From David Vincent in Shrewsbury: The doctor will not see you now

January 29. I cannot remember the last time I had a face-to-face conversation with my doctor. Probably in 2019, perhaps earlier.  To know how he and his profession are managing in the pandemic I turn to the new account by an Edinburgh GP, Gavin Francis.*

Francis and his publisher, together with the Wellcome Collection, deserve praise for getting the book out while the crisis is still in full flood.  Inevitably there is a cost in coverage.  The narrative ends in the autumn of 2020, before the third surge in infections and deaths.

Throughout Intensive Care, Francis is concerned with the consequence of talking with patients only by phone or through masked faces:

“As GPs we’re taught to value the subtleties of human communication – to glean as much from what the patient doesn’t say as from what they do say. As trainees we have to submit videos of our consultations to demonstrate how carefully we attend to body language, to silences, to the way patients hold or evade eye contact.” (p. 56)

My surgery is located in a nearby large village. In common presumably with all practices, its switchboard has been greeting callers with a recorded message explaining that only telephone appointments can be made; the doctor will then decide whether it is necessary to see a patient in the surgery or at home. If you stay online, you then get a recorded message purchased from some third-rate utility:  “Your call is very important to us. Please wait for the next available agent.” This week, however, there is an additional message which I encounter when I ring to renew a prescription:

“Our phone lines are very busy due to the volume of calls we are receiving about the covid19 vaccine. The NHS is prioritising vaccinating those people who experts have agreed would benefit from it the most. We will let you know when it is your turn to book you a vaccination. If would like more information about the vaccine, please visit http://www.nhs.uk/covid/vaccination. If your query was about the covid vaccine, please hang up now.”

So not even a someone to talk to on the other end of the phone. Rather implied censure for making the call in the first place. Clearly this is a surgery under stress. But it is possible to suggest another response which acknowledges that:

• receiving the vaccine is for vulnerable groups by a distance the single most important event, medical or otherwise, that they are facing;

• at this moment, potential recipients are being treated differently in different regions and you well may know of people in similar circumstances who have already been vaccinated;

• in so large a project there must always be an apprehension that as an individual you may fall through some bureaucratic crack;

• over your lifetime you have been used to treating your GP surgery as your portal for all health enquiries, and that being re-directed to an impersonal website offers little comfort.

In the concluding discussion to his book, Gavin Francis is preoccupied with the defects of non-face-to-face medicine, necessary though it may be in the crisis:

“As time goes on, and if telemedicine prevails, those relationships forged in person will become more remote, and the medicine GPs practise will become more perfunctory, based on the avoidance of being sued rather than on what’s best for the patient. Those conversations would be not ‘consultations,’ but triage, fire-fighting, damage limitation. It’s difficult enough to engage with the unique complexity of another human being’s suffering in ten or twelve minutes when sharing the same space, but on the telephone it’s near impossible.” (p. 191)

With doctors, as with so much else, the meaning of this pandemic will not just depend on the temporary expedients that are adopted. Rather the question is which emergency devices are rescinded the moment the crisis is over, and which are allowed to persist, whether out of inertia or institutional self-interest.

 * Gavin Francis, Intensive Care. A GP, A Community & Covid-19 (London: Profile Books and Wellcome Collection 2021).

from John in Brighton, UK: an email from the GMC – the General Medical Council

April 10. I readily accept that examples of “being desperate” for the man on the Clapham omnibus would pale into insignificance in many parts of the World. The inveterate smoker on a long haul flight or train journey (not me) or urgently needing a leak on the motorway and the sign you pass says “Services 5 Miles” (been there, done that). Or more topically as the curtain is soon to come down on Lent my current yearning for chocolate after six weeks abstinence – surely that’ll mitigate some of the corona pain that we’re all feeling. But then there’s Matt Hancock’s desperate need for more doctors as their numbers shrink thro’ ill health (including a few deaths) and the vast numbers of patients. There’s no point building giant Nightingale hospitals if you cannot staff them. I was positively reassured that it was only to be doctors within three years of retirement who would get the call “Your Country Needs You” but just replace Kitchener with Matt or Boris. Let’s me off the hook, no need to feel guilty. 

But stone the crows on the afternoon of 2 April an e-mail from the GMC arrives out of the blue to tell me that my licence to practise is temporarily restored and if I don’t opt out within three days my details will be passed to the health service. My heart tells me that this is an opportunity to do my bit, something that will make a difference and is urgently needed – I’d love to do it. My head tells me otherwise and it’s unsafe in two ways. Firstly I’ve just received another text to say I’m high risk and essentially housebound for twelve weeks so that alone kicks it into touch. Maybe I could act as a telephone doc / advice helpline. But more generically I haven’t laid a finger nor a stethoscope on a patient for over five years. Medicine moves forward fast, my abilities retrograde with equal haste. I’m sceptical that a short refresher would get me anywhere near back to speed. I’d be worried that I might be something of a potential liability and I know from personal experience if you do make a serious error the stain on your conscience stays with you to the grave. Even in these unprecedented times I question whether I would want to take the risk and who covers my indemnity? Sadly I’ve declined the offer. Sorry Matt.

There is a final irony to this. I retired a little earlier than planned because of the bureaucracy and demands of revalidation – a process to weed out unsafe doctors (not that I was ever convinced it could). Politically correct, reassuring to the public but we all know that Shipman would have had no trouble revalidating. Maybe I would have still been in a position to help if I had stayed on – press-ganged into early retirement ‘cos I eschewed the safe doctor assessment, unwilling to resume now because I don’t feel safe.