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Knowing nothing about everything



Maternity care and breast disease have already been hived off to others. Are GPs becoming de-skilled, asks Jobbing Doctor

If you talk to the average GP trainee, and mention the technique of External Cephalic Version, they look at you as if you are a crusty dinosaur from a previous era.

It is from a different era, as we do not attempt to change a baby’s presentation from breech to cephalic any more. Frankly, the baby tended to revert to its original presentation pretty quickly.

However, we had the skills to examine a pregnant uterus, work out the presenting part, and listen with a foetal stethoscope to the heartbeat. We don’t have those skills any more. I am pretty sure that my registrars would not actually examine a pregnant uterus once in a six-month attachment at my practice. This is for 2 reasons – firstly the midwives have pretty much taken over community-based maternity care, and you don’t need skills when you have such ready access to obstetric ultrasound.

This is one area of general practice that used to be a core activity and we don’t do any more. When I tell registrars that we used to put up drips, and accelerate labour and do forceps deliveries in the community, they have that ‘old-Jobbing-Doctor-is reminiscing-again” look on their faces.

But, suffice it to say, I could easily do an unexpected delivery in the community. I don’t think they could.

The changes in maternity care have resulted from a variety of causes – consumerism, defensive obstetrics, professional rivalries (with midwives and obstetricians) and Government decisions.

I’m not sure that having a baby is safer now the old GP maternity units have shut down, and certainly I have a very strong relationship with those women who I cared for before pregnancy and during pregnancy; and before, during and after labour. I don’t with my pregnant patients these days.

The same can be said with managing breast disease. There is a huge pressure in the media to reduce deaths and damage from breast cancer, and this has been led by the cancer charities and pressure groups, and others. So it was decided, by the Government, that they would re-focus breast services to be secondary care based. Before this decision, I was able to get mammograms for my patients, and now they all need to be referred.

The breast surgeons are now effectively running a primary care service in secondary care, and we are gradually becoming de-skilled in managing breast disease.

This salami-slicing of clinical areas concerns me, and yet (at the same time) we are expected to be able to deal with a huge amount of chronic disease management (epilepsy, asthma, hypertension, diabetes, to mention but a few).

It really focuses the mind down to the basic level – what does a GP do? Are they able to do it?

The old epithet says that a consultant ‘knows more and more about less and less, until they know everything about nothing’. The corollary is that a GP knows ‘less and less about more and more, until they know nothing about everything’. Clearly, this takes things too far, but it is worthwhile considering if we can continue to fulfil the role that we are trained for.

The fact that we allow physicians’ assistants, nurse practitioners and paramedics to take on our role suggests that many feel that we don’t need the high level of skill, training, qualifications and income to do this.

There are other areas that some people think that GPs aren’t able to deal with. Over the years they will become apparent.

It’s not just External Cephalic Version that is becoming antiquated: look in the mirror.

The Jobbing Doctor is a general practitioner in a deprived urban area of England.

Jobbing Doctor