I recently read an article from a reputable newspaper which questioned the need for general practice. If you have a knee problem, it asked, why not go directly to a knee surgeon? Feeling a bit psychotic? Why not refer yourself to a psychiatrist? When reading Dr Michael Dixon’s article ‘Do partners have a duty help “risk-averse” younger GPs to cut unnecessary referrals?’, I was reminded that the role of a GP is to often act as a gatekeeper for referral – something my fellow GPs to be blogger Julie wrote about last month. Our work saves unnecessary worry and investigation for the patient, and saves resources for the NHS.
Are we as trainees too risk-averse? With every patient we see, the decision to refer comes down to risk. I am a bit of a worrier, and one of my trainers always jokes that the safest thing to do with my elderly patient who keeps falling over would be to move her into my flat. I know what he’s saying: we can’t refer everybody, but equally we cannot take on all the responsibility ourselves.
Dr Dixon talks about ‘tolerating uncertainty’ in an increasingly demanding and litigious patient population, and I would agree that part of becoming a good GP is about developing that intangible ‘acceptable’ level of risk. Certainly this is facilitated by feedback on my decisions to refer or not to refer, and I have had a lot of help in this so far as a GPST2. (I wonder whether this dynamic changes as you progress towards first5…).
But the big question seems to be, why do trainees practice more defensively? From conversations with my colleagues, deciding what is serious or not can make you feel vulnerable.
We recently had the news of a 23% increase in complaints about doctors. I think this gives out the message that practicing medicine should be foolproof and mistake free. As Dr Dixon says, older GP’s have ‘less to lose’ from complaints. By contrast, rising complaints cause a lot of anxiety amongst younger trainees. If what we are saying is that fewer referrals will save patients suffering unnecessarily but might produce more mistakes, then there is a huge role for partners in training younger GPs.
In the decision about referral, it seems there is a lot at stake for both patient and doctor. Knowing that, I would be happy and more fulfilled to work in partnership with older more experienced partners… And I might get my spare room back.
Dr Martin Wicks is a GPST1 in Bristol