Friday, 25 January 2008

The future

The good news is that I am committed to writing this blog for another year. The bad news is that the material will then dry up.

I had my annual appraisal this morning with an old friend. Martin was in the year above me at school, but I only really got to know him during our time together on the local Vocational Training Scheme (for young doctors training to become GPs). I was happy to remain a simple trainer but Martin rose to the giddy heights of Course Organiser. He has always impressed me by his kind-heartedness and dedication. He is from a medical family and is now the senior partner in the practice where his father was senior partner before him. Although the patients are mostly from deprived council estates, many hospital consultants choose to register with the practice which speaks volumes about the quality of care and the dedication of the GPs.

I thought he looked a little tired and careworn. We discussed the future of general practice, which looks as though it is going to change markedly. Our workload has increased considerably over the past few years. We now do a lot of the management of chronic disease that used to take place in hospital out-patient clinics, and are doing a huge amount of public health work, screening treating and monitoring heart lung and kidney disease. All this is in addition to our traditional work of dealing with the new symptoms that bother patients, explaining and interpreting what is going on, doing terminal care, and generally being kind. Our days are long, busy and stressful, so working extra hours in the evenings or weekends really is a big deal for us. Our practices are mostly too small to allow the doctors to work shifts to cover long periods of time.

There are a large number of young GPs coming through the system and most of them have never been a partner, taking the risks and the profits of our small businesses. Instead they have been employed by practices as salaried GPs. I think that the practices that exist at present will gradually be replaced by large “polyclinics” run by large private sector companies, employing numerous doctors nurses and other staff. This will not necessarily be a good thing for patients. You might be able to get an appointment at a relatively convenient time, but this would undoubtedly be with a nurse in the first instance. If your condition were deemed severe enough to warrant seeing a doctor it would not be with “your” doctor who knows you and whom you trust. It would be with someone you might not have seen before and might well not see again, who could well be efficient but might not have a lot of commitment to you as a person. The “doctor-patient relationship” would be just a duty owed during a ten minute encounter rather than something of value built up over time. It is hard to see how doctors would take an interest in and responsibility for the ongoing welfare of individual patients, and there could be less kindness shown. Visits that were not strictly necessary would not be done, hands might not be held as often or for so long. Or so I fear.

Martin was very supportive and encouraging (as I had expected) and, bless him, he had read the entire 100-page print-out of this blog. One of the items in my “Personal Development Plan” is to continue to write it. We didn't put much else in the Plan because I have decided to retire as an NHS GP in March 2009. As I hinted back in August I am going to move to France and “live on my wits”. I should be able to live on the pension I have built up, and may or may not supplement this by doing a part-time job once over there. I shall be sorry to leave Martha and my other colleagues, and I shall miss many of the patients. But I will not miss the stress. Myrtle perceptively said that my love affair with the job has gone. To me it seems that I have worked dutifully at school, at university, during house jobs and GP training, and then for over two decades as a GP. Back in my training days, a hospital consultant whom I very much admired said “the danger of this job is not that you might kill a patient, it is boredom at thirty”. He was some twenty years out, but his judgement was otherwise sound. I think I ought to do something else now, or rather in fourteen months' time.


Mousie said...

Your retirement will be a loss to the NHS, to general practice and to the blogging world, but of course, I wish you very well.

In the meantime, however, I shall find some consolation in enjoying your next fourteen months worth of posts!

Anonymous said...

There goes another dedicated and gifted GP, ground down by the system.

The BMA is trying to stand up to the government's changes from personal family doctoring to polyclinics but is being shouted down in spin about lazy greedy doctors. Your blog has opened up the surgery doors of so many GPs who aren't like that at all but are permanently tired, worried and depressed by all this negativity.

From what you say about how long you have been working you must be about 50, so your patients and the NHS have lost a great doctor ten or fifteen years before time. What a shame.

However I wish you joy and happiness and an escape from stress. Meanwhile may the thought of future freedom lighten your heart!

Elaine said...

I cannnot say better than the last two posts.

However, some of what you foresee as the future of general practice is here now; before I moved to this town I was registered with a gp, with whom I developed a good relationship and whom I trusted - this was helped by the fact that when I needed to see a doctor, I usually saw him.

Now that I have moved, I am registered with a practice, not a gp, they pride themselves in keeping good notes, but I see a different doctor each time. While I have no complaint about the medical care I have been given, the trust has gone and there is no real relationship with any of them

This has left me feeling somewhat vulnerable.

julie said...

While I echo the sentiments of the previous comments I think there is something in knowing when it is time to get out. You could stay, but if you are unhappy then it will affect the way you do your work and that will affect your patients. I have worked with too many people who I would describe as 'retired at work' and people begin to forget the caring person you previously were. The other thing is that while life expectancy increases, and of course you can make those lifestyle choices you never know what is round the corner. I only have to look at my 46 year old brother in law sitting in a wheelchair with motor neurone disease to know that.

The Shrink said...

At least your appraisal meeting was useful, in deliberating the true issues of your ongoing practice and in generating a plan you're happy with.

Hope you can enjoy the next year all the more, for knowing there's an end in sight, so feel less fraught and frazzled since you're not floundering forever now!

The Little Medic said...

All the best for the next year or so then enjoy your retirement! :)

Anonymous said...

Please don't give up blogging. Living on your wits sounds really interesting :)

I find I'm not too worried about seeing the same doctor every time. When we first joined our current practice we allocated to a doctor and then found we were obliged to see him unless it was an emergency. Thankfully they have since relaxed that. There is a stage between emergency and being prepared to wait three weeks.

cogidubnus said...

Whilst feeling sad that the NHS is to lose such a caring GP so much earlier than iy normally would, I cannot blame you...

Whe all is said and done, we work to live, not the other way round, and if this means you get to spend many more happy years in an active retirement, (rather than plodding from work into relative infirmity like the rest of us), then good luck to you..

I too look forward to the next year or so of blogs though!

cogidubnus said...

I knew it...I knew I should have checked for typos, but did I? Did I b*ggery...just clicked the button...

mutter, mutter, mutter....

Disillusioned said...

Sorry you have decided to leave - though I agree that it is probably the best thing.

I feel myself very lucky to have a GP in my local practice whom I trust greatly. There are other GPs there, and I am happy to see most of them for most things - but when I comes to discussiong my depression / anxiety I am reluctant to see any other GP, having had a couple of less helpful experiences in the past. The relationship with a good GP is really important, I think.
I wish you an enjoyable last year of practice.

Anonymous said...

I entirely echo Mousie's words.

Here's to the future, Doc Brown and long may your love affair with life continue, wherever you are!

Your insight is truly inspirational!

Anonymous said...

This sounds like a really positive, and promising, plan. I hope it works out well for you. And I look forward to reading your future GP posts.

I can remember when I finished my career, rather abruptly, some years ago that one of things I really regretted was missing out on seeing people, visiting places, and doing things "one last time". Somehow, however much I disliked some of the regular features of my work, such as getting up at the crack of dawn to drive long distances to participate in meetings of questionable value, I would have liked to have experienced them just "one last time". I imagine that knowing I would never have to do so again might have enabled me to look at the experience in a different way, to see different things in it, maybe even to gather material for my memoirs. You will be able to do all that, and effectively write your memoirs as you go along if you mange to keep up the blog.

So all in all it sounds like a pretty good plan to me, although I might have given it just a bit more time - you're going to be busy!

Dr Andrew Brown said...

Thank you all for your posts, which are (as usual) delightful. I've been agreeably surprised by the quality of the comments I have received on this blog. They are almost all supportive, interesting and insightful.

I am trying not to feel guilty for "abandoning" my patients, but slogging on while increasingly unhappy would be good for neither me nor them.

I have lots of things that I want to do outside medicine and I don't want to drop dead of a heart attack at 60 just before I retire, as a local GP did recently. I suspect that I will end up being of use to people, it will just be a different group of people and in a different way.

Wise old woman: I like your idea of gradually saying goodbye. I shall take a lot of photographs and, as you say, this blog will form a sort of memoir. Many of my patients will be disappointed that I am leaving, and I am not looking forward to dealing with that.

PhD scientist said...

As a scientist and teacher of medical students, and the other half of a hospital doctor (and thus friend as well as professional colleague of various others) I often wonder about this aspect of "doing the same thing for 20 - 30 - 40 years", Andrew.

After 20 years in my own job (University bioscience lecturer) I definitely have the feelings of "same same same, can I keep on doing this another n years", especially WRT some aspects of it. The saving grace of academia, and the difference from the professions, is that you have a fair degree of "operational freedom " (though increasingly curtailed) and can always find new or at least slightly different things to do, like taking on more teaching rather than research, or vice versa, or writing a textbook, or even the dreaded administration. Sometimes the attraction of switching tacks is simply to have to learn to do something new, rather than keeping doing what you are good at bit a bit bored with.

Anyway, I really do wonder how doctors, especially GPs, manage with the routine, and I even sometimes try and interest the medical students in thinking about this aspect of their future.

I have always suspected that early bail-out from medicine must be common when people "run out of steam". Do we know if it is more so in GP (where presumably people qualify younger, on average) than for hospital consultants (who in most cases would only reach that status in their mid-30s?)

I also wonder if "medical 20 yr itch" was less of a problem in times past - when there was perhaps less pressure, and also when it was probably easier to move to a different type of medicine - although I base this view largely on reading the brief obits in my wife's BMJ and seeing how many of the older doctors obituarized had tried various different things, or changed tack in their 40s or even later. Of course, these days in medicine it seems people get "tracked" into one or other specialist path earlier and earlier, and the large amount of training and qualification-stacking necessary for any specialty must mean that changing later is very hard.

My mind has been running on such things lately partly because my wife, who has spent 10+ yrs in hospital medicine but has only once been on a specialist training scheme (she changed her mind about the relevant -ology), is contemplating quitting medicine for good a couple of years shy of 40. Partly, I guess, lack of prospects beyond career grade jobs and distaste for shift work with a family, but also a weary sense of "been there, done that, got the postcard" about hospital medicine, whereby I see in her some of the same sorts of ideas you have been blogging about.

Dr Andrew Brown said...

PhD scientist: thank you for your thoughtful and helpful comments.