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At the heart of general practice since 1960

Bramall’s five commandments for new GPs

Dr Katie Bramall-Stainer offers some sage advice for newly qualified GPs embarking on their careers in the coming months

1. Thou must be patient-centred, not patient-led

The first tenet of the GMC’s Good Medical Practice is to ‘make the care of your patient your first concern’. In an ideal world, with an ideal funding stream from government that’s no problem. But we practise in the real world and it’s important I remind you that this should not mean that the care of your professional self should be your last concern. Be mindful of stressors, take time to relax, learn how to say no. You have needs of your own, which may not be the same as your colleagues’.

You do not have to say yes, or indeed continue to do something because ‘that’s always how it’s been done’. This is true for diazepam requests for nervous flyers (next day nervous flyer courses available from many airlines, has the patient seen ‘Bridesmaids’?!) as it is for writing back to secondary care to request they give your patient a certificate that will last the full post-operative period. The patient will see the sense in the end, even if they are unhappy in the consult. Just try to be consistent in your approach, otherwise you are at risk of allegations of discriminatory behaviour and worshipping false idols.

2. Thou must have regard for the regulations

Whilst you are contractually bound to care for any patient who is ill, or believes themselves to be ill, you are not contractually bound to write every prescription requested, sign every letter thrust upon your desk or change your best practise at the behest of someone, or something else. If you feel under pressure, your can politely ask the third party to clarify what the statutory, regulatory or contractual basis is for their assertion or requirement. But check with colleagues first before wading in, in case something has been commissioned locally as a Local Enhanced Service or Local Initiative Scheme – your practice manager might be the best person to ask.

Be mindful of local targets – you need to be sure you can robustly defend your position not to issue that FP10 and not make that referral. When the proverbial hits the fan, you are often on your own. If unsure or if under pressure despite sharing concerns, speak with your LMC first, and use the best of social media support (for example, Resilient GP or GP Survival on Facebook – other fora are available) but never post anything on social media that you would not want to see quoted back at you in a formal written complaint. If you wish for your question to be posted anonymously, the moderators of these fora are usually happy to help. Otherwise you will only be inviting that plague of locusts.

3. Thou must do what only thou canst do

You have been expertly trained to deliver care for specific complex and multimorbid patient needs. Stop, think and consider where your role ends and where someone else’s might begin. Who is best placed? You or a health visitor in supporting a young family with weaning? You or a SENCO for a child struggling at school? You or a heart failure nurse who has more than ten minutes to go through a patient’s questions on their breathlessness? You or a practice nurse to take that cervical smear? You or your receptionists to book that appointment? Value your time. If you don’t, others will be less likely to – and will start to expect the gold standard of service, and may even complain if on another day you are not able to reach the dizzying heights of the standards you once set. Manage everyone’s expectations. Don’t always do jobs for people who are capable of doing it for themselves. And I include friends, spouses and children in that! The BMA and your LMC will have many resources to support you in managing your workload, Londonwide LMCs has a suite of support and has new guidance on engaging your patients to advocate for you. The BMA’s Quality First resources also have numerous templates and guides.

4. Thou must obey the ‘magna scientia’

By which I mean, the important stuff: for example, your performers’ list status and that you are in good standing with your MDO cover (minimum £10 million). Both of these are legal requirements for clinical practice. Check your performers’ list status after your CCT, and after you change jobs and contractual status. Never assume. Likewise MDOs – if you decide to ‘shop around’ for a better deal – caveat emptor. Ensure you allow for overlap between policies. You may find your new MDO revokes their offer and you are left with no cover, and no MDO prepared to cover you. This can potentially be a career-ending move as policies with alternative providers can have eye-watering premiums. Best to be cautious and conservative in these areas. The same mantra is true for documentation. Remember, never amend an original note. (It just looks really bad, as though you were coveting your neighbour’s donkey, to stretch the metaphor to dangerously tenuous levels). Always add a separate addendum. If you do find yourself in trouble remember your three Rs: reflect, remorse and remediation. Access support through your LMC; contact the Practitioners Health Programme 0300 0303 300 / gp.health@nhs.net and the BMA’s Doctors for Doctors Counselling Service 24/7 for members on 0330 123 1245. You never know when you or your colleague may need this. 

5. Thou must imbibe and micturate, or risk being smited

It is easy, while under pressure, to think ‘I’ll just telephone those next five patients’, ‘I’ll just call the next two in’, or ‘I’ll just get that visit out of the way and clear these scripts’ when you have a full bladder, you haven’t eaten or drunk since 07.30am, you have just received a task from a colleague concerning a complaint in which you are cited and your letters list is into three figures. Those signs of hunger, thirst, fatigue or more base functions calling your attention are red flags. They are signs that you are neglecting yourself. We are fortunate in primary care that the time it will take to make a coffee or empty your bladder will not have a direct and detrimental impact upon the outcome of the next patient you manage. But! If you neglect these red flags you may end up communicating hurriedly or poorly in a delicate consult, resulting in an avoidable complaint or missing a detail on a repeat script for a DMARD whose shared care bloods have been missed again, leading to a significant event. Everything we do is subject to decision fatigue – and until we negotiate what an acceptable level of patient interaction is, demand will continue to outstrip supply – so you need to police and protect yourself. Now go in peace, my brothers and sisters of Asclepius, to love and serve your registered list. Amen.

Dr Katie Bramall-Stainer is a salaried GP, a medical director for Londonwide LMCs, a member of the GPC and was educated in a Dominican convent in Staffordshire.

 

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Readers' comments (11)

  • Azeem Majeed

    Thank you for your article Katie.

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  • I agree taking care of yourself is really important

    'HALT' is useful

    Patient safety incidents more likely if you are

    Hungry
    Angry (often resentment)
    Late
    Tired

    Be aware of how you are feeling, if HALT stop and take a break

    other tips

    avoid over-investigation for 'reassurance'- does not work

    use time and watchful waiting

    continue to develop/ have a confident approach to problem solving e.g. diagnosis and decision making e.g. most likely, less likely, rule out

    ensure knowledge of local referral pathways usually

    problems sometimes arise because doctors are uncertain of their role-helpful framework
    e.g. three part role contact me for more information

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  • Vinci Ho

    Five stars.
    Anybody remembers Wayne's World(1992)?
    In front of a highly knowledgeable Alice Cooper:
    Garth and Wayne: [bowing down] We're not worthy! We're not worthy! We're not worthy!

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  • 6. Cancel BMA and RCGP membership; these people are not your friends.

    7. Worship not the NHS, it is the sickly child of a failed ideology that feeds upon the naivety and vulnerability of it's staff, and should be allowed to expire sooner rather than later.

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  • 8. Don't read Pulse

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  • Hypocrite

  • Remember when they say salaried with a view to partnership ....
    its like prisoner
    with a view of the guards

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  • Don't be tricked by that carrot on a stick

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  • The 10 Commandments List, Short Form
    1.You shall have no other gods before Me.
    Do not make the NHS your God

    2.You shall not make idols.
    As above

    3.You shall not take the name of the LORD your God in vain.


    4.Remember the Sabbath day, to keep it holy.
    No OOH

    5.Honor your father and your mother.
    6.You shall not murder.
    Do not become a Shopman

    7.You shall not commit adultery.

    8.You shall not steal.
    Probity

    9.You shall not bear false witness against your neighbor.
    Keep the notes real

    10.You shall not covet.
    with 7 and 10 ... always use a chaperone and behave

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  • Thanks Katie.Some excellent points made

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  • Don't try to save the NHS, ...recognise it for what it is a vast employer, one of the worlds largest, note surprisingly highly disfunctional.
    Save your self, .. or at least look after your self. The NHS will not.
    Do your best for your patients but try to put them first but not before yourself.. they will not thank you either.
    Do your best for your practice, don't just work for yourself or everyone else may start doing the same.

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