When I was a medical student, with every new rotation or placement came a new potential career. After my house officer posts I was not really sure which to choose so I spent some time as a senior house officer in a research post, looking at ethnic factors in health and disease. I did an MA in Ethics and Law and even toyed with the idea of medical journalism. Then I spent some time in community paediatrics. But eventually it became obvious I was missing the variety of patient contact, so I went back and completed training for general practice.
Many excellent GPs may recall being greeted with the cry of ‘Oh, no, what a waste’, when making similar decisions. General practice is not always considered a prestigious career option – but this is mostly only the view of those who have not looked closely enough. Dr Barbara Starfield, an American paediatrician at Johns Hopkins University, writing in the Health Affairs Journal in 2009 just two years before her death, pointed out that her life-time’s worth of research showed:
“Too few true generalists and a surfeit of specialists is bad for population health, bad for the economy, and even worse for health equity.”
Not all generalists are in primary care, but every doctor in primary care is a generalist. We see unfiltered, undifferentiated illness at an early stage and need to develop the skills of living with uncertainty. We see patients who are ill, or who believe themselves to be ill, with vague, multiple, or hidden diagnoses. As Prof David Haslam, past-President of the Royal College of GPs once said:
“General practice is the hardest specialty to do well, and probably the easiest to do badly…the next patient could have schizophrenia or piles, unhappiness or cardiac arrest, anything and everything, and in no particular order.”
Of course, healthcare needs specialists – technical experts in well-defined areas of medicine. If my next patient does have a cardiac arrest, I need to recognise that and enlist the support of the appropriate specialist; I of course cannot manage surgical emergencies alone and where conditions are too rare to maintain competence, I need to have the humility to recognise if I am getting out of date and the patient needs specialist intervention.
Strong primary care, with creative and imaginative GPs, can be a vehicle to address health inequalities. There is international evidence that primary care is important for the development of Universal Health Care which is defined in the United Nations Sustainable Development Goal (3.8) as:
“the aspiration to provide all people with access to essential high-quality health services, safe, effective and affordable medicines and vaccines, free at the point of delivery”.
Areas with better primary care services, including within a given country, have fewer disparities in health between socially advantaged and socially disadvantaged population groups. Improvement in health outcomes is more marked in more deprived populations when primary care improves. In 2018 Chris van Weel and Michael Kidd wrote that:
“Primary health care improves the performance of health systems by lowering overall health care expenditure while improving population health and access.”
So, what is this magic that happens in general practice? ‘I thought it was all sore throats and bad backs’ I hear you say. Well, there is a fair amount of that but these days we are supported by a wide team of senior nurses and advanced practitioners that can manage some of this with us. And sometimes those symptoms represent brewing, sinister conditions that we need to be on the alert for. This ability to provide a comprehensive service avoids referrals for common needs and makes care more efficient. As first contact we can avoid unnecessary specialist visits. But GPs are more than a ‘gatekeeper’ to further care. 90% of healthcare is delivered in primary care and our person-focused care over time avoids disease-focused care, which makes care more effective. Our coordination of care role avoids duplication and conflicting interventions, making care less dangerous.
The final advantage of being a GP, in my view, is we are self-employed and this brings a flexibility that can led to development of so-called portfolio careers. Being blessed with very tolerant partners, who let me go off from time to time to do other things, I have been a university academic since 1999. GPs often combine clinical work with teaching and research, just as our specialist colleagues do, and in addition we might also hold part time positions in expedition medicine or medico-legal work, or have a special interest such as minor surgery or endoscopy. As a partner I have say in the running of the business and we can be innovative with service planning and delivery. Some GPs are even writers and journalists…
Why would you not want to be a GP?
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