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Why GPs must learn to say no

Dr Jason Twinn suggests some GPs' workload problems are self-inflicted

Be it for antibiotics, benzodiazapenes, letters, prescriptions, forms filled in, home visits, requests from secondary care ­ GPs get ever more inappropriate requests from all and sundry. Although we complain about our high workload, we are to some extent responsible for the mess we're in.

Part of the problem is we are unwilling to say no to extra or inappropriate work. Saying no is not easy and takes a lot of practice and skill, and you may or may not have had experience and training in it as a GP registrar. For some it comes easy and for others it's completely alien.

Part of the problem is our poorly defined role, 'health being a state of complete physical and mental well-being and not merely the absence of disease or infirmity', as defined by the WHO. Such a woolly all-embracing definition makes it hard for us to draw boundaries of what is health and what is social work, housing, counselling, financial advice, benefits advice and so on.

The fact that nobody else wants to take responsibility for their own decisions confounds the problem.

Take, for instance, letters to say a person is fit to do exercise. Do you:

·just write the letter for a quick and easy life

·politely decline, explain that while exercise has health benefits in the long-term, it actually increases the chance of dying in the short-term, thus you cannot write a letter and suggest the patient tries a different sports centre?

Why saying No is worth it

The paradox of saying no is that often, in the short-term, it can increase your workload. You have to defend and explain your position without damaging the doctor-patient relationship. But in the long- term if you set your boundaries clearly you can actually stop a lot of work. It is worth it and is particularly effective in a group practice if you agree to what you will and won't do.

It makes the situation more confusing if one doctor in a partnership becomes known as the weak point: word soon gets around that Doctor X will give you antibiotics, letters for central heating, letters to excuse you from certain roles and so on.

Work being offloaded from secondary care is another area where saying no can cut your workload. You know the sort of letter: 'Dear Doctor, I have just started this patient on a really toxic drug that requires monitoring weekly, can you prescribe it, do all the blood tests, see him weekly and write me a note to let me know how it has gone. Oh, and could you arrange a chest X-ray for me as well, there's a good chap? Warmest regards.' Do you:

·do it unquestioningly or

·politely decline, explaining to the patient that the drug is too dangerous for a mere GP to monitor and write to the specialist explaining that you are not their handmaiden.

Unnecessary letters to all and sundry seem to be becoming ever more common. 'Doctor can you write me a letter excusing me from taking my bin out?' or 'Can you write me a letter so that my son doesn't have to do PE?' Do you:

·quickly dictate the letter or

·refuse to do it or

·do it but charge a fee for your time, the secretary's time and stationery.

Similarly private medical attendants' reports can still be an excessive amount of work, although the fee has gone up. If the patient has reams of notes about major and minor problems the report is going to take a lot longer than the 'five minutes' the insurance company buys for £60. You can either:

·do it, moaning about the length of time it takes you, but appreciating the money or

·calculate how long it will take you and bill the insurance company at your standard rate per hour in advance.

Obviously we are all different and will do things in exceptional circumstance above and beyond the call of duty. I am sure some will think me stubborn and uncaring.

But there is little point in GPs as a profession moaning that we have too much paperwork ­ and too much work in general ­ while unquestioningly doing more unnecessary work.

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