What you can’t teach

In relation to general practice, I’ve learned some lessons only come from experience

I am going to put myself on the line here and say that, after many years as a GP teacher, I have come to believe that general practice cannot be taught. 

Amassing, distilling, and imparting the knowledge, skills, and attitudes required to be a GP is like trying to funnel the ocean through a narrow channel. The content is vast and always in a state of flux: Guidelines rapidly changing year after year. And while these guidelines are perfectly reasonable when applied to populations, they are not the least bit helpful for Mrs Murphy or Mr O’Brien, who have their own unique set of symptoms, mix of diagnoses, and very definite opinions. So, what do we teach aspiring GPs? Why teach this and not that? How much is enough? Is there a saturation point? A point of diminishing return?

To add to this, most GP registrars, by the time they come into practice, have their own ideas about GPs. Throughout their two years or more in hospitals, they have heard comments from hospital colleagues that illustrate the many ways GPs fall short: Inappropriate referrals, not enough detail, or referrals for defensive reasons rather than actual need. To be fair, most of these frustrations are born out of the pressure of the hospital system and a lack of understanding of the limitations of general practice rather than criticism of individual GPs. Nevertheless, these comments can generate beliefs and doubts that take root and, like Japanese knotweed, spread rapidly and produce large numbers of seeds that undermine the emerging GP.

Surgeons study anatomy, observe more experienced colleagues, and repeat the procedures they observe. Anaesthesiologists study pharmacology. Drugs given at the correct dose and in the correct combination usually have a predictable outcome. GP registrars spend four years studying general practice, two of those years in hospitals far removed from the challenges they will eventually encounter. When they eventually arrive in the GP surgery and get the opportunity to observe a GP at work, what exactly are they looking at? What are they meant to learn? 

GPs vary greatly in how they consult and manage patients. Patients vary in how they present and in how they seek advice. Some doctors make decisions for patients while others let the patient decide. No two consultations are the same.

Some time ago, a very attentive GP registrar sat in with me, notebook in hand, pen poised. A frail lady in a wheelchair was pushed into the room by her husband. The woman had been on a neurology waiting list for 18 months and they wanted me to write to expedite her appointment. I said I would, even though it was obvious that this lady would not live to attend a future appointment, and even if she did, it was unlikely that the specialist could do anything for her. But I had a more important agenda and the quickest way to get to it was to agree with her request. 

Tentatively, I started a discussion about her wishes if she became acutely unwell. Did she want to go to the hospital or stay at home? (At this point, the registrar had not made any notes, but was sitting forward with a concentrated, attentive demeanour. I’m sure he was wondering why I was sending a patient who appeared – and most likely was – terminally ill to an overcrowded clinic, while at the same time discussing end-of-life care.)

In a voice so weak that I could barely make it out, she, Martha (not her real name), said ‘no’ to the hospital if she was going to be offered treatment there and had a chance of survival. But she said ‘yes’ to the hospital if she was so unwell that she was going to die. This took some clarification, but I persisted until I was sure I understood. Both she and her husband agreed. I knew them for years and had visited her home. Her house was not suitable for a prolonged end-of-life stage. Her husband would not be able to manage that type of care. But she wanted to be home as long as she could. During a recent admission to the hospital, she had been unable to communicate with hospital staff because her voice was too weak.

“They were too busy,” she said. “It was too noisy and they couldn’t hear me.” She had become progressively weaker because there was nobody to help her get out of bed and do her daily walks. If she were conscious and able to make decisions about her care, then she wanted to be at home. If she was so ill that she was unaware of her surroundings, she wanted to be in hospital. 

The registrar’s page was still blank and he had put down his pen. I asked him what he made of the encounter and was met with a look of complete bafflement.