Writing this column makes me feel like Coleridge's Ancient Mariner (I even have the authentic grey beard and glittering eye). My suave, well-dressed colleagues are minding their own business, strolling towards the wedding feast of their real interests – seeing patients, planning the next dawn strike on the NHS, the delights of the Back Pages, or the real pleasures of life, when I grab them by the arm: ‘Read this. It will change your life.’ Embarrassed, they do their best to shrug me off and move on without creating too public a disturbance. But then every so often the pleading becomes more insistent. ‘No, no, this is really important. You have to read it.’ Such a paper appears on page 503, exploring the events of the lives of people who subsequently committed suicide. As qualitative papers should, it describes a range of behaviours and events and readers will draw their own conclusions. The authors feel that some of these suicides could have been prevented by more prompt action from the GPs, but make it clear that, even among those who did consult in the month prior to their suicide, this would only save a small proportion of the total. Others conceal the severity of their illness from their doctors and their loved ones. But beyond the conclusions, the reason for recommending the paper is that the stories are so moving – tragic tales of inexpressible sadness, of stoicism and of the ordinariness of it all. It may not make us succeed in saving any lives, but I challenge anyone reading these accounts not to finish with a redoubled desire to do so.
This is one of a number of qualitative papers this month. On page 539 the message comes out of appraisal once again, that the effort to make it perform the disparate functions of education and licensing will not be supported by GPs. Worse, this study suggests that it will encourage collusion and reduce the opportunities that appraisal offers for reflection and subsequent professional development. The study from Northern Ireland on page 544 comes to the same conclusion. Meanwhile, the study on page 534 identifies the various barriers standing in the way of optimum treatment for patients with raised serum cholesterol (of which the problem of interpreting conflicting guidelines was one). The thought that application of incentive payments has encouraged practices to overcome the barriers need not reduce the value of the paper. The same conclusions can apply elsewhere and illustrates the range of problems that need to be addressed to bring about substantial change in clinical behaviour, and why simple interventions so often fail to do so. The study on page 522 comes to a similar conclusion, documenting the long-term fate of secondary prevention clinics set up for a major study 10 years ago. Many practices had not continued with the clinics, frustrated by the organisational, training, and physical space demands that the specialist clinics put on the practices.
The other side of this is, of course, that we all work in a social environment that influences patients in so many ways completely beyond our control. Sometimes it works with the grain of what we are trying to achieve, as on page 516 where the authors find patients (with some exceptions) tending to consult less for minor ailments. The study from Denmark finds that frequent attendance is related to living alone and being without work among men, but not among women (page 510). For UK practices contemplating GP commissioning, the study on page 529 provides some timely data: there is a wide range of referral rates between and within practices, and morbidity explains a substantial part of the variation. Finally, the longer term follow up of an earlier study of different decision aids on page 551 finds little to choose between them. More striking, several years after the initial intervention there seems to have been little reduction in the overall cardiovascular risk for these patients. Perhaps it is all a lesson in humility. As one of the people interviewed for the study in suicides says:
‘Mother never thought very much of doctors at all, you see. Very over-rated people, she thought.’
- © British Journal of General Practice, 2005.