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At the heart of general practice since 1960

It takes a GP to see the bigger picture

Consultants get on my nerves sometimes. Too many of them at the moment seem to be unable to see outside their immediate sphere of interest.

Consultants get on my nerves sometimes. Too many of them at the moment seem to be unable to see outside their immediate sphere of interest.

I'm afraid I am going to have to moan about some of them, as I seem to be the only doctor who can see the issue of the whole patient.

My patient is a lady who is well into her seventies, and (as is often the case) she has many things in her poor tired body that aren't working as well as they might. She gets quite a lot of reflux, and has been subjected to an endoscopy which showed that she had, well, reflux. She also has had a small, uncomplicated heart attack and atrial fibrillation.

Herein starts the problem, as at this point the various departments start compartmentalising my lady. The geriatricians decide that she needs to be treated as a small heart attack with atrial fibrillation. They put her on a gallimaufry of treatment including three anti-hypertensives, a statin, and warfarin. You need all these, she is told: you have had a heart attack. She starts the treatment. So far so good. I get a letter about this three weeks later. I enter all the medication into her electronic medical record.

Then she attends the gastroenterology clinic. They are not happy. She on warfarin with reflux. She may well be bleeding from an area in her lower oesophagus. So they immediately stop the warfarin, tell her not to take it, and start her on iron tablets.

She starts to explain that she has been put on this treatment by the other department, and then gets hit with the ‘doomsday' scenario. If you carry on with warfarin, you will get a lot of internal bleeding. She is scared. She stops the warfarin. She is not impressed with the geriatricians for ‘endangering her life.' I get a sniffy letter four weeks later telling me all this.

Meanwhile she goes back to see the geriatricians. Much tut-tutting. ‘Oh, no!' she's told. She must have the warfarin because she might have a stroke if she doesn't.

And so it goes on. This is not an isolated event. The same occurs with non-steroidal anti-inflammatories and the gastroenterologists and the chest people.

I'm left as the referee in all of this to-ing and fro-ing. I am trying to get over to my patients that (a) my colleagues are not incompetent and (b) the concept of risk. This is not easy, as the conversation is quite subtle and people don't like subtleties. So I have to decide on the basis of comparative risk.

This is the problem with the NHS at the moment - it is a combination of over-specialisation and lack of experience. Many of the consultants are too inexperienced and they behave and think like the old registrar. Unfortunately this means that they turn out to be partialists: only knowing a small area of medicine. The old-style general physician is dead and gone.

Much of the general medicine of old now takes place in general practice. Management of diabetes, asthma, hypertension and other diseases is largely done in primary care, with the attendant increase in workload. This is good for us as we now practice medicine at the level of the old-style general physicians, but with a community focus. A simple example is when I started a diabetic clinic in my practice in 1981 we had one a month, and it was not very busy. We now do two hugely busy diabetic clinics every week!

We are the masters now.

The Jobbing Doctor: It takes a GP to see the bigger picture The Jobbing Doctor: It takes a GP to see the bigger picture

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