Thursday, May 17, 2012

Bloody GPs...


I think there is probably something wrong with me. I am not sure why but somehow I have yet to master the art of saying "Sorry can't do that". A few months ago, I bump into a bubbly energetic brunette while doing a teaching session...turns out she was one of the GP educators, her name was  Lois Bowd (damn, don't they look young nowadays!) and she wondered whether I would be keen on doing some teaching for GP trainees. I could clearly hear in my mind the words..." Partha, say I will look in my diary, say No, say I will have a think"...so naturally I came out with those immortal words..."Oh yes, would love to". Damn...suckered....again! Intriguingly, a week or so later, a Respiratory colleague asked me to swap an on call which I couldn't do, as I had committed the day to teaching. His comment? "Teaching bloody GPs,eh?"

So yesterday...that's what I did...a whole day of education for GP trainees in their formative years..helped, again, by those wonderful folk I work with...a dietetic colleague, podiatrist, nurse specialist...all there..trying to help pass on the knowledge which could help patients. And you know what? I really REALLY enjoyed myself! This was a whole day with junior docs who were going to be the workforce of the future, the workforce who would take the brunt of the expectations of the public, deal with the impending challenges....and what was striking was the refreshing lack of cynicism.In the audience sat folks I knew, folks who were junior doctors doing ward rounds with me...and they knew what I did, what I stood for.There was Laura, there was Nina...trainees I would give my right hand to be hospital doctors...but you have mixed feelings about that.Partly sad that such trainees chose not to do hospital medicine, but partly delighted that the first line of contact for patients were replete with some of the best trainees.
Let's face it, we need to seriously look at the workforce balance. If we are facing the reality that most patients need to be in primary care, then primary care training has to change. Due to the usual passion and drive of Clare Gerada, the pugnacious RCGP chair, finally a 4th year training haw been agreed and good on her for persisting with that! The outline she has given as to what the 4th year training should look like is also sensible and with a clear eye on the future. The challenge of the NHS lies in multiple disease management, not singular ones and say it softly, but do say so with conviction at least...this country needs more generalists and better trained generalists at that.

So where does that leave us, the diabetes specialists? Well I suppose you/I/we can make of it whatever we want of it. We can sit down, cry over a beer, curse those "bloody GPs" for mismanaging patients...or we can still and enjoy that beer while being part of the new revolution. Hang on...did I just hear someone say "but we do?"....ok...so question for those "seen-it-all-before" brigade...how many of you have formally approached your local Deanery, or the RCGP offering your specialist centre as training venues for the GP trainees? How many of you have said "come to our preconception clinics, pick up tips what to say to women with diabetes"....so that when those trainees are on the coal face they can apply them in reality? I will bet my shirt it's a number close to zero...but hang on Partha,I hear some say...we have done some guidelines, we have done some leaflets..we have put it in the post, emailed then...what do you mean we haven't cascaded knowledge? How very dare you challenge our educator status...We have sent a pigeon from our castle carrying our word to those minions in the village..it will work, it has to work...why wouldn't it? 

And I come back again to what we as specialists can do. Teaching or educating is a skill. Just because we are Consultants doesn't make us all fantastic trainers, it's a skill we need to learn and acquire. Hands up how many of us have undergone formal training to educate? Well...if one of the major roles of a diabetes or chronic disease specialist is to teach, then it's a bit odd that only a few of us have done this,isn't it? Standing behind a lectern and reading through your PowerPoint slides does not make one a good teacher...it's actually very boring and as a trainee, usually that involved me sloping off for a beer, just to avoid falling asleep! On the other hand, get me to listen to David Mathews, Edwin Gale, Jiten Vora...you know what...the beers can genuinely wait. Not all of us have natural flair to teach, so shouldn't one of the aspects of our training include being how to be an educator?

So let's think outside the box, shall we? Let's think what clinics we run that would/could be useful for our primary care trainees? Let's be rational about this..no point in getting them to an antenatal diabetes clinic ( as such patients will continue to be under specialist care) but surely there's mileage in a preconception clinic ( to advice the young woman with type 1 diabetes), surely benefit in showing them the intricacies of a foot clinic, what the end results are if early pick up is not done, how about low clearance renal clinic to understand which drugs causes hypos and why, what about an adolescent clinic..just to showcase the essential difference between the physiology, challenges and management of Type 1 and type 2 diabetes..better than any PowerPoint presentation....think different guys!! If we want to make patient care better, asking all patients to be sent to us is an unsustainable model. Rather support your primary care colleagues, help in their training so the right patients are picked up, the right patients get appropriate specialist help.  We cannot sit back and watch it all go past us and then complain when someone else does it for us.

I have said previously and continue to say how incredibly lucky I am. I am surrounded by incredible colleagues, specialists, primary care, nurses alike. I have been fortunate to have met Lois Bowd and Simon Tricker who are keen to help facilitate this, am fascinated to have met Mark Coombs, Andrew Holden, Sue Crane..all Gps engaged in training...who appreciate the knowledge gap and are keen to improve things. I also do not believe for a second that I work in an oasis of excellence and firmly have faith that such GPs exist everywhere...it's up to us to extend that hand and not be worried that sharing all this knowledge will "lessen our work load".
From August, we are ready to open our specialist centre to GP trainees in our area to sit in on specific clinics which Lois and Simon have felt were appropriate and would help in day to day practice. What stops anyone else from doing that? Did I hear someone say "will we get paid?" Instinctively I would say "get a life..aren't you doing this for the patient at the end of the day?"....but for the hard nosed business focussed ones..here's my tip...why don't you have a cost neutral arrangement, where in return for GP trainees attending your specialist centre, the specialist trainees spend time in GP surgeries understanding the pressures of a diabetes practice nurse, the pressures a GP lead has with their QoFs etc. Our trainees need to learn too, get trained for a future where they will be advising GP surgeries on a regular basis..so why not give them an understanding of how GP surgeries work? Training them for a job which may not exist in the future is not good training really, is it?

So there we are..some ideas of what we can do to improve the face of healthcare training. Try to get the primary care trainees in...get our trainees out...and no...you don't need anyone's "permission" to do any of that....you just need to find others who share your vision, will and endeavour to champion the cause of education. Step out from behind that lectern, ditch that PowerPoint....use your flair, show that passion which made you a Diabetologist and believe me..at the end of it all, there will be a rapt audience who will take away something from that, something not as dry as the nth guideline, but something personal...for example...diabetes was, is and never will be about population based targets...it always will continue to be about individualised care. The 91 year old in a residential home does not deserve to be given a tablet induced hypoglycaemic event...just because a target has to be attained or a guideline "forbid" you from thinking of a safer option. If as a community we want to change that, then go and spread that message, not simply nod your head in disapproval at the "bloody GP".
When you are facing an avalanche, you put your faith and strongest bricks in your first line of defence...and those bloody GPs are exactly that. Step away from the shroud waving and stand next to them....it's going to be one heck of a "party"....make sure you don't miss out. 

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