The patients are not the problem

Dr Rant has been around for a few years now and has worked in many different settings. His great insight from all the places he has worked is simple;



"The patients are not the problem."



The scenery changes, the accent changes but the fundamentals of health and illness remain the same. A basic rule of good medicine is not to break rapport with anyone unless you really need to. The old rule, “Oh Lord, make my words as sweet as honey, for tomorrow I may have to eat them” applies here.

On Dr Rant we haven’t said huge amounts about patients, and we thought we should redress the balance a bit. This lack arises as on the whole we get on seeing patients day by day and as far as I can tell we do a reasonable job for them. (The Dr Rant team are not pathological caretakers (apart from dear old Carey Cardigan and are not after 100% satisfaction ratings.) My patients are a part of my life, and if I didn’t like patients I would be a sad doctor who should go and do something else.

Any job is a combination of satisfaction, salary and support and on the whole I currently have good levels of all of these. The medical dissatisfaction and lack of support arises from frustration with the NHS structures, not from the patients.

Patients are human beings. They have problems which emerge out of their lives and have medical, social and psychological components. As doctors we try and disentangle the threads, helping with medical intervention where it will help and with other suggestions if they might help. The old surgical maxim applies:

“A good surgeon knows how to operate. A great surgeon knows exactly when to operate”

As GPs we can open up old wounds in patient’s lives, or make new ones, or we can help things heal over. On the whole the third option is infinitely the most sensible.

We make errors of omission and errors of commission and our patients do the same. On the whole doctors and patients get on reasonably well.

Of every 100 patients I see, I find that about 90 are straightforward help seekers. Sometimes I can help them and sometimes I cannot but the basic transaction makes sense and the patient and I reach a shared understanding, which is a sensible route for both parties.

About 5 are medically complex: that is I have to think across many areas of medicine at once to achieve a sensible balance for the patient. This is the area of co-morbidity and GPs should be good at this. This is where my medical knowledge gets stretched, and where I and the patient learn new things.

About 5 are just flipping awkward- they are some combination of mess, chaos, illness and social dysfunction. They reject help, then they want help but won’t take any suggestion off me, they have very messy social (maybe criminal) lives, they are feckless, they miss multiple appointments, they behave badly for whatever reason. They turn a problem into a drama, and create a mess wherever they go. I think if I swapped notes with PC Copperfield we’d name the same names. The social workers would know them, as would the local magistrates’ court. The teachers would have excluded them.

The more experienced I get the quicker I am to put boundaries in on the flipping awkward ones, and give them “tough love.” There’s a way of handling the flipping awkward ones and as I get better at it I can sometimes enjoy the challenge they present.

A simple rule for heartsinks is that if my heart sinks when I see a patient then it’s probably my problem. If I find that all my colleagues have the same reaction to the patient then the patient has a problem. I was working in a small market town once and spent 30 minutes with an awkward customer (this was when I was much younger). The patients waiting for me got restive. However when they saw who it was who had held me back they said “Doctor, you poor soul. How do you stand seeing that person?” 10 minutes of free counselling later I had made friends with another patient…..who then got his problem sorted another day!

So to sum up, the impression of the Dr Rant team is that the patients are not the problem in the NHS.

The problems arise as the systems are not set up well to deal with patients, and for all the hollow talk of a “patient focused NHS”, the reforms currently being implemented look likely to give rise to ever poorer patient care. This is the tragedy of the NHS at present, and why Dr Rant and colleagues are so upset.