Different folks, different strokes

What is a good GP? Most GPs are professional and medically competent, so what makes a really good one? It’s hard to know, because we don’t see what our colleagues do in their rooms.

Imagine you can sit in, unnoticed, on different GPs’ consultations. I think what you would find is a lot like the following.

The young Indian GP holds herself with unflustered dignity and, when she shifts from English to Hindi, the old man with her stirs and smiles. Her patients love her.

The young GP multitasker can simultaneously produce a script for cardiac drugs, look up HealthPathways to check anticoagulation six weeks post-myocardial infarction, text a thumbs-up to the nanny and engage the patient in a conversation about his erectile dysfunction. Her patients love her.

The old Pākehā guy in his jersey and worn leather shoes isn’t so au fait with HealthPathways, but he has seen so much stuff, so many diagnoses so many times, so many things that aren’t diagnoses, so much of the pain of life, that he’s a walking guideline for what really matters.

The young ones aren’t impressed because he hasn’t mastered the “they/them” pronoun, but he has lived through the diminution of the pronoun “he”, so he’s phleg­matic about change. His patients love him.

The Chinese GP is speaking in Mandarin. He is very animated, explaining the limita­tions and workings of the New Zealand health system, so as to reduce unrealistic expectations. The couple nod intently and smile. His patients love him.

The young whippersnapper, straight from hallowed school and home with pool, wears a pricey but casual floral shirt. He is a brainbox, that’s for sure, he doesn’t need HealthPathways because he has looked once and it’s all in his head.

He can’t understand all this fuss about the 15-minute appointment, he can detangle complexity in a nanosec­ond, bring it on. He’s better at complement than compli­ment, and his patients love him.

The woman in her late 50s is looking a bit frazzled. She was brought up in the 1980s’ “Girls can do anything” decade and has spent her life doing everything: running practices, college faculties, playcentres and doctors’ orchestras and, in between, she had five kids and wrote the first HealthPathways. She’s heading for a gong, that woman, and she runs her consults like you would expect: efficient, pragmatic, not too much nonsense. Her patients love her.

The Māori GP walks into the consult, hugs the patient and kisses her cheek; they share a whakapapa. There’s a lot of chat and laughter like a soft circular dance is being performed. His waiting room is full, but waiting is okay. His patients love him.

The power-broker GP, like the ones you read about in New Zealand Doctor Rata Aotearoa, seems to spend most of the consult talking about politics and tractors while typing loudly into his computer, but somehow pulling it all together at the end. He even raised an eyebrow in solidarity when the guy mentioned “trouble with the missus”. His patients love him.

And what would you see if you came into my room? I confess, often a lot of laughter. And I sure need Health­Pathways, because I can’t remember half of what I knew and what I did know is now not quite right. But I seldom look it up because I always seem to sense something else that deserves my attention, like yesterday, when a patient had a simple, benign spot and just as I was thinking, “yay, a catch-up appointment”, she slipped in the word “husband” ever so quietly. I just couldn’t ignore it and so we went to the trauma of his car accident, the ambulance and the intensive care, which all lead back to his drinking and general unhappiness. And I am supposed to walk her out of the room to do a warm handover to a health improve­ment coach she has never met, but I can’t find a moment between tissue deliveries to orchestrate such a manoeuvre.

Yes, I run behind, but I am happy to see all the patients no one else wants, to take the time to understand what ails them and, even if we never work it out, it’s the process that counts. They say my patients love me but, even if they don’t, I love them.

And I’m not going to always be right for them: I’m only human.

What troubles me is that some GPs are seen as better and more valuable, and this “better” is increasingly about external performance measures: have they harassed all their smokers, CV-risk-assessed everyone to death? Or, doctors are defined as “good” when they keep to time, as though seeing everyone in 15 minutes is a surrogate measure of effectiveness.

We are understaffed, under pressure and underfunded, but financial and performance targets should not define us, nor divert us from what really matters. General practice is full of important and mysterious transactions that defy a measuring stick.

I know that “their patients love them” is a sort of embarrassing and grandiose idea, but there is a truth in it. There is something important in there about trust and safety, and being heard and understood, that is the essence of what has to happen, before we can hope to improve any health outcomes.

The vast majority of GPs are sound and safe and professional, but beyond that, they are very different, and all these different ways are good.

Patients find the ones they love because they know that matters.