When a surgeon praises the achievements of primary care, you sit up and listen. Admittedly, Professor Sam Leinster was welcoming delegates to the Society of Primary Care meeting at the University of East Anglia where he is Dean. And he did say he was fed the script by Amanda Howe, Professor of Primary Care. But, he certainly endeared himself to his audience. Deborah Askew (Queensland, Aus) asked him if he thought he was unique- to the amusement of the audience. He challenged the established research pipeline which starts in the laboratory and ends with the patient suggesting it would be much more sensible to ask: What are the health problems, what are the causes, and what are the solutions. A different paradigm – applied clinical research. Looking at illness, which he categorised as acute, chronic, and self limiting, he pointed out that two of these three grouping were based in primary care. His message was that we need to look at what illness means to people rather than the disease of an organism. And he put primary care at the centre of the model.
Are you breathless? At a talk on the prevalence of dyspnoea by Helen Booth, her colleague Patrick White (Kings College, London) mentioned response shift- the idea that one changes ones internal standards to accommodate illness. It is one reason why very breathless patients may not come to the doctor. Though short of breath by any objective measures, they are managing well enough by the standards against which they have learned to judge themselves. If you ask how they are, they will say, quite genuinely, that they are fine. It is one reason why it is so difficult to find a validated measure of breathlessness and why there are such problems in measuring COPD morbidity in the community. Specialists in secondary care don’t really understand this and often ask a breathless patient why their GP didn’t send them up sooner. Understanding response shift may soften your indignation.
Scott Murray (University of Edinburgh) made us think, as always, about palliative care and shared some of the ambivalence he found in three key research studies on advanced care planning. It seems like a good idea, we are all talking about it, but not everyone wants to think about it in practice, and medical staff are concerned about standardising questions in a tick box exercise. Advance care planning is scary. Maybe that’s why.
But death doesn’t scare everyone. Sue Hall (Kings College, London) described a randomised controlled trial in older people in care homes. Never mind that the intervention didn’t work, what was most interesting was her finding that “older people were not concerned about death itself.” And from her work in Africa, Elisabeth Grant (University of Edinburgh) described care in the developing world. In a community without electricity or running water, communication with the nurse was, surprisingly, by mobile telephone. But, what do you do in a poor community when there is no credit on your phone. You “flash” the local nurse- sending a “missed call,” just like your children.
Who are you? An exhibition in the garden restaurant at the conference venue entitled “Photo-ID: photographer and scientists explore identity” had medical relevance. In the past your identity was embedded in your photograph- it was how people recognised you and how you recognised yourself. In this technological age, a photographic image is much less relevant. You are a finger print, an iris scan, your DNA. To know you, people google you, your profile is your pubmed, blog, or twitter trail. You have a thousand face book friends. Someone can steal your identity without knowing what you look like or you can create a completely fictitious online identity for yourself. In the past you were a person or a patient. Now you are an electronic file and a list of goals on a QOF score. In the past, if your doctor wanted to know more about you he could dig his way into your paper records; a wadge of hospital letters and indecipherable scribbles. Older GPs will remember when patients were real people- but the fat file was always a heartsink.
Domhnall MacAuley is primary care editor, BMJ