Personal Views: A foray into unfamiliar territory
Authors: Charles P Swainson
Journal: BMJ (2006)

I went to a GP surgery one day recently. Not as a patient, you understand, but as a visitor. I have seen my own GP only once in the past five years, for trivial complaints, and haven't visited a general practice to see how they work for 10 years. As the medical director of a large teaching board in Scotland, with responsibility for primary care as well as hospital services, it was time for me to learn.

I chose a practice in one of the most deprived areas of my patch. Car parking was easy to find on one of the streets around the corner from the practice. The reception area was nicely furnished and freshly painted, with signs clearly showing where to go and which doctors were consulting that morning. The receptionists were busy but polite and welcoming. I noticed that their desks had no telephones, so they were not interrupted and could deal with everyone almost as soon as they arrived.


The GPs were wearing chinos, open neck shirts, and informal shoes, and they looked, well, normal


The place was busy. Eight or nine patients were in the waiting room, and more were arriving all the time. The treatment rooms were busy with the nurses. There was a general air of calm and orderliness, in contrast to my last visit, which was to an acute admission unit.

I was shown around by a GP who had broken his holiday so he could welcome me to the practice. The rooms were all rather small and crowded. I was pleased to see a small research area with computers and the usual paraphernalia; doing high quality research in such an isolated environment must be challenging. The practice has a reputation for good quality research.

I was shown the computer system. When the doctor logged on to the system an in-tray appeared with messages, test results, and other information about patients. Doctors can quickly access a patient's record and annotate it with a comment on the results and any changes in treatment, and the in-tray was quickly emptied. Some of the contents of the doctor's in-tray were audit messages from one of his partners, who had been conducting an audit on patients taking warfarin. Comments provided direct observational feedback from one doctor to another about the danger of a drug combination, departure from the local formulary, and the wisdom of continuing treatment with the drug for more than the recommended time. The practice is proud of its record of clinical audit, and it was clear that the partners were accustomed to giving or receiving constructive clinical feedback. It is part of their everyday lives.

I sat in on a number of consultations. The first thing I noticed was that GPs dress differently. They were wearing chinos, open neck shirts, and informal shoes, and they looked, well, normal. They speak differently from hospital doctors; they introduce themselves by their first name! They converse with the patients, and medical jargon was distinctly absent. They listened. I was impressed that in a 10 minute consultation the GP I sat with would spend the first three or four minutes just listening. He got to the heart of the problem quickly, he established what the patient's main concern was, and he quickly established a pen picture of the patient's surrounding circumstances, other illness, difficulties with money, the problems of looking after a husband with dementia. It was just like one of those spare, simple Picasso drawings. Medicine here is clearly an art.

I didn't see anyone with a trivial complaint. I saw patients with major drug addiction, major alcohol misuse, severe hypertension complicated by polymyalgia rheumatica, type 2 diabetes, and gastrointestinal bleeding caused by steroids. I saw a possible case of acute Wernicke's encephalopathy in an elderly alcoholic man with a pronounced nystagmus, recent short term memory loss, and confusion. I heard a conversation between the GP and a twentysomething senior house officer in the acute admitting department at a local hospital. It took the GP six minutes to get through. The GP gave a succinct and convincing account of this possible case of Wernicke's, only to be subjected to a barrage of hostile questions from a doctor who not only would have been half his age but would have had far, far less experience. I cringed.

General practice is alive and well and in rude health. It delivers high quality health care to people who are really sick. It tries to provide holistic care that covers many dimensions of patients' experiences of their health. It badly wants—and tries—to link up with social care, welfare rights, and economic opportunity.

The coffee break was loud and cheerful and buzzing with anecdotes about the busy morning surgery, in which everybody had run late. But who cares? General practice is fun, and there is a great deal to learn.