Provided the doctor can change and, if appropriate, the practice agrees to equal workload, a further period of assessment is appropriate. A colleague should be nominated to support and monitor this doctor's work and health and a date set for review of all the issues.

Should the doctor decide that this is not the practice for him, there are as many different practices as doctors. Perhaps a small list size would be of help, or a move outside general practice to mental health or medical politics.

One of the great things about medicine is the huge spectrum of work.

Iain Mclean is a GP in Wigtown, Scotland ­ previously he worked in the drugs industry

Dr Prashini Naidoo

'A patient satisfaction survey and audit of working methods would be worthwhile'

The senior partner's inquiry may be a routine question after the period of mutual assessment, or it may be motivated by grumbles from staff and patients.

If I were this doctor, I would reason things out as follows. Since the issue has been broached, now may be the time for me to review the situation and consider my options. The dilemma is that while the work is satisfying to me, the extra time spent on some appreciative patients is eating into administrative time. In addition I currently keep a good many patients waiting, including the acutely-ill who request home visits.

My tardiness may also be causing problems with receptionists, who are not only facing the irritation of the waiting patients but who are also kept from going home because they have to stay behind to lock up the surgery after my late clinics.

I need to assess whether my long consulting style is beneficial to the patients and the practice in the long run. A patient satisfaction survey and an audit of my working methods would be worthwhile and would provide a more meaningful spectrum of opinion

than the comments of a few satisfied patients. I would check for written or verbal complaints about my lateness.

I would review the significant events and near misses. I would audit the quality of my work and, in particular, my contribution to the Q&O income. I would explore with a mentor whether my consulting technique is making a real difference to patients or whether, by my lack of assertiveness, I am inadvertently colluding with the worried well and perennial whingers!

If the evidence from the surveys and audit indicates my working method keeps the majority of my patients happy, produces good-quality work and is tolerated by most staff, then I would suggest the practice advertise the availability of 20-minute appointments to patients and that the receptionists give me some catch-up time.

If the evidence is to the contrary, then I will have to learn to prioritise my work more effectively, which of course, is easier said than done!

Dr Prashini Naidoo completed her GP registrar training in August 2002 and a Diploma in Occupational Medicine in 2003­ she is now busy with an MSc in primary care development and works as a salaried GP in Oxfordshire

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