Dr Lucia Gannon
Edward de Bono’s thinking methods have helped sort out many a circular discussion in our house. So when the question of whether or not we should resign from the GMS arose recently, due to the now familiar problem of not being able to find holiday locum cover for the practice, the logical thing to do was to examine this course of action using de Bono’s ‘Six Thinking Hats’.
The Six Thinking Hats tool is a simple, effective, parallel thinking process that separates thinking into six clear functions and roles. Each function is represented by a symbolic coloured hat, as outlined below. The abridged discussion went something like this:
White Hat: This hat calls for information, known or needed. The most important consideration is whether or not it would be possible to make a reasonable income without a GMS contract. Information needed includes other potential sources of income for an experienced GP in their mid-50s, current practice income and expenditure.
Yellow Hat: This hat symbolises optimism and calls for exploration of the positives and benefits of a particular course of action. One positive outcome of resignation would be that time off could be planned and taken as desired. Finding alternative work would not be a problem, as there is always a demand for locum or sessional work. Not running a practice would result in reduced overheads, administrative work and staff management.
Black Hat: This hat calls for exploration of all the negative aspects of a course of action. Patients may have to travel further for medical care, as it is unlikely a full-time doctor will be appointed in Killenaule. There will be more ambulance call-outs, increased and longer hospital admissions, more medication errors. The local pharmacy will reduce its staff or close. There will be job losses from our surgery. It would be difficult to explain our decision to our patients, as they are also our neighbours and friends and they have come to trust us. It could take a long time to regain that trust as a non-GP member of the community. There would be loss of the security of the GMS contract, a risk of reduced income and a risk of loss of self-esteem that comes from the perception of self as a ‘failed business-owner’.
Red Hat: This signifies feelings, hunches and intuition. We would feel sad that 22 years of financial and emotional investment ended in failure. Sad to finally admit that long-term personal care, by the same doctor, which has been shown to significantly reduce mortality rates, is no longer available to the people of Killenaule. Worried that we have let people down by not managing to make this practice sustainable. Fearful about such a change at this stage of our lives and uncertainty about the future. Relief that we are no longer solely responsible for the running of a GP practice in difficult circumstances with no reason to believe that these circumstances will improve. Happy to be able to plan time off and know it will not have to be cancelled or delayed at the last minute. A sense of freedom at releasing ourselves from an archaic and punitive contract of employment that can be altered at any time at the pleasure of the Minister.
Green Hat: This hat focuses on creativity and growth and calls for exploration of new ideas and possibilities. Perhaps the resignation of two committed and outwardly successful doctors will help highlight the plight of Irish general practice, leading to some attempt by Government to improve it. This is probably magical thinking, but this is allowed when wearing the Green Hat.
Blue Hat: This is the ‘managing hat’ that ensures the thinking tool is used correctly and brings the discussion to a close. There are many factors to consider in trying to come to a decision, not least examination of outstanding White Hat information. We decided to re-examine our options once we had accumulated this information.
Carrying out this exercise uncovered two important factors, the first being that we are not responsible for the current state of general practice. Failure to reverse FEMPI is one of the main reasons that there is a shortage of GPs in Ireland and until this is reversed, nothing will improve. The second is that the only reason we are still in business is that we are resilient individuals who work hard to overcome both personal and professional challenges. But resilience, while it allows us to survive and thrive, does not tackle the underlying problem of abuse of GPs by Government. Resilience has not resulted in attracting young doctors into our practice. Resilience, coupled with magical thinking, may be the reason that many of us ‘keep on keeping on’ long after we should have quit.
In 2017, the Royal Australian College of General Practitioners ran a public awareness campaign to promote general practice. I have to admit, it almost had me, with its soft-focus cinematography, attractive, confident, caring GPs, perfectly balanced for gender, age and colour. And the evocative language: “I interpret the great unknown, but I’m not an astronomer. I understand dark clouds, but I’m not a meteorologist.” I was almost convinced, until the final statements: “I am a GP. But I’m not just a GP. I’m your ‘specialist in life’.” A slogan that clearly undermined the very profession the campaign was trying to promote. “Not just a GP… your ‘specialist in life’.”
It sounded like something that would have prompted Fr Trendy to pose his signature question: “Can I get in there, Mike?” on the Live Mike Show many years ago. Possibly followed-up by: “We have to ask ourselves the basic questions. What IS a GP? What IS a specialist? And what IS life?” In Ireland, it is not the public that need to be convinced of the value of general practice, but the politicians and Department of Health. Answering Fr Trendy’s hypothetical questions might be as good a place as any to start.
A GP is a general practitioner, not a specialist practitioner. As a GP, I can help you if you think you are ill; if you are wondering if that chest pain you had last week is angina or costochondritis. If you think your sore throat might need an antibiotic. If you need extra blood pressure tablets or your bloods checked. If you are wondering if you are just a bit sad or clinically depressed. If your baby’s six-week check is normal and if it is a good idea to get that same baby vaccinated. As a GP, I can fit your Mirena, do your smear test, inject your carpal tunnel, stitch your head and syringe your ears. I can meet a whole host of diverse needs, but I am not a specialist. I did not train to be a specialist in anything. I trained to be a GP. Specialists are found in hospitals or some newer version of secondary care and they are better able to explain their own role.
And what is life? A little word for a big concept. Advice on ‘life’ is probably best taken from the lifestyle section of the weekend newspapers, because I am not an expert in the latest fashions, the best anti-wrinkle creams or this year’s favourite holiday destinations. I don’t know any more than the average Sunday newspaper reader about adventure sports, meeting your soulmate or making plans for retirement. I cannot ‘interpret the great unknown’ and do not necessarily understand your ‘dark clouds’. I have a hard enough job managing my own little life. I have no desire or expertise that qualifies me to advise you on how to manage yours.
A few weeks ago, a friend who works in HSE finance asked, “but what is it you actually do all day? Sitting at a desk, in front of a computer, what can you actually do for people’s health?”
“If you need to ask, you probably don’t need to know,” I replied. Blessed with robust good health and already well into his 50s, he was one of the lucky ones who had never attended a GP. But his question was genuine. Also, he might need a GP some day and it would help if he had some idea of what we were about. I tried to convey the constant navigating between health, illness and disease. The management of the ill who deny their illness and the well who are convinced they are ill. The effort it took to be there, at that desk, in front of that computer, with no idea what would come through the door. No idea what knowledge, skills or attitudes were going to be called out before leaving for home that evening. I added that as well as practising medicine, most GPs that I knew were also business owners, employers, teachers, lecturers, researchers, health advocates, college representatives and even some writers. Others work with emergency services, advise the Government, attend the dying, the homeless, deliver care to refugees. “Right, I get the picture,” he interrupted me. “I’ll stick to balance sheets, regular hours and a predictable paycheck.”
General practice is in crisis. At the heart of this is the fact that those, like my friend, who do not use the service do not know what it is worth. GPs and their patients are the only ones who can explain its value. But the lily does not need to be gilded. We should never need to pretend to be anything other than just GPs.
Healthcare should not be used for political gain, as in the case of the Government’s response to the recent cervical screening programme controversy. The actual problems at the core of the controversy were straightforward. A number of tests, initially reported as negative, were subsequently found to have evidence of disease and the women involved were not informed of this. So, how is this rectified by offering women a repeat smear test if they, or their GP, are concerned? The CervicalCheck website indicates that GPs have been given the information necessary to make an informed decision. But the information does not answer three important questions frequently asked by women. Why is it not possible to review my previous test result rather than subject me to another test? How confident can I be that my previous test result is accurate? Where will my test be processed? In the absence of this information, the only reasonable option is to offer a further test and hope that this is also reported as normal.
The CervicalCheck website also states that a smear test is a “simple procedure that only takes a few minutes”. In the UK, a cervical screening campaign suggested that women put having a cervical smear test on their to-do list, alongside booking a hair appointment or buying cinema tickets. But consulting your doctor about a smear test is not the same as asking your hairdresser for advice on whether to have a half or a full head of highlights. I suspect many men have no idea of the complex decisions women have to make in the hairdressers, just as I suspect they do not give much thought to the anxieties, fears, embarrassment and discomfort that women experience when it comes to having a smear test. I would choose to have 20 blood tests over this most intimate and invasive procedure, as would the many women who turn up at my surgery, having taken time off work and/or arranged childcare. Women only attend for smear tests because medical professionals and public campaigns convince them that this is the best way to protect their health.
Dr Robert O’Connor, Head of Research at the Irish Cancer Society, stated recently that the advantages of cervical screening far outweigh the risks (Medical Independent, 17 May). According to the article, in the decade since cervical screening was introduced in Ireland, more than 1,300 cancers and 87,000 high- and low-grade abnormalities have been diagnosed. This means that for the 130 women diagnosed with cancer each year, 8,700 women will have either repeat tests, colposcopy, biopsy, laser or large loop excision of the transformation zone (Lletz procedure). Cervical cancer is rare. Abnormal smears are common. But no-one knows which ones will turn out to be significant, so all women are followed-up and treated. Of those who require biopsies, many will experience bleeding, infection or premature delivery. Many women experience considerable anxiety while waiting for their test result, a well-recognised harm of screening, and many others delay presenting to their doctor with significant symptoms because they have had a normal test. This “simple procedure that only takes a few minutes” has an impressive array of potential unintended consequences.
The article also states that cervical screening saves lives, and GPs are urged to protect the programme. The evidence for this is that prior to the introduction of the cervical screening programme, cervical cancer rates in Ireland were increasing. Since its introduction, the rates have been falling. But correlation does not necessarily equal causation and diagnosing cancer does not always translate into saving lives. Even though the decline in cervical cancer rates coincided with the introduction of the programme, it could still be due to a myriad of other factors, such as: Improved overall health; changes in sexual behaviours; reduced child-bearing; or reduction in sexually-transmitted diseases. Dr Margaret McCartney, in her book The Patient Paradox: Why Sexed-up Medicine is Bad for Your Health, explains that the decline in cervical cancer mortality rates in the UK pre-dated the introduction of the cervical screening programme. In reality, the only way to know if cervical screening saves lives is to perform a randomised, controlled trial that compares a group of women who have had screening with a similar group who have not. This has never been done. At one time in the early 1970s in the UK, such a trial was suggested but deemed unethical. Yet the ethics of subjecting millions of women to an invasive test without clear evidence of the benefits and potential harmful effects is ignored.
It is disappointing that the political answer to this controversy has been to ask GPs to paper over the cracks, rather than addressing the real issues of test limitations and poor communication with patients.
Murphy, a man in his 50s, hesitated at the door of the consulting room. “I wanted to ask you, doctor, would there be any chance that you would take on my mother? Her doctor has retired and I really would like her to attend this practice.” Mr Murphy was not the first person to request that I take on the care of a relative in recent months. I was well aware of his mother’s situation and while she had my sympathy, in the interest of professionalism, safe practise and self-preservation, the answer had to be “no”. ‘I’m sorry,” I said, “we have no spare capacity right now. I can put her on a list and contact her if we manage to get another doctor. That’s the best I can offer for now.”
Mr Murphy, a rural-dweller all his life, did not need to be told that communities such as his are being eviscerated by Government policies and that the demise of the rural GP is just part of this process.
His mother was a patient in a practice close to me where the GP had recently retired. The list had been advertised for over three years with no applicants. A solution was found whereby a city practice, 40 minutes from the village, agreed to register these patients and provide them with a GP for four sessions a week, in exchange for a rural practice allowance. It is understandable that these patients wish to move to a neighbouring practice with a choice of three doctors, a nurse and a secretary. But providing these services costs and, as currently, there can only be one rural practice allowance per rural area, there would be no extra resources provided to another rural practice to take them on. Hence, the solution to support a city practice and reduce the service commitment.
In order to come to terms with this development and realising that living and working in rural Ireland for over 30 years could result in biases, I applied one of Edward De Bono’s thinking tools to the situation. The one I chose is called ‘Other People’s Views’. This involves assessing a situation from the point of view of all the stakeholders.
Actually getting into their shoes and trying to understand their reasoning.
The stakeholders in this scenario include the patients, the doctors who decided not to apply for the post, the doctors who agreed to take on the list, the HSE/DoH, the neighbouring doctors and our negotiating bodies, the IMO and NAGP.
1. The patients at least have a doctor, but it is a much-reduced service. They no longer have a doctor living or present in the area, outside of the four sessions provided. They must travel a considerable distance to see a doctor at any other time. They will probably never have a local doctor, nurse or secretary again. They are unlikely to be able to get a doctor in the case of an emergency and are a long way from a hospital.
2. Some recent graduates did consider the possibility of taking on this list but changed their minds when they calculated the cost of premises, equipment, staff, medical insurance and Caredoc fees. Even with a rural practice allowance, it did not make any financial sense. They went on to find work in urban areas.
3. The doctors who agreed to take over the list have additional patients and increased workload. As compensation, they get a rural practice allowance and all the benefits this accrues. They are providing a service that no-one else can provide, offering a helping hand to a community that would otherwise have no doctor, in an arrangement that makes perfect business sense for them.
4. For the HSE/DoH, this solution is the best possible outcome in the circumstances. The post is no longer vacant. Patients have access to a doctor at all times. The responsibility for care rests with the new GP.
5. As a neighbouring GP, this development is the worst possible outcome. I see the helping hand as a greedy paw. It creates inequality of care between neighbours and friends. It puts pressure on surrounding practices to take these patients on with no additional resources. As a rural-dweller and experienced rural GP, I consider this level of care unsafe, uncaring, and unresponsive to patients’ needs. I also consider it ineffective, as it will almost certainly result in increased out-of-hours consultations and emergency department admissions. To me, it demonstrates poor judgment and leadership by both GPs and the HSE and should not be facilitated or tolerated.
6. Finally, if GPs on the ground consider this level of care adequate and collaborate with the HSE to dumb-down rural practice, what hope have our negotiating bodies of attracting resources to re-feed this starving specialty?
I am taking up a lot of your time, doctor,” the young woman said, as she positioned herself on the edge of the chair, already fully dressed in coat, scarf, boots and cap, following her physical examination. I looked up from the computer, where I was typing a referral letter. “Just a few more minutes,” I said. “I’ll finish this and you can be off.”
When she first came in she had sat in that same way, on the edge of the chair, as if to convey that she didn’t want to take up too much of my time and in an apologetic tone, informed me that she had two problems that she would like help with, if that was okay.
The most pressing one was recurrent abdominal pain that had resulted in a recent visit to an emergency department. The second was a recurrent headache that she thought might be migraine. I reassured her that these were legitimate reasons to come to see me and that I would address both today. I suggested she give me her coat, scarf and cap so that I could hang them up and she could sit back in the chair, relax a little before we began. She did as I suggested and the consultation proceeded smoothly with a focused history and examination followed by a negotiated management plan for both problems.
It was at this point that she voiced her concern about the amount of time she was consuming, causing me to disengage from my typing and become aware of my external circumstances. I looked at the clock and saw that she had been in for almost 25 minutes. I could have sworn it was five. But, for once, this didn’t matter. This was the morning of Storm Emma and ‘Mary’ was the last of only four people who had attended me that morning. A further 12 had been afraid to brave the elements and were present only as red cancellations on the computer screen. All four who had attended had received more than 20 minutes each and like this consultation, every minute had been focused and necessary.
Freed from the usual time constraints, I had the opportunity to fully engage with each patient, deal with their agendas as well as a few of my own, conduct necessary examinations and decide management plans in an unhurried but effective manner. I had worked hard, but did not feel drained or overwhelmed and did not have a mountain of paperwork to attend to before my afternoon surgery, as is usually the case. It was a good feeling. I realised that what I had been experiencing throughout the morning was a state that psychologists call ‘flow’: A state where body, mind or both are fully engaged in an activity to accomplish something worthwhile. A state more associated with artists and creative work than run-of-the-mill workers like myself. A state that not only makes work seem effortless, but has proven beneficial effects on wellbeing.
According to psychologist Mihaly Csikszentmihalyi (pronounced Cheeks-Sent-Me-High), there is no reason why any activity cannot induce this state of flow, provided the conditions are right. These conditions include: Clear goals, no interruptions, being able to complete the task, immediate feedback, a sense of control, and absence of intrusive worries about everyday events. These conditions lead to an altered sense of time when minutes can seem like hours or hours like minutes and the experience is one of a deep sense of enjoyment. It is a state not often experienced in general practice with over-booked surgeries, constant interruptions and often, an inability to complete one task before having to consider the next one.
“You picked the right day to come in,” I said. “I wish it was like this all the time. I hate when I have to rush people or when I keep people waiting.” The woman raised her eyebrows and gave me a look of surprise.
“Well, the worst day ever it was here, wasn’t a patch on the NHS,” she said. “There, I don’t think I ever even took off my coat. I could wait up to three weeks for a GP appointment, go in, start to say something and find I was back out in the waiting room before I had finished my sentence. I saw a different doctor every time and to be honest the place was so busy that they barely looked at you. I gave up going in the end as I found it such an unpleasant and pointless experience. I hope it never gets that bad here,” she added, as she made her way to the door. “I hope not, either,” I replied, feeling a little selfish that I was grateful for the storm and the enjoyable morning’s work, but also wondering how long it would be until we are just as good as the NHS.
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