Learning the craft – own experience

Life so short: the craft so long to learn. (Hippocrates, 5th century BC)

This is the second of two extracts from D. Pereira Gray’s book: Just a GP: Diaries from a Career in General Practice.

I once visited a child at home who was dying of leukaemia. He was the same age as our little boy, Peter, and looked very like him. I was in an upstairs bedroom when the young mother, in her twenties, looked anxiously at me and said, ‘He is going to be alright isn’t he?’ To my horror, it seemed that either the specialists had not told her or that she had not understood. I sat her down on a bed and as gently as possible explained. She was shattered and sobbed almost uncontrollably. I sat down on the bed beside her with tears in my own eyes, put my arm around her shoulders for several minutes and then we went downstairs and had a cup of tea together to give her time to regain control. The child died soon afterwards, and the family stayed with my practice for years. Although we did not talk much about it, there was always a bond, as that mother knew that I knew what she had been through. This is how I learned what Iona Heath ¹ was later to call the ‘witness role’ of GPs; being there when it mattered and really understanding the patient’s feelings.

Nowadays, conventions are different. It would probably not now be possible for a young male GP to sit on an upstairs bed, alone in a house, and put his arm around a young woman patient’s shoulders for quite a long time.

One of the most interesting events in family practice is when girls that one has known for years grow up and have babies of their own. Suddenly the girl is a mother and often consults for her child. However, simultaneously, her mother has become a new grandmother still retaining her patient–doctor relationship with me. Then, interestingly, I noticed that sometimes these new grandmothers would send messages: ‘Doctor, Mary is not coping with that baby’. I would then do a home visit. Invariably, the new grandmother was right. Usually, the new mother had postnatal depression, but twice the baby had an important physical abnormality. In 38 years of practice, none of those calls wasted my time. They improved the efficiency of the practice and my health visitor teased me about having ‘X-ray eyes’, as I often got to those mothers before she did. Hoggart ² observed that working-class people knew the family doctor better than any other middle-class person.

Once a teenage girl said, as she was leaving the consulting room: ‘Mum asked me to tell you that she is getting really worried about Gran, who is leaving the gas taps on’. This was a three-generational consultation. These three/four-generational consultations show how families learn to use their family doctor to help other generations of their family. Family medicine across generations is both particularly interesting and, through earlier diagnoses, more efficient.

One of the special privileges of being a family doctor for more than 25 years in the same practice is that one can see not just three generations of families, but four generations. I kept a record of my families with four generations and when I retired from clinical work, 7% of all the registered NHS patients on my personal list had a four-generational relationship with me. That meant I had a baby registered, one or more parent, one or more grandparent, and one or more great-grandparent, all patients at the same time. As 7% is one in 14–15, and my average surgery session had 16–20 patients, it meant that on average in every surgery I would see a patient for whom I could picture four generations of their family. It is a rich experience being a real family doctor.

A little boy died in an accident. I knew the mother well and had looked after her through the pregnancy and had done the baby checks. She seemed relaxed, well integrated and did not consult much for herself. However, as she stayed in the practice for the next 25 years, I watched her become a patient with chronic anxiety state, which nothing and no referral could relieve. One day, her husband, whom I also knew well, said: ‘She’ll never stop grieving for that boy’. That insight from within the family summed her up in seven words. Family doctors gain greatly from seeing several members of a family and hearing their views. This, and many other similar events, led me to try hard all my professional life to encourage different members of families to register with me. Personal lists help this and the added value is huge.

Although specialists in hospitals are best at making diagnoses of rare diseases, GPs are the main diagnosticians in the NHS. They make more diagnoses than any other kind of doctor, particularly for the 86% of patients who are not referred. ³ They also make diagnoses over a wider range of conditions than any other kind of doctor. GPs also make the diagnoses in more than half of the patients who are referred to specialists, as about half are for routine surgery: cataract, hip or knee surgery, or when the referral is not for diagnosis but for investigation or treatment. Sometimes, GPs make diagnoses of even rare or difficult conditions, although these are not often reported. My only diagnosis of scurvy was rubbished initially by a consultant.

Narrative medicine includes the study of the use of metaphors and similes in medicine. Patients often use metaphors when they consult, as this is a standard way in which people communicate in everyday life. All doctors need to learn about patient metaphors, but especially GPs, for whom they are meat and drink. Decoding them is an important and undervalued clinical skill. One day, I saw an upper-class man with a stiff upper lip and after several minutes’ discussion, I was lost and did not know why he had come. ‘How do you really feel?’ I asked, a standard GP approach with an open-ended question. ‘Like a rowing boat with a hole in it!’ he replied. I decoded slowly: ‘But rowing boats with holes in them sink,’ I said. Then he started crying and the consultation about his depression, which he could not previously report, began.

I taught my GP registrars to ‘Trust your guts!’ Even though I am fascinated by the theory of general practice, this a-theoretical advice was based on my experience that doctors, especially GPs, including GP trainees, absorb a vast mass of information when consulting, much of it subliminally. Intelligent and sensitive doctors continue to process such information unconsciously. Vague feelings of unease may be more important than they appear.

One Christmas Eve I did a home visit to a small baby with a chest infection. I told the parents I would call again in 48 hours, on Boxing Day. However, I awoke on Christmas morning with that baby in my mind and feeling anxious about her. I decided to do a home visit, although I was not on call on Christmas Day that year. The parents were surprised to see me but grateful as the baby had had a bad night. I re-examined her and found pneumonia. The mother burst into tears when I told her that her baby needed to be admitted to hospital on Christmas morning but she went in and did well. I believe this happened because I had picked up some cue, unconsciously, on Christmas Eve and my subconscious went on integrating the information afterwards during that night. Children, when ill, particularly benefit by seeing the same GP each day, as small but important changes are then more likely to be picked up.

Research on doctor hunches or intuition from Oxford^4,5 followed up on GP ‘gut feelings’. They calculated the likelihood ratio for ‘gut feeling’ being important and found it as high as 25 times. This validates GP ‘gut feeling’ as clinically important. As NHS policy is for more patients, including children, to be seen first by other professionals, there is a question whether they have such gut feelings too. If it is a medical phenomenon, not seeing a GP may be costly. Some hunches are beyond explanation. I saw one patient for many consultations for vague abdominal symptoms. I had known him for over 25 years and he had been referred and fully investigated at the local hospital with a barium meal, barium enema and colonoscopy (before scans). He was seeing an experienced consultant surgeon regularly. I had examined him thoroughly. I sat back in my chair, non-plussed. Then I had a strong feeling that he had bowel cancer, but there was no evidence. I recommended referral to St Mark’s Hospital in London (which specialised in bowel disorders and this was when GPs could refer anywhere within the NHS). He declined, reasonably saying that I had no evidence and that he had confidence in the consultant. His wife, sitting beside him, asked why I was suggesting this, and I replied that I had a ‘hunch’. She turned to her husband and said, ‘Let’s back Denis’s hunch!’ He still declined and they started to argue, so I suggested they went home to discuss it. Next morning, they agreed to the referral. St Mark’s found a Dukes Grade A carcinoma of the bowel. This is the very earliest stage with an excellent prognosis. It was removed and he was soon home. As an enthusiastic teacher, I struggled to work out how I got that hunch, but could not. I later discussed this referral with the patient’s wife, and she said, ‘I just knew he wasn’t right and the hospital hadn’t sorted it’. So, her feeling, which made the referral possible, and her own separate patient–doctor relationship with me, were two other factors, showing how family medicine can add value.

Decades later, I found out that I was not alone. Smith et al. ⁶ studied GPs with ‘gut feelings’ and did a systematic review of the literature. They found that GPs’ intuitions of cancer had substantial diagnostic value, with a 4.4-fold increased chance of cancer being found, and that GPs who knew their patient well had more accurate gut feelings, especially older GPs.

GPs talk much about the patient–doctor relationship but those outside general practice value it less. Valuing it is difficult, but it is higher than is realised. Sometimes, I was approached by families who, when moving to better, more expensive houses, would ask if the new address was in my practice area. If told that they would have to change doctors, several families decided not to move. Similarly, when doing palliative care at home, some families gave me the key to their front door, a striking non-verbal symbol of trust.

Insights from home visits

Before there was a medical school in Exeter, our medical students came from older medical schools, often in London. One of these came with a strong commitment to paediatrics. This student conveyed the expectation that there was nothing much to learn in general practice. One day, on a home visit to a deprived council estate, we examined a small girl with a nasty chest infection. He took a good history, did a good examination and recommended an antibiotic, which I prescribed. I said we would call again in two days. When we did so, the child was no better, indeed worse. We went out to my car where I used to teach, and we discussed possibilities. He rattled off rare complications and even tropical diseases. I kept shaking my head and when he had run out of ideas I said, ‘Let’s go back and look behind the clock’. On re-entering, he found our prescription from the first visit showing behind the clock! As he realised the child had had no treatment, I saw he was about to say something that might have hurt the young mother. I quickly said, ‘Say nothing, sit down and listen’. It is important that the patient’s interest comes first. Then the mother, who knew me well, said:

I am so sorry, Dr Denis. I know I should have gone to a chemist but as you know I’m a single mother, my mother does not live in Exeter, the neighbours are awful, and there is no chemist on this estate. The rain has been heavy and I did not like to take Mary out with her chest infection.

It was a moving statement about reality for the socially deprived. As we drove away, I taught that the care children receive is largely determined by their immediate environment, which GPs are best placed to understand. Later, on an NHS authority, I supported a plan to establish a pharmacy on that estate.

Most junior doctors believe, consciously or subconsciously, that the hospital is the centrepoint of medical care and that general practice means practising superficial hospital medicine outside hospital. This is wrong but it is difficult to teach the opposite. However, one home visit vividly illustrated the different perspectives of general practice and hospital medicine.

I was telephoned by a former trainee working in hospital. He sounded upset and said the hospital staff were laughing at me and the consultants were amused that the Professor of General Practice had admitted a nappy rash as an emergency! I said I would report the story at the next week’s vocational release session. The trainee chair invited the paediatric registrar. The room was packed. I reported I had been on call for several practices and had received an evening call from a teenage babysitter asking for a home visit for a baby she was looking after. This was unusual. I had been in general practice for 25 years and had never had a request from a babysitter before – the first red flag. Arriving in the home around 11 pm, I found that it was in one of the poorest districts, where social problems were rife, so social deprivation was a second red flag. I was visiting a family where I did not know the baby, its parents or the babysitter, so I had no continuity of care – red flag number three. I asked the babysitter many questions about why she was worried and why she had phoned but could not get a clear answer. She was young and inarticulate and shrugged her shoulders saying ‘the baby was crying’. I was left not knowing why she had called – red flag number four. I asked her to undress the baby completely and did a careful examination.

There was a big nappy rash. While nappy rashes are common, a big one implied that this baby might not be getting optimum care – red flag number five. There were no bruises or signs of injury, but when I flexed the hips, the baby cried. I repeated this gently but every time the baby cried. Was this because of the nappy rash, or the obvious alternative that there might be a hip problem? – red flag number six. Could the ambiguous communication mean guilt, like non-accidental injury when presentations are often atypical? Could the babysitter have dropped the baby? Then the two parents came home having had much to drink. The father shouted ‘Who are you?’ I replied I was a family doctor and had been called. ‘Called?’ he shouted. And seeing the babysitter, shouted at his wife in front of the babysitter, saying, ‘Why’s she here? She is not reliable!’ – evidence that the babysitter was not reliable – red flag number seven. I said that the baby cried when I touched its hip so an X-ray was needed. My referral letter, presuming it would be read by the family, described ‘unusual social circumstances’, signalling to the paediatricians. The baby was X-rayed in hospital about midnight, which was reported negative, and the baby was discharged next morning with a diagnosis of ‘nappy rash’.

In discussion, the paediatric registrar said it was important that as hospital beds were precious, they should not be used for nappy rashes! A female GP trainee asked if it had been necessary to order an X-ray at midnight. The registrar said the consultant paediatrician had requested an immediate X-ray. The trainee persisted: ‘Could the X-ray not have waited until the morning?’ The registrar snapped back: ‘No. At that point the baby might have had a fractured hip’. The room burst into laughter, upsetting the registrar because the group was laughing at him. The trainee chair summarised:

As a consultant paediatrician had decided at midnight, with the baby in a place of safety, surrounded by qualified nurses, that an X-ray was immediately indicated, then it was reasonable for a GP with the baby in very unclear social circumstances, only an hour earlier, to want one too.

Later, a male trainee finishing GP training told me the incident was a turning point in his professional development. He had come, thinking I had made a big mistake and wanting to see how I would handle it, but he had learned that GPs could assess risk in the community better than hospital-based doctors.

Stories like these helped me to learn my craft and understand general practice as a human discipline. They helped me to relate my practical experience of being a GP with the theory of general practice, which emerged during my professional career.

This article is a reproduction of part of chapter 6 in D. Pereira Gray’s book: Just a GP: Diaries from a Career in General Practice (Boca Raton, FL: CRC Press, 2024). It is reproduced with the permission of the publisher and the author.

Declarations

Competing Interests

None declared.

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None declared.

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Ethics approval was not required as no individually identifiable patient is described.

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DPG.

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DPG was the sole author of this text.

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Not commissioned; editorial review.