During a sabbatical in 2004 I transcribed qualitative interviews with 19 of the GP registrars (GPRs) I had trained from 1983–2003. Among the themes arising, we talked about secrets encountered during the training year. These might be secrets we shared, secrets that they kept from me, or secrets that were kept from them.
Registrars recalled various ‘secrets’ in the practice that they had become aware of — such as a problem partner, illness in a partner's family and marital discord. One disclosed just how another GPR had managed to obtain such an excellent reference from her previous consultant.
THE 1:1 TRAINING RELATIONSHIP CAN BE VERY PERSONAL
‘You read me like a book. There was absolutely nothing that I could hide from you.’
‘There were secrets … that we shared that we didn't share with anyone else.’
PARTNERS MAY NOT WISH TO DISCLOSE PRACTICE FINANCES, WHICH CAN SEEM A GREAT SECRET TO REGISTRARS
‘Seeing the accounts was an extraordinary event. Finding out that you earned quite rightly four [sic] times what I was earning, and were paying a lot less tax than me, and the fact that you were actually being paid to have me there. That was a shock; I was naïve in those days. Suddenly realising the commercial aspect of it all; yes we all have noble causes but there are fees and bills to pay. That was quite a defining moment.’
‘I didn't have any insight at all into how partners actually conducted the business. I remember at practice meetings there was a slight darkening of the air, and the assistants would become hushed and then rather soberly retreat and suddenly the meeting would happen; to go back to mysteries it almost feels as though the practice meeting is the holy ark, I've seen it paraded about but I've never actually seen what is within the ark.’
‘[I missed out on] the partners' [financial] meetings … I would have loved to know what went on … I wasn't a part of that club.’
ONE REGISTRAR DISCLOSED A SECRET YEARS LATER …
‘When I was a trainee I nipped home one weekend and Mrs Thatcher was coming to my parents' house for luncheon, and I felt that was top secret and I daren't tell you at the time, I'd be lynched. She'd just moved to Dulwich and wanted to meet some local people. Dennis came too, I remember we poured him about three or four very stiff gin and tonics in the hour and a half they were there.’
THE GPR AS MEDIEVAL APPRENTICE
‘It felt as if I was being trained in an art and a craft, almost as a stonemason might have been introduced into a guild in the Middle Ages. That probably does reflect that medicine does have a kind of a mystery to it. I felt as if I was being initiated into the inner workings of medicine at the same time as learning a lot of clinical skills.’
TRADE SECRETS WERE RECALLED
‘A neighbouring doctor told me “Don't sprint on the marathon, my boy”’.
‘With difficult heart-sink patients, you told me once when they really got to you, you wrote their name down and you put it in a drawer, and that was your ultimate sanction, … and I thought that's a good use of humour and voodoo.’
ONE REGISTRAR GAVE US SUPPORT DURING A DIFFICULT TIME, AND KEPT A SECRET
‘I found myself in a storm within the practice and somehow I felt both at the centre of it and excluded from it at the same time, clearly the partners had to deal with it and it wasn't my business …’
‘I liked the way you guys dealt with it, you had a very difficult job … I felt that my only role was to be confidential, the most important thing I could do was not talk about it, even to my GP young principals …’
NEW ARRIVALS MAY INTUIT INTRA-PRACTICE TENSIONS
‘It's like being billeted with a family as an au pair, and if you come into a family that is rowing or dysfunctional you can intuit that. There are issues there, I think, for any training partnership to realise that registrars will want to know quite a bit about the dynamics within the group to allow them to settle down.’
PROBLEMS WITHIN SUBSEQUENT PARTNERSHIPS WERE OFTEN ENCOUNTERED
‘We've had two very serious problems … too sensitive to discuss; most practices including ours have had serious difficulties within the partnership which are very difficult to address.’
THERE ARE SKELETONS IN THE CUPBOARD IN OTHER PRACTICES
‘Every practice has skeletons in its cupboard.’
‘Every practice has had its problems in the past that they don't like talking about, quite rightly.’
‘Secrets, and the unmentionables that you eventually do find out about, and how to perhaps find out about them more quickly when you think about joining a practice.’
‘The secrets help define where the lines are drawn, and what's right and what's wrong.’
‘They're an important part of the practice. Why the current people are there and the ones that aren't, why they've left.’
‘It made me realise how you all worked and just what your standards were and some of the dynamics.’
Every practice has its own skeletons in the cupboard, several opined. Partnership meetings and practice finances were described as a great secret, a Holy Grail. As described in other surveys, the financial side of practice was something many registrars felt subsequently unprepared for.1
Part of growing up is becoming aware of the family secrets. Apprenticeship involves learning trade secrets and how to practice the discretion described in the Hippocratic oath. Knowing what the secrets are defines the values of those who are keeping them.
Learning about a practice's secrets — absorbed informally rather than through formal education or reading — enables GPRs to become part of the practice's (and the profession's) network of confidentiality, trust, and mutual support.
Notes
Funding body
My prolonged study leave was supported with an RCGP scientific foundation grant (SFB 2004/01)
- © British Journal of General Practice, 2005.