Continuing care and comprehensive care are two of the hallmarks of general practice and represent some of features that distinguish it from hospital practice and most specialist practice, which tends to be episodic and disease or organ focused.
The provision of continuity of care for individuals and their families requires the development of a trusting relationship between the GP and the patient. Trust is built over a long period of time so that the patient has faith not only in the GP’s knowledge and skills, but also on the GP’s availability, accessibility and readiness to act as an advocate for the patient.
This may require the GP “going the extra mile” within the confines of ethical and legal practice, to meet the patient’s needs.
Trust and faith go hand-in-hand in underpinning the subtle and unwritten contract that forms an integral part of the doctor-patient relationship. Faith and trust may be built on a background of the GP’s correct and timely diagnosis of a medical condition, or simply by the GP making a phone call to the patient to check on their progress after a hospital admission, to inform them of the results of tests or even in the event of a death to express condolences and visit the family to pay one’s respects.
Some patients have faith in their GP because they manage a range of difficult and complex problems of a physical or psychological nature and they are thorough in investigating their patients with a range of blood tests and imaging to establish or exclude a diagnosis.
Others have faith in their GP because they are prepared to refer early to specialists when the diagnosis is unclear, rather than taking on the responsibility of multiple investigations themselves. Faith and trust, therefore, have idiosyncratic qualities which vary from one doctor-patient relationship to another.
Tom was in his late 50s when I first met him 30 years ago. He was new to the clinic, even though he had lived in the area for some years. He informed me that his wife Eleanor was my patient and that he had decided to change doctors because his previous GP had missed Eleanor’s ruptured ovarian cyst which I had seemingly diagnosed six months earlier. Eleanor was then in her late 40s.
Tom had a broad Yorkshire accent. He came to Australia in his late 20s as a “£10 Pom”. He had a passion for gardening and ultimately established his own horticulture and landscape business which now employed 10 staff.
Tom was “stocky”, with a ruddy complexion and large hands with sausage-shaped fingers. The dirt under his nails indicated that he was still active at the coalface in his business. He claimed that he was getting short of breath with some of the gardening work which he attributed to “getting old”, and a past history of smoking 30 a day which he had stopped 10 years ago. He felt it was time for a check-up.
Tom was obese with a BMI of 32, his blood pressure was elevated at 170/110 and so were his lipids and his uric acid. His resting ECG was normal and his respiratory function tests were consistent with mild obstructive airways disease, a legacy of years of smoking. He also had impaired glucose tolerance. He was referred for a stress ECG which was normal.
As the years went by I was able to manage many aspects of Tom’s metabolic syndrome successfully.
He lost weight, his blood pressure was well controlled on medication, however he did develop type 2 diabetes, which required medication.
In his late 60s, he developed ischaemic chest pain and required stents in three of his coronary arteries. An episode of rectal bleeding at the age of 72 revealed several large but benign rectal polyps which were removed.
I had developed a good rapport with Tom, and other family members as well. Tom and I shared an interest in AFL and cricket. Coincidently we both supported the Western Bulldogs in the Australian Football League and had much to discuss during the footy season.
I felt confident that Tom trusted my clinical judgment, and he indicated, that despite my decision to work part time in the clinic (and the rest at Monash University), he hoped I had no plans for retirement as he had built trust and rapport with me over a long period of time and that now, aged 76, and semi-retired himself, he was not keen to find another doctor.
Last year I was absent overseas for three weeks. Partly conference, partly holiday … not very unusual. When I returned to my first clinical session I noticed that Tom was first on my list, also not unusual, except that this time he had developed a new and serious problem.
He had complained of severe right-sided headache for a week or 10 days which he treated himself with OTC painkillers in in large doses, but over the past 24 hours had lost the sight in his right eye. Tom thought the headache would go away and that it was worth waiting for my return, rather than seeing one of the other doctors in clinic.
Clinical and haematological investigation confirmed the diagnosis of giant cell arteritis. Had he presented earlier when the headache appeared he would have been treated with prednisolone with resolution of the headache and prevention of blindness in his right eye.
Now, with the right retinal artery occluded, there was little that could be done to salvage the vision in his right eye. Urgent ophthalmology opinion confirmed this.
Tom’s faith in me extended too far. Trust and faith in one’s GP requires the presence of the GP. Availability and accessibility are critical. As I was unavailable and working part time, I was going to be unavailable more often than a full time GP.
I had told Tom on many occasions to see one of the other doctors, when necessary, in my absence, but he clearly overvalued our relationship, in this case to his detriment. Blindness is a big price to pay for trust and faith in one’s GP.
Given the increasing numbers of GPs in part-time practice, perhaps it is time to systematically educate our patients to have faith in the practice, not just in an individual GP.
Dr Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for almost 40 years
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