I was recently speaking to a friend who’s preparing to sit PACES, the fearsome last component of the MRCP exams.
The rumour is that the examiners have tired of gathering patients with one-in-a-million endocrine disorders, and have started lacing the exams with something even more devilishly obscure: normality. This, apparently, is the typical candidate’s biggest fear – being presented with a patient who is completely well, and having to muster the confidence to tell the cackling, palm-rubbing professor that there’s no pathology.
When you’re a teenager, it’s a rite of passage to spend at least a summer declaiming that ‘there’s no such thing as normal’. But, medically speaking, there really is. And finding it is one of the most valuable roles a GP has.
But it is difficult at times, and requires a professional who is experienced and willing at times to shoulder a little risk. Life is infinitely varied, and will never fit with what a prepared protocol says it should be.
Our gatekeeper role isn’t just about saving the NHS money and being miserly with referrals, although unarguably we should be conscious that we’re engaged in spending taxpayer’s money. Perhaps more importantly, gatekeeping is about giving appropriate reassurance to those who think they might need medicine’s attention, but don’t.
Of course this saves money, and I suspect consultations that end in reassurance pay for themselves many times over. But more importantly, they stop anxieties, and prevent the shared tragedy of iatrogenic harm.
And it can be fun – I can’t imagine the day when I don’t get a boost from watching someone’s face brighten, as I explain the gulf of difference between the imagined melanoma and the real seborrhoeic keratosis.
A diagnosis of normality requires time in several forms. Time to get to know your patients, and to listen to their story properly. A longer form of time, pre-invested in the vast number of cases of pathology and normal physiology that must have been seen to confidently differentiate the two. And more subtly, time to yourself – to play the violin, read a novel, or go surfing; whatever it is that makes you come back to the surgery refreshed and ready, keen to learn more and do all that you can.
All these forms of time are being squeezed out of us. We need longer consultations to deal with the new levels of medical complexity that we face. We need the older GPs with their hard-won experience to stick around. And we need time to keep ourselves human.
If all this goes, then we’ve lost, and our patients have lost more. In a callous world of protocols and payment by activity, over-investigation and iatrogenic harm will be our new normality.
Dr Nick Ramscar is a GP in Bracknell, Berkshire