Win the crowd

Gladiator was a seminal film in my early medical student days. My housemates and I knew the lines and tried to replicate the flashy sword work. Luckily no digits were lost! But why does it still hold my imagination? Was it the plot? Excellent story telling? A yearning to be a hero like Maximus? Or simply an enduring fascination with the Roman era? Before watching Gladiator 2 at the cinema, I rewatched the original with my teenage daughter (she relented after me going on about it for a while) and it became clear why it was so poignant to me — ‘win the crowd’, Maximus.

Following his escape from death at the hands of Commodus, Maximus finds himself in the provinces as a slave/gladiator. Despite rapidly overcoming his opponent in the arena, the crowd are not warming to him. He is too transactional. His mentor, Proximo (former gladiator), explains that he won his freedom not because he was the most efficient but because he won the crowd. When the film moves to the Colosseum in Rome, Maximus and his colleagues put on a display showcasing teamwork — ‘strength and honour’. They win the crowd. You can/ should watch the rest.

Throughout my decade or so of medical training (2001–2013), role modelling and mentorship was embedded in my education. We learnt the science of medicine in lectures and from books, but the art was role modelled. We learnt how to doctor by witnessing consultants and GPs talking to patients on ward rounds, side rooms, in clinics, in GP surgeries, and on home visits. We learnt how to engage with patients — know the footy score! Be human with them — a well-placed joke/ banter. Give them the correct amount of information at that time and then follow them up. Work out what matters to them. Who’s at home? Can anyone bring them back if needed? Take an interest. Ask why. Care. These lessons were ingrained and became part of practice.

At the time, some of it seemed irrelevant to me and to the medical model — why was the professor of neurology asking me what type of dog the man with myasthenia gravis had? Now, as a dog owner, I can see the relevance of this question. Patients in their context and what mattered to them.

Later in vocational training I was taught how to be a GP; run a good practice — ‘focus on good core patient care and the rest will fall into place’; hidden agenda — ‘do the tester problem but keep exploring the agenda’; relational care — ‘same patient’s different diseases’; candour — ‘admit mistakes quickly and apologise, most forgive’; safe practice — ‘when busy slow down’; and build your reputation — ‘phone a few patients about results without prompting’. There’s a rabbit off — ‘something’s wrong we don’t know what yet. But find out!’ — that’s my favourite one!

However, I fear that as a profession we have lost the crowd. In 2011 most patients (70%) usually saw their preferred GP (Tom Marshall, personal communication, 2024) but in 2023 only a small minority (35%) did.¹

Why has this happened?

There are societal factors that play their own part — ageing population, shrinking GP workforce, chronic underfunding, and work shift. But primarily we have lost the crowd because we focus on the transaction above all else. We’ve left our agenda setting to receptionists and online triage tools. We’ve replaced the holistic generalist and split them into a pharmacist, community psychiatric nurse, social prescriber, paramedic, physician associate, cancer care coordinator, and frailty coordinator, for example. Rather than adding additional skills into the primary care team, Additional Roles Reimbursement Scheme roles have replaced GPs in many settings rather than adding additional skills into the primary care team. Uberisation is king. Any GP will do. Patients are unknown to us. Consultations take longer as a result. The public has lost trust in us. Clinicians become ever more defensive and mitigate risk by rigidly adhering to guidelines. We seek comfort in protocols. We are working harder and harder but still missing the mark. Rebecca Payne and colleagues’ recent study in the BJGP explores the reasons why and highlights the inefficiencies of transaction-focused models.²

But all is not lost. We can win back the crowd, it is workable. Payne and colleagues urge us, as a profession, to refocus on the core values of general practice (personal, holistic, relational, and generalist care).² The British Medical Association’s Patients First plan to fix primary care starts with bringing back the family doctor — ‘by seeing the same clinician, patients can build trust in who delivers their care and receive a better service’.³ To achieve this, we need more doctors spread evenly across the country and an uplift in funding. With professional focus on our core values and incentives to make it work we can ‘win the crowd’ once more.