Most GPs I know pride themselves on being true generalists, and have gravitated towards this area of medicine because they enjoy the challenge and variety that comes with the territory. They also tend to value holistic, patient-centered care and the satisfaction that comes with long term doctor-patient relationships.
Inevitalby, though, each GP has strengths and weaknesses when it comes to their clinical expertise. For me personally, I’m very confident with women’s health, pretty good with infants and neonates, comfortable with suturing and minor procedures, but much less assured when it comes to men’s reproductive health, elderly patients with complex mutli-comorbiditiy, and skin cancer checks, for example.
I’m not overly concerned by this, and nor should my patients be. I feel that I’ve got enough of a grasp of the basics that I can at least make the first steps towards investigating and managing pretty much any presenting complaint, and am happy to do some further research, “phone a friend” or refer on when it gets beyond my capabilities. I’m also resigned to a life time of “upskilling” and “continuous professional education” in order to keep filling in gaps and rounding out my clinical knowledge.
The question is: Are GPs obliged to cover the full spectrum of health and illness of the entire population? Or can they chose to limit their own scope of practice?
For example, if an individual doctor is really really great at musculoskeletal medicine, but hates doing mental health and women’s health, could they chose not to see any mental health patients? Could they refuse to do pap smears? And if so, how do they communicate this to their patients?
This question was prompted by a recent discussion I had with a good friend of mine, who has taking the brave step of setting up his own practice, where he is currently working as a solo GP. He’s considering this very thing in his own practice and was interested in my opinion.
His rationale is that if he is not very strong in a certain area of medicine, his patients are better off seeing someone else from the outset who is. He’s also concerned about the risk of burnout from spending large chunks of his working life trying to manage patient conditions that are out of his comfort zone and that he finds professionally unsatisfying. He’s now decided to advertise on his website and printed information what he will and won’t see, and feels like a big weight has been lifted off his shoulders.
Although I can understand the logic behind that decision, I do feel somewhat uncomfortable about it. My personal feeling is that as a GP, my patients should be able to come and see me for ANY reason, without fear of being turned away or getting the impression that “it’s not my problem”. Philosophically, I think that my patient’s problem is my problem and my role is to walk beside them, do what I can myself, and then help them navigate whatever other health professionals or services are required to optimise their health and wellness. I worry that patients would feel, at best, mildly annoyed, and at worse abandoned or even stigmatised if their GP wasn’t willing to even talk about some concerns that were important to them.
At the same time I acknowledge that none of us will ever know it all, and that we may not always be the best person to help our patients with their particular problem. Luckily, I’ve always been in practices which are big enough so that usually one of my colleagues will have the skills in a certain area and we can all ask each other for advice. I know not all practices have this luxury.
So I thought I’d put it out to the collective wisdom of the internet to see what others opinions are about this. Am I being overly idealistic? Is it ok for a GP to limit or exclude some types of presentations? What do you think would be the risks or harms of this strategy? Or would our patients in fact be better off if we all limited our practice to the areas that we were really good at? And would our own well being and job satisfaction be better? Is it different for solo vs group practice? Small country town vs inner metropolitan? Do we even need to be having this discussion or is the world big enough that everyone should practice how they want and let the patients decide?
I’m really interested to hear your thoughts in the comments below, or tweet me at @nomadicgp.
Featured image: Illustration by Jared Rodriguez https://www.flickr.com/photos/truthout/3901813960/