Saturday, 19 March 2011

The de-skilling of GPs

Yesterday's post was a little rushed, and I didn't have the time to mention the de-skilling of GPs. In my youth, GPs were capable of dealing with nearly all of the medical problems of their practice themselves; most patients will have routine and minor medical issues, and the number that used to require referral to hospital or to a consultant was, from memory, low. The stethoscope and the sphygmomanometer were the tools of choice, and clues in the patient's eyes, tongue, fingernails, skin, demeanour and so on aided diagnosis. White flecks on the nails? Vitamin C deficiency. A little yellow ring around the cornea? A smoker. Blue nail-beds? A pulmonary disorder. If confirmation was needed, the GP would take a blood, sputum, urine or stool sample and send if off.  


Now of course a GP won't even bother to look at your hands or eyes, let alone ask to take a peek at your tongue. Unless you've brought one of the half-dozen common and minor complaints he or she feels capable of dealing with without further investigation, these days it's a battery of blood tests to start with. Everything from Cholesterol to Zinc. Then they use a little book like a primer, with easy to follow flow charts, to tell them what the numbers mean. Half of these flow charts end up with the instruction 'Refer to Consultant'. 


Again, when I was younger, consultants were men (and yes almost always men) at the peak of their profession; members of the Royal Colleges in expensive suits and with a Bentley in the hospital car park. They were not to be bothered with trifles. Now, they're as ubiquitous as ward-cleaners, younger, and a lot less well qualified. In short, in the same way that 'A' levels have regressed to the level of the old 'O' levels, a first degree to the level of 'A' levels and a Master's to the level of the old Bachelor degree, so newly qualified GPs have regressed to the skills level of a nurse, and consultants to the skill level of the sort of GP that one found in my youth. To be frank, unless you've got a British-qualified GP over 50 you're probably better off using Wikipedia.  

16 comments:

lilith said...

Very true. They take those blood tests and ignore the results. Perhaps they don't understand them?
The number of people staggering around with macrocytic anaemia or low thyroxine or high blood calcium beggars belief.

gyg3s said...

Hey Lilith,

Got a list of indications apart from staggering and blood tests? Got any remedies?

lilith said...

Get a copy of your blood test results and use Google. And never, ever take statins.

Anonymous said...

Absolutely true. Also fantastically over-paid following the criminal mismanagement of P Hewitt.

One of the more amusing recent episodes of Come Dine With Me featured a Sheffield GP who was overweight pretentious and had a house full of Manolo Blahniks and vintage Krug. She thought she was very special indeed but was hilariously exposed as a dim poseur when she raved about supermarket wine from a box represented in a fancy bottle. In a noticeable sign of the times the other contestants hated her and she came last.

Its also noticeable that (like all such modern categories of incompetents occupying formerly respected positions because of dumbing down and diversity based positive discrimination) they are arrogant, unhelpful and likely to take action against you if you complain.

Thank god for wikipedia in a few years time Medecine is going to be full of belligerent "left wing" numpties just like the schools and universities.....

talwin said...

'Refer to Consultant', or as it used to be referred to in those junior management courses visited on some of us, 'getting the monkey off your back'.

Anonymous said...

First off I think I should declare I am a Doctor although not a GP. Now that’s out of the way let me begin.
Clinical examination rarely leads to a firm diagnosis, contrary to what we are taught in med school. In the past it seems probable that diagnoses based on this were either wrong and the patient healed themselves or they died and no one knew about it
When you were young pathology and illness progressed to a point where it could be identified on physical examination no matter how poor this method is, because people did not go to the GP that often and soldiered on, the pathology was florid and easy to see. Now that is not the case.
Also simply there were less things to do to investigate and treat illness in the past (No CT, no MRI, no angiography, no cardiac enzymes etc.), hence no possibility of ordering them and no need to know about them.
When you were young if a GP made a mistake you would be unlikely to know, now he or she would be likely sued. Defensive medicine is the phrase used.
Combined with less training and less time on the job results in disaster
These reasons and possibly more are the reasons you feel unhappy.
Consultants have also been 'specialized' simply because doing a few things well is better than doing many things badly.
As for pay. I would agree the salaries earned by GP's are ridiculous.

Anonymous said...

First off I think I should declare I am a Doctor although not a GP. Now that’s out of the way let me begin.
Clinical examination rarely leads to a firm diagnosis, contrary to what we are taught in med school. In the past it seems probable that diagnoses based on this were either wrong and the patient healed themselves or they died and no one knew about it
When you were young pathology and illness progressed to a point where it could be identified on physical examination no matter how poor this method is, because people did not go to the GP that often and soldiered on, the pathology was florid and easy to see. Now that is not the case.
Also simply there were less things to do to investigate and treat illness in the past (No CT, no MRI, no angiography, no cardiac enzymes etc.), hence no possibility of ordering them and no need to know about them.
When you were young if a GP made a mistake you would be unlikely to know, now he or she would be likely sued. Defensive medicine is the phrase used.
Combined with less training and less time on the job results in disaster
These reasons and possibly more are the reasons you feel unhappy.
Consultants have also been 'specialized' simply because doing a few things well is better than doing many things badly.
As for pay. I would agree the salaries earned by GP's are ridiculous.

DP111 said...

"A" levels equivalent to "O" levels - it depends on which decade you base the "O" levels.

Anonymous said...

Many off the olden 'signs' of diseases either were only present when the disease was advanced and all to often used more of a medical "look what I know" form of ione upmanship than useful diagnosis.
As for lost skill - than God. The GPs in Australia used to create areas with no tonsils, appendices an even gall bladders.

john miller said...

"If confirmation was needed, the GP would take a blood, sputum, urine or stool sample and send if off."

At my age, they just ask for my pants...

Anonymous said...

In our local GP surgery, I can remember patients smoking - waiting seated in queue to see the quack. When you were marched in, there he was, smelling of booze and lighting up, he was a damn good doctor though God Bless his soul, always, peering down the oesophagus - made you say AH!

Anonymous said...

There is barely anything you can actually diagnose by looking at people's urine, tongues, eyes, ears or much else. The signs that are useful, like jaundice are obvious to everyone else anyway (not least the patient).
I realise you probably don't need to keep up with the journals but signs such as blue nailbeds have been closely examined more recently and they have been objectively been shown to be highly unreliable. Smokers corneas may well be yellow, I wouldn't know but "diagnosing" smoking isn't exactly a major priority for modern medicine.

As per the commenter above, the specialisation is helpful. We get through twenty cataract operations a day now - one surgeon, one anaesthetist. Thats five times as many as would have been done in the good old days when people were still wasting their time staring at piss samples.

Anonymous said...

"In our local GP surgery, I can remember patients smoking - waiting seated in queue to see the quack. When you were marched in, there he was, smelling of booze and lighting up, he was a damn good doctor though God Bless his soul, always, peering down the oesophagus - made you say AH!"

What's your point? What did he achieve looking into your mouth? I wager- nothing, even had he been sober enough to consider it properly.

Raedwald said...

I think the excellent and considered responses from the two doctors above actually help make my point; in the old days there was considerable reliance placed on the diagnostic skills of the GP, today there is not. In fact if NHS Direct could arrange appointments with a phlebotomist or the medical radiographer over the phone, one could cut out the GP altogether from the diagnostic process. If the GP's only remaining function is a sort of crude filter, shouldn't we be training nurses for this role instead?

Anonymous said...

No. Because while that would work much of the time, they wouldn't have the insight to rush someone to the cardiac lab when the patient has a 'sore elbow' but is grey-tinged and about to die of a coronary infarct. Would be like building a large project without a project manager. you can't just assume that someone will notice the wrong windows were shipped from Italy and then the whole sequence is screwed up. And the client- the patient- generally doesn't have enough insight to take over, even if he is a doctor himself.

Anonymous said...

One of the Doctors again.

An awful lot of what Doctors do could be done by a Nurse, indeed it is being done by Nurses for far less money.

But you do not know when you will need that Doctor and no amount of training, forms or protocols can change that.

The problem is, GP pay has made the potential errors of Nurse led medicine affordable in the long run and hence attractive.