Posted by: GPs To Be14 November 2013
As an ST2 new into practice, ‘consultation models’ have inevitably formed part of my early teaching. I was brought up on the Cambridge-Calgary model and fortunate enough to be taught by Drs Silverman and Draper themselves. This does mean their model is fairly hard-wired into me such was the commitment with which it was taught, so that the shape to each day is like a series of familiar fugues, some in major, others in minor, and some only faintly recognisable as though a novice on the violin. The former give a little kick to one’s morale and the day, the latter are good material for e-portfolio reflections, tutorials, and if one is really brave, group video work.
Pendleton (not the cyclist) described consultations as ‘the central act of medicine’ which ‘deserves to be understood’. As a Cambridge-Calgary girl it will not surprise you that this was the creed I was brought up on, but we need to be on our guard where there are pressures to consider this as ‘yesterday’s medicine’. The stuff of ‘in my day’.
I worked in one trust where the physician’s assistants gained access and took blood as people arrived through the doors. Inevitably a protocol surrounded it and for all chest pain this included a D-Dimer and Troponin. Our audit showed that for the majority of patients there was no indication for a D-Dimer according to the British Thoracic Society Guidelines for Pulmonary Embolism (P.E.). However a significant number of patients, despite having no suggestive P.E. history or risk factors, went on to be admitted and exposed to radiation because of their positive D-Dimer result. The ‘old fashioned’ consultation, grappling with probability and risk and making a shared management plan with the patient did not come into it. It has been superseded by efficiency and pathways and people who don’t understand the test and the medicine having more influence than they should have.
I don’t write to have a dig at hospitals per se, as the increasingly scrutinised inter-professional and inter-agency environment we all work in necessitates supporting pathways and protocols. However there is a fine line between putting systems around patients rather than making the patient fit in.
If you feel a bit lost and overwhelmed, it’s worth pausing to ask ourselves how we want our GP to look after us in 40 years’ time. Do we want them to be a robot ordering tests, or add something in addition? If our generation does not excel in consultation skills, the test will win and we will not be able to pass on the essence of good primary care to future generations.
So yes, for those of you swotting for AKT, learning who said what is exceedingly tedious. While the CSA is forcing others to experiment beyond their consultation comfort zone. However this is the stuff the giants before us called medicine, and requires a logarithmic scale to plot it against most pharmacological, surgical and other current fads on a cost-effectiveness or patient satisfaction comparator. Let’s not lose it!
Alex Thomson-Moore, an ST2 in the Severn Deanery.