How do GPs consult with patients?

#GPFUQ 34 How do GPs consult best with patients? The essentials are 1. Shut up and listen, 2. Care 3. Know something

#GPFUQ 35 What is the Art of GP Medicine? All of medicine minus anything that is evidence based

#GPFUQ 36 Are guidelines obligatory? No – just advice and not a guarantee of best outcome. But if you ignore good guidelines you need a good reason.

#GPFUQ 37 What's wrong with 'what’s the matter with you' medicine?  'What matters to you' medicine is more important.

#GPFUQ 38 Why do GPs need to be part of the community? In a community people know when you’re ill and they care if you die.

#GPFUQ 39 Do GPs have to be well rounded individuals? No, but they need to be part of a well rounded team.

#GPFUQ 40 Is continuity of GP care useful? The unique selling point (USP) of GP is longitudinal continuity of care that meets the needs of the patient

#GPFUQ 41 How long is a career in general practice? About 200,000 consultations. You can use them more quickly each day or more slowly over a 30 year career. You only have a finite capacity, use it well. When you have used up your supply, its time to change your job or retire

#GPFUQ 42 Are all General Practices dysfunctional? Possibly but some are much more dysfunctional than others.

#GPFUQ 43 What happens when you think it’s all going well in GP? It means that you havn’t been paying attention and havn't realised what’s gone wrong yet.

#GPFUQ 44 How do you recognise another bad idea in the NHS? The opposite idea seems just as reasonable and/or it's based on the ‘specific vagueness’ of a Govt policy.

What is GP wisdom?


#GPFUQ 25 What is real GP Knowledge? Information with experience, context, interpretation and reflection. Tacit knowledge is personal know-how, explicit knowledge is the evidence based medicine.

#GPFUQ 26  How do GPs survive complaints? Accept that it will ruin your day. Acknowledge and share the problem. All GPs make mistakes. Learn from each mistake, and avoid making the same mistake again


#GPFUQ 27 What is GP wisdom? The reward for a lifetime of listening when you really wanted to talk

#GPFUQ 28  How long does it take to become a wise GP? Less time if you know its unachievable, you just get smarter than you were yesterday because you learn from your experiences. Only the wisest and stupidest GPs never change. Mostly, you don’t discover any great truth just recognise your mistakes more. The more mistakes you have made the wiser you may be! To become old and wise you usually have to learn from being young and stupid. The opposite of wisdom is making the same mistake over and over.

#GPFUQ 29  What the difference between experience and making mistakes. Experience reminds you and makes you recognise a mistake when you make it again. Its inevitable that you will make mistakes – that fuels learning. It you keep making the same mistake – that’s incompetence.

#GPFUQ 30 Why do smart people do stupid things? We are overwhelmed by an illusion that influences our thinking and makes the nearest and easiest solutions seem the biggest and best options. This is known as ‘the hyperbolic discount curve’. We may be trying to make decisions without sufficient information, when we are distracted, or based on flawed assumptions. We need our wisdom to lash us to the mast and let us override impulses and compelling illusions and direct a different way of thinking and action based on life experience, self awareness, patience and choice. With increasing experience wisdom gradually governs our willpower. See also #GPFUQ 33

#GPFUQ 31 Can wisdom be taught? There is a faster way to be wise. Wisdom is way of travel rather a destination. Its always influenced by your age and experience. Asking the question – is this a wise choice is a good start.

#GPFUQ 32  What's the personal difference between success and failure? Success gives you a habit, failure gives you learning

#GPFUQ 33 What is gut reaction? That personal special sense that warns you that something isn’t right. This is really expert intuition – its nothing more than recognition of patterns. You may not be aware that you have recognized a pattern or something that doesn’t fit in the expected pattern but the mind processes more quickly than we can comprehend and if you’re aware of it you are alert to its warnings. There is a danger when you leap to conclusions that you have insufficient information to recognise a pattern but are influenced by something similar you have just seen..this creates the 'strong but wrong' gut reaction.

Whats the difference between change and improvement in general practice?

#GPFUQ 17 Why does so much change in NHS cause worse care? It creates a constant struggle against difficulties which would not exist without the change.

#GPFUQ 18 Whats the difference between change and improvement in general practice? Quality. If you want to improve, not just makes changes you must ask and answer the basic quality questions before you plan any change.

This is  ‘continuous quality improvement’. The five basic questions you need to ask (and answer) when you try to improve something are: 

1.            What are you trying to achieve?

2.            What do you currently know about the subject?

3.            How will you know if you have been successful? i.e What are the success criteria?

4.            What can you actually do (with the resources you've got) ?

5.            How and when will you continue this cycle of action, question and feedback?

#GPFUQ 19 What do you need in a good health service? Easy access, low cost and high quality

#GPFUQ 20  What should GPs trying to achieve?  Make your organisation provide higher quality at lower cost and make the practice systems better and easier to use. 

#GPFUQ 21 Who achieves high quality GP? The best practices usually have a mix of one or more of three cultures.  

1. The enthusiasts are the early adopters of new ways to practice. They are technophiles. There is usually a GP who looks for high quality care and efficiency. These enthusiasts find new ways to practice and often speak in terms of the time it takes to get something done. They are innovators and can change practice quickly and easily and stimulate practice wide improvement as change champions. 

2. The motivators put extra effort into motivating and enabling staff to play important roles in improvement efforts. Strategies include a GP promoting importance of new activities in conversations and behaviour, meetings to check feedback, progress and make plans, work with practice staff to select indicators for improvement and designed activities to achieve improvement, and quarterly half day meetings when the practice was closed dedicated to making improvements. These practices have more mixed feelings about software than the technophiles. 

3. Lastly there are the businessmen – practices take a business approach shaped by customer services and risk management. They organize special service in the form of focused management clinics, hiring staff as needed. Problem-focused clinics (e.g. diabetes, hypertension) are designed to provide comprehensive, competitive, guideline-adherent care convenient for the patient and ensure that the doctor has done everything possible to manage care. Lead doctors delegate care management responsibilities to staff and provide regular supervision, such as weekly care coordination meetings between nurses and doctors. They redesign delivery systems to support the special services. They conduct point of care tests and use in house lab so that test are available for the patient when they attend. 

A mix of all three works best.

#GPFUQ 22  Why do we need bad GPs? Look around if you can’t see any bad GPs maybe its you.

See also https://www.bmj.com/content/370/bmj.m3415/rr-2

#GPFUQ 23 How to make quality GP?  Improve all the time, define the problems, challenge others, share knowledge, respect others opinions.

These are the Toyota principles for creating  a high quality organisation? The culture needed promotes the organisation to:

Improve all the time; improvement is a continuous process, it's never complete. 
Define the problem rather than produce solutions; go to the source or find the facts. 
Challenge others; problems create the need to improve. 
Share knowledge; teamwork makes improvement more efficient and effective 
Respect other opinions; if two people always agree, one of them is superfluous.

#GPFUQ 24 Whats the reality of quality improvement? Constant effort with occasional success and frequent failure. 

Andrew Perrin summed up the reality of quality improvement when he was quoted in the New York Times talking about how his University planned to reverse grade inflation and make grades more meaningful.  ‘Its going to be modest and nowhere near enough to correct the problems, but its our judgment that it’s the best we can do now’. 

Are GPs specialists?

#GPFUQ 11  Are GPs Family Doctors anymore? More than 50% encounters are family orientated in some way, and family problems are discussed in about 25% of encounters .

#GPFUQ 12 What are the 4 essentials of being a GP? 1. good relationships with patients 2. skilled clinicians 3. a resource to a defined community, 4. being adaptable professionals

#GPFUQ 13 What’s the perfect GP? There are no perfect GPs or practices, just  imperfect ones. Some are more imperfect than others. You can you spot the differences if you know what quality looks like.  See #GPFUQ 4

#GPFUQ 14 What’s a modern GP need? Common sense medical wisdom, enjoys patients trust of patients and provides continuity with personalised care

#GPFUQ 15 What are the biggest problems for GPs?  Time & performance management. Having the time and knowledge to cope  with the increasing demands of patients for help managing their chronic medical conditions, their self limiting conditions and their anxiety and depression.

#GPFUQ 16   What's specialist about being a GP? You can classify your usual way of working using four assessments based on your skill level and personal philosophy. Do you have basic or advanced skills, and do you have a simple or complex approach to problems? You can usually assess yourself by recognising what sort of patient you are comfortable with, and what sort of feedback you get from patients, staff and other doctors about your performance. Depending on your approach you will tend to fit one of four distinct profiles. 
The basic simple profile is ‘the mechanic’. You have basic skills, dispense medications and direct advice. Your encounters are problem-focused, and at times you can seem abrupt, ignorant of emotional distress and not patient centred. 
The basic complex profile is ‘the counsellor’. You are bio-psychosocially orientated with basic skills and you offer advice. You explore the patients backgrounds, concerns and spiritual dimensions of illness in a patient centred fashion. 
The more advanced simple profile is ‘the investigator’. You are bio-medically focused but when the occasion warrants you have a repertoire of detective skills that allows you to sense patient cues of emotional distress that shed light on the patients condition. 
Finally the more advanced complex profile is ‘the healer’. You use the full breadth of bio-psycho-social skills taking into account cultural and existential dimension and integrate most aspects of care seamlessly. You appear comfortable with different patients in different situations. 
When you know your style, if you want to change it to treat the person, not the just the disease you will need consultation skills advice. This can be a difficult process but rewarding to cope with difficult consultations better.