Hummingbirds and Foxes

GPs PRACTISE ON THE THRESHOLD

A hummingbird is a specialist, highly adapted to hover in front of a flower and extract nectar from it. It does this extremely effectively, and looks amazing doing it, but is limited to a very specific setting in which its adaptations will work. A fox, by contrast, is very much the generalist, at home in a variety of settings, and particularly able to exploit the opportunities that our modern urban environment offers an omnivorous species. Foxes are liminal, scruffy chancers sneaking around among the dustbins under cover of dark.

GPs are liminal too, practising on the threshold between the medical and the everyday. We rarely dazzle with our clinical acumen. Rather, we help our patients to negotiate the gloomy landscape of ill health and make good decisions when there are no perfect ones, sharing with them the uncertainty of the world outside the guidelines. There is much well-intentioned guesswork, and experience is measured in lessons learned from our mistakes. By and large, patients are looking for someone they can trust to do their best, rather than a wizard with all the answers.

We will never be specialists in the sense of either the hummingbird or our colleagues in secondary care. Our strength lies not in being able to do one thing perfectly, but in doing many things effectively in the grey zones of medicine. Physicians, surgeons, anaesthetists, psychiatrists, radiologists, and pathologists all occupy clearly-defined niches in the medical ecosystem, but the GP’s place is in the territory outside these niches. And yet, despite our obligate generalism, we still act as consultants in the sense that other professionals within the practice team consult and refer patients to us.

If a re-branding is in order, how about ‘Consulting Primary Care Generalists’? As the role of non-medical clinicians in our practices continues to grow, we are well-placed to lead, oversee, and support colleagues whose scope of practice is more closely bounded by protocols, while they see the majority of patients and involve us as needed. This would mean abandoning any aspiration to personal continuity of GP care, but to put it bluntly, something’s got to give. Even if we double medical school places tomorrow, can we really wait another decade for the new recruits to arrive at the coalface?

The current realities may mean that rather than holding on for an increase in our numbers to maintain the status quo, we consider instead what might be the optimal role for a smaller number of highly-skilled doctors working alongside colleagues from a variety of professional backgrounds. In this context, it would make sense to lengthen GP training, while aligning the training of non-medical clinicians more closely with general practice.

Resilience is not just about personal toughness, but about adapting as a profession to changing circumstances, and foxes are survivors.