Monday, 4 October 2010

The past

When I trained as a GP there was consistent recognition of the book "The Doctor, his Patient and the Illness" by Michael Balint. Given that Balint's work involved GPs and psychiatrists meeting up and chewing over discussions of patients the GPs had been seeing, the themes and processes were right up my street. Although I enjoyed working in GP land, having swapped to psychiatry I still find the work equally appealing.

Work within my training in Primary Care was about medicine, obviously. Delivering it as a GP needed additional, specialist training that took 3 years. Much of this training was on clinical content, I knew I was weak at rashes so spent a year sitting in a dermatology clinic for a day a week which was great training, both on dermatology and on consultation style/case load management/clinical decision making that you attend to when training as a GP. I learnt more about rashes through that time, but also learnt a lot more about broader patient care.

A good proportion of time training as a GP was rightly devoted to considering the patient's agenda. Firstly it's the right thing to do, because it purposefully addresses what the patient presents with and wants addressing, attending to what the patient's concerned about. Sure, clinicians may note that the cause of the patient's issues/concerns are something else, or see a chance for opportunistic health promotion, but it evidently makes sense to help the patient with what the patient brings. Secondly it's the right thing to do, because patients usually know what's normal/right for themselves so presenting with an issue that may initially seem to be of dubious medical relevance oft times does become of import. Maybe it's an uncommon symptom manifesting. Maybe it's an explanation used to show me something they can't otherwise describe, which we all commonly do (such as describing ourselves as "off colour" or "out of sorts" or "feeling blue" or "not myself today" which medically means nothing but practically is important) so describibg "being tense" but having normal muscle tone and no headaches isn't as spurious as initially I might have thought.

As a medical student I used to think of things in categories, we were trained to do so. There's a medical problem or there isn't. It's mental or physical. It needs surgery or it doesn't. Medication is indicated or it isn't. Someone is coping or they aren't. I look on my past training and am very glad I've had these training experiences. Even in the training posts for both General Practice and Psychiatry, when I was doing them I really enjoyed them, it isn't just a rose tinted view that time's given me. The training, over so many years, taught me the clinical content to start working as an autonomous, unsupervised medic (a Consultant, in the NHS) but also developed my approach and understanding of consultation style that's much richer now than it was, as a medical student. As a medical student I thought I needed to know all the medicine, and it was true. But as a practitioner, I need to know the medicine and need to know how to work with patients. Sitting in with GPs and Consultants in surgeries and clinics was of enormous value in helping glean an understanding of what works well, what can be done better, what I shouldn't be doing and what I can adopt in my own practice.

On talking through a portfoloio and training with my junior doctor, it dawned on me how diverse and interesting and valuable my own training has been. The brevity of current training concerns me. Even if the tick box clinical content can be delivered in such a short time, will future practitioners step in to post with the balance and maturity that my colleagues developed through longer and more flexible training? No, no they will not. I try with my junior doctor we focus on clinical topics and on broader consultation style and operational/management matters but he's not at a point in his training when he's receptive to this. He needs to know the medicine, he can't pass his exams without it. Anything else is interesting but not as important to him. But, in a bit over 3 years, he'll probably be a Consultant.

"The past is a foreign country; they do things differently there."
- L P Hartley

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