Posted by: Shaba Nabi18 December 2014
One of the first concepts I learned during my GP training year was that ‘the doctor is the drug’. Indeed, there was a certain sense of familiarity about this mantra as it evoked childhood memories of being visited by our GP (on reflection, a completely pointless home visit) and feeling instantly better as soon as he entered the room.
We are hugely therapeutic to our patients, with or without our prescription pads. The effect of placebo treatment is well established, but we tend to underestimate this in terms of our behaviour during a consultation.
The child who enters my room, opens all my drawers and tries to break my weighing scales is still given a top-to-toe examination. Maybe I do this for fear of a lawyer’s letter, but it is also partly to fulfil the expectations of my patients and their carers.
With any treatment, one needs to consider the indication, the dose and the inevitable risks and side-effects. The doctor-patient relationship is no different.
Demand for this ‘doctor-drug’ has mushroomed in recent years. Patients are receiving very high doses of it with little thought about its indication. And each dose of temporary relief for the patient simply reinforces their belief that they need to return for more. So now it is crucial to prescribe the scarcest drug – ourselves – appropriately and responsibly.
This has been under the spotlight recently in Devon, where a GP practice was forced to withdraw a leaflet advising patients on other places to access before contacting them. Managers made some flimsy arguments about the risks of missing pathology, but, in reality, the crux of it was that these GPs were no longer prescribing themselves prn.
But a change of mindset is needed if we are to tackle this unfettered demand on our time. In a world of telephone triage, multi-professional working and targets, we can no longer afford the luxury of the co-dependent doctor-patient relationships of the past.
The indications for this type of therapeutic relationship are obvious in palliative care and less so for acute, simple physical ailments – but there is a whole spectrum of illness behaviour in between.
One justification for having firm boundaries about how much of myself I give is the knowledge that I must have something left in the tank for those with greatest need. Of course, this is a value judgment, but it is a relatively easy call given my role and what I have been trained to do.
Successive governments have acted as pushers for the doctor-drug. Yet if we do not ration it, we will encourage an overdependent patient population that lacks self-care skills and knowledge of self-limiting ailments.
We all need to help wean patients off this drug. After all, if it’s a choice between indulging the parent of a perfectly healthy toddler and visiting a palliative care patient, I know how I would rather spend my time.
• Thanks to Dr Dominic Maginness for his help with this column
Dr Shaba Nabi is a GP trainer in Bristol