In general practice, patients stay and diseases come and go. In hospitals, diseases stay and patients come and go. (Heath, I. BMJ 1995, 311:373)
While GPs have sailed through the waters of hospital specialties and deal with all specialties on a day to day basis, general practice is uncharted territory for hospital doctors. Significant difficulties occur in patient care due to hospital doctors’ poor understanding of the modus operandi of GPs.
Ninety-five percent of patients’ contact is with GPs and most of the issues are dealt with at primary care level. Only a small percentage needs secondary care involvement like admissions of referrals. Admissions tend to cause much friction between GPs and hospital doctors. A few years back, I was doing a night visit at 2 am. The patient was a 23-year-old woman, a single parent with two-year-old daughter, living on her own on the fifth floor of a tower block. The clinical picture was appendicitis.
When I requested her admission, the hospital doctor was rather insisting on rectal examination findings. The doctor was purely checking the possible diagnosis and not visualising the predicament of the GP who had assessed the case and made a decision that the patient could not be managed in her own home in the middle of the night, and needed hospitalisation. This, I believe, is due to the tunnel vision of specialist doctors, failing to recognise the danger in carrying out the procedure, something that could turn out to be career threatening in the situation. In my own experience, there have been various similar examples over the years.
Often, patients view the hospital as a transit lounge since they know that they are there only for a limited time and are well aware they will go back to the GP shortly. Also many patients talk highly about their GPs. This attitude of patients can irritate many hospital doctors, since they feel undervalued and underestimated for their services. For the hospital doctor, dealing with the patient lasts a few days or weeks but for the GP, the commitment is lifelong until retirement or death. If two people have to ride a horse, one has to sit at the back. Naturally the horse prefers a familiar rider than a short term one.
While hospital doctors haves thorough knowledge of their speciality, GPs have a broad working knowledge of all conditions affecting all ages and extending over all specialities. Moreover a GP is not just clinician but has various other roles – family practitioner, counsellor, disease interpreter, administrator, social worker, gate keeper, primary care leader and so on.
The hospital doctor’s responsibility often ends with the discharge letter. Also, in the hospital setting, the burden is shared and the buck stops with the consultant. For a GP, the buck starts and stops with him.
A group from the European Working Party in Family Practice (EQuiP), involving over 20 European colleges of primary care, has found that the quality of care at the interface between general practice and specialists needs much improvement. Many patients feel that they are left in limbo when care is being transferred from one branch to another.
The European Task Force on Quality in General practice (EUROPEP) has developed an instrument to measure patients’ evaluation of quality in general practice. Also, benchmarking of hospitals has been in force over many years. With the rapid advent of social media, patients have become much more knowledgeable about their health care and rights.
The General Practice Forward View set up a working group in September 2016 to (a) improve communication between primary and secondary care, (b) include new measures in the NHS Standard Contract to improve processes across the interface, and (c) identify and share best practice and innovative ways of working.
One of the key recommendations by EQuiP is that specialists should be trained in the patterns of diseases, signs and symptoms within primary care system as well as those presenting to specialist practice. All trainees should have appropriate training and insight into possible organisational problems at the primary–secondary care interface from both patients’ and providers’ perspectives. These can only be achieved by spending enough time in general practice.
If two years of hospital medicine is part of GP training, in my view, every hospital specialist doctor ought to spend at least one month per year in general practice. Rather than viewing ‘my patient’ and ‘your patient’ we all need to view it as ‘our patient’ and the medical profession needs to work ‘hand in glove’ among all branches and cadres to achieve the common goal of best possible holistic patient care.
Dr Thomas Abraham is a GP in Hull