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Independents' Day

GP trainees focus too much on what patients want

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In 2007, it became compulsory for GP trainees to become a member of the Royal College of General Practitioners and to undertake integrated training, culminating in the award of the Membership of the College. Most trainees spend around 18 months in hospital-based servitude, then learn their trade in the style of an apprenticeship. 

Once working in general practice there are several hurdles to overcome: a multiple choice examination, case-based discussions, patient feedback, colleague feedback and the dreaded wallet-emptying Clinical Skills Assessment (CSA), which has itself prompted headlines in the last few years.

Looking back, the over-riding question that I had to ask and answer to pass my assessments was: ‘What does the patient want?’

I also asked: ‘How can I keep them happy so that they complete my patient satisfaction questionnaire?’

I wonder if the question of what the patient wants was asked so much during my training that the more important questions that a GP trainee should be asking get obscured.

I wonder if trainees sometimes forget to ask themselves, ‘What does the patient need?’ or, ‘What is the right thing to do?’

It is a fallacy to assume that making the wants of your patient your primary concern is the correct approach to patient-centred care. By all means, a decent history and assessment may include working out what the patient actually wants from you; I find it helps to know what you might have to turn down from the start (I’m thinking full body MRIs, antibiotics for viral infections and spurious referrals).

There are multiple dangers connected to the excessive emphasis on the wants of patients. It can lead to us feeling that it is our job to meet their demands in order to keep them satisfied, not just for questionnaires but for the Friends and Family Test.

It also means that patients can have unrealistic expectations about what we can actually help with. For example, as a trainee I once found myself acting as a marriage counsellor between two patients, quite by accident.

There’s also a danger that we don’t give our patients the right treatments, or more commonly, we don’t withhold the wrong treatments and thereby waste NHS resources.

Finally, and perhaps most seriously, if we create a cohort of new GPs who feel that they are required to meet the wants and not the needs of their patients, we are setting them up for burnout.

The demands of the job are difficult enough without feeling that you have to please every patient.

Dr Samir Dawlatly is a former secretary of the RCGP’s adolescent health group and a GP in Birmingham.

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Readers' comments (17)

  • Uncovering pts Ideas Concerns Expectations can help understand context of consultation but does not mean expectations have to be met. rather it provides a framework to explain why, as a highly trained health professional, an alternative course of action is recommended. Friends and Family test creates a situation that encourages poor practice, I dread getting my results - definitely a 'marmite' doctor! Some of my colleagues are consitently popular, get great feedback but obviously give in to patient demands - I will always strive to practice 'good medicine' even if this means a few unhappy punters!

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  • Why assume that wants and needs are two different things. If a patient wants a referral to oncology, and is in fact dying of undiagnosed cancer, then they also have a need for a referral to oncology.

    Still that scenario wouldn't fit the fashionable patient-dissing narrative would it?

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  • I have to agree as a current trainee it does seem to me that the entire NHS not just General Pracitce is focusing on patients' wants not needs. The issue is that it is a difficult tap to turn off. I think in terms of consultations though finding out their wants is useful as it then provides a framework for shaping the consultation and plan with the patient. Their wants may not always be correct, but they normally aren't far off the mark and once a successful consultation is done they normally adapt what they want to what they need.

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  • Anonymous | 07 April 2015 4:42pm

    Fool. Nobody is assuming (or asserting) that wants and needs are necessarily different However you do seem to be assuming that they are identical which is exactly the problem here. Mum may "want" antibiotics for her snotty child but the child certainly does not "need" them.

    Go and be foolish somewhere else. This site is for health professionals.

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  • I remember having a great tutorial on patient led vs patient centred. We need the balance it is a fine line. The other good book to read is the games people play.

    Good read guys

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  • I'm sure you are right, but why include a pointless dig at hosptial jobs.'Servitude' vs 'learning a trade' indeed! Actually, you were paid for doing a job. Surely you're not so arrogant as to believe you learnt nothing from hospital medicine. Given the outcry about any criticism of general practice, please chose your words more carefully next time.

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  • Unfortunately 'servitude' still accurately describes the exploitative situation that many junior doctors find themselves in. Despite being paid, many rotas involve juniors working excessive hours looking after very high numbers of extremely sick people. It's not a healthy working environment and I think we all know that many NHS hospitals are unsafe as a result. If you're a patient, you should care about this because being exposed to such continuous stress levels tends to harden even the nicest of people and can lead to lack of empathy and compassion. So called 'burn-out' is unfortunately a well recognized phenomenom in the NHS. 'Please chose your words more carefully' is the typical response of someone who wants to shut down the debate but this is a discussion that needs to be had if the NHS is to remain sustainable.

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  • An excellent article that should form a tutorial discussion point for every VTS in the UK, and indeed, beyond.

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  • Speaking as a senior GP i have to disagree."Need" is something that you decide and "want" is something that the patient presents with.You may not necessarily ask about it every time as it depends on the clinical context but it can sometimes help to unlock the consultation.We cannot be a gatekeeper AND act as a patient's advocate.The two roles are mutually exclusive.Both the GMC guidance and the courts favour putting the patient's best interests above our wider political gatekeeper role.

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  • GP training needs ripping up and starting again.

    Too many trainers and a lot of programme directors are quite simply out of date both medically and managerial and are not preparing GPs for the next 20 years.

    We all must see trainees in poor practices and wonder what they are actually taught.

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