Cathy, Liam and Todd were all looking for work experience to strengthen their Ucas applications for medical school, so I invited them to spend the tail-end of their summer holidays observing what we get up to in the practice.
I was interested to find out what they knew of how we go about diagnosing things. Todd (who has experience of being a patient with an unusual condition) made an attempt, straight away citing blood tests and scans. Cathy and Liam were as clueless as I had been at their age. So I introduced them to the time-honoured hierarchy: history first; examination next; only then investigation.
For such a small word, history encompasses a huge amount. Doctors start by finding out what symptoms the patient has been experiencing: when and how they started; how they’ve progressed, factors that worsen or relieve them; other symptoms that are associated. We probe the patient’s previous illnesses, diseases that run in their family, what medications they’re taking, their lifestyle. “About 80 per cent of the time,” I told them, “once you’ve taken a good history, you’ll have the diagnosis.”
The sixth-formers listened as I made calls to patients on speakerphone. At the end of each, I talked the students through the key points in the history that had steered me towards one conclusion or another. I also highlighted the reasons for inviting in those who needed to be seen face-to-face. “Examination helps clarify things maybe 20 per cent of the time,” I said. “And sometimes it’s vital for gauging severity. The same is true of investigations.”
I got them doing blood pressures. They came with me on home visits to some of our complex housebound patients. They watched me perform a minor operation under local anaesthetic; the blood, coupled with the stark clanging of surgical instruments on the metal trolley, caused one of them to faint. I reassured them it will happen to most of us at some point.
I was curious, though, as to what they thought about this new telephone-first version of general practice. There’s a widely propagated myth that Covid brought it into existence. In fact, it pre-dates the pandemic, driven by companies such as AskMyGP and Babylon Health, which have been turning traditional NHS practices into remote-access services for at least a decade – a trend strongly encouraged by the former health secretary Matt Hancock. Pre-Covid I had resisted the change: I like to have patients in the room on at least one occasion, partly because of the subtle information I can gain, and partly in order to establish a rapport.
Covid turned the rest of the UK’s traditional general practices into remote-access services over the space of a few weeks at the onset of the first wave. Despite my scepticism, the pandemic has taught me that most follow-up consultations, and a good proportion of initial assessments, can safely be undertaken by phone as long as one remains vigilant. Contrary to the fulminations of various columnists in the right-wing press recently, our patients certainly don’t want to go back. We undertook a sizeable survey this summer; the majority said they preferred to continue the “phone first, come in if necessary” model, which they generally find so much more convenient.
Neither Cathy, Liam nor Todd seemed to think there was anything at issue with this new way of working; all three belong to a generation for whom it is normal to conduct much of life virtually. They impressed me, though, with the strength of their desire to care for others and to make a positive difference in the world, and with the intelligence and maturity they brought to our discussions about ethical issues and clinical dilemmas. It will be fascinating to watch how this next generation preserves the core values of the profession while the way medicine is practised evolves ever further through technological advance and cultural change.
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This article appears in the 15 Sep 2021 issue of the New Statesman, The Fateful Chancellor