Monday, June 17, 2024

Denis Pereira Gray | An Academic Journey

by Editor

This interview took place at the University of Exeter at the meeting of the Society of Academic Primary Care.

Watch the interview and enjoy his personal story

The Life and Career of Professor Sir Denis Pereira Gray

"I was very lucky, I'm the son and grandson of an Exeter general practitioner so I grew up living in a family doctor's house so I saw it first hand all through my childhood...

 I noticed that he had very good relationships with his patients, which seemed a sort of very nice way to live and work really, and then when I came into general practice, of course, I didn’t have it for the first few years.  It does take a few years to get to know patients and it was really, sort of after I’d been in a few years, it suddenly began to dawn on me just how much more effective, how much more efficient, and how much more pleasant it is if you are seeing patients who have got to trust you, and you understand where they’re coming from.

 

The Department of General Practice.  

There was a very interesting development in that Exeter was the first city in Britain to develop a Postgraduate Institute outside the big London teaching hospitals, and that was done by a set of very far-sighted Exeter Consultants.  They had a new University founded in 1955 in Exeter and they said, why don’t we have a medical department in it and they managed to get the money from the Nuffield Trust and so, I came along and said what happened, we’ve got a medical department and they said why shouldn’t it have a Department of General Practice. 

Exeter is one of those unusual places, as Robert Kennedy said, it has a can-do attitude. So, instead of everybody’s saying- that’s a silly idea, nobody’s done that before- people on the whole said to me, well that’s fine, try it out but who’s going to pay.  And we then had three, four years struggling to find the (money). The Nuffield Trust didn’t follow it up although they’d funded the parent body.  And then there was an accident of history, and you need a bit of luck in life.  

The accident of history was that  the Royal Commission on medical education suddenly said in 1968 there ought to be postgraduate training for General Practice and there wasn’t any, and the Department of Health then said, we ought to treat it like we treat the hospital specialties which meant the Health Service ought to support it.  And suddenly there was a crisis in the Department of Health because they suddenly had the biggest branch of medicines (and they) had got to start from scratch, and don’t know what to do.  

At that very moment in time our application from Exeter dropped in their lap saying we’d like to form a Department of General Practice that might actually be able to develop vocational training.  And it’s the only time in history that the Department of Health has funded a university department, and it’s never done so since. So I had the most extraordinary good luck that the application from Exeter arrived at the very moment when the department of DHSS, as it was in those days,  was struggling to know what on earth to do about vocational training.

 

Royal College of General Practitioners 

 My involvement with the College was…I didn’t know anything about the college, I mean that’s an indictment of my medical education. When I was a young GP one of my local colleagues said you know you really got to join this College. 

I didn’t know anything about it so I became what was called an associate, which means you just sort of sent a subscription, and then I got a little white journal every couple of months or so, and I was sort of browsing through this and suddenly I found that in this journal at a time when everybody was saying general practice was finished, and people like Lord Moran were going around saying GPs have fallen off the ladder. Suddenly it was this little white journal saying this is a great job, and this is how you can do it better, and we can do this and we can do that, with a really positive attitude and that lit me up.  So, I sort of got involved with this College, it seemed to be where my heart was.  

Meanwhile I got on to the BMA Council and I was an active member of the Council for four years and then one of the leading College people  came along to me and said Denis,  Gray he used to call me those days- it was surnames.  Gray,  you can’t ride two horses.  You’ve got to make your mind up, are you a College man or are you a union man? And that was actually quite easy because it was perfectly clear that the union was always reacting to the problems of the day, as a reactive organization that was looking after the interests of doctors,  (while) the College was a proactive organization looking after the interests of patients, so it was a very easy choice.  

Then I got hooked into the College Journal that had lit me up and I got put on the editorial board and then suddenly there was a vacancy because the editor retired so, to cut a long story short, I was appointed as a very young editor. A dangerous appointment for the college because I was 35 (and) that’s a very dangerous age to appoint a young man with no academic experience but they took a chance on me and I’ve been very privileged to develop the Journal. For the nine years I did it. And then, of course at the end of the nine years when I was an observer on the Council, I suddenly realised that I was hooked on this organisation so then I stood in an election. I was lucky enough to get elected to the Council and then I stayed there.

 

Creating the GP Vocational Training Scheme

It was very interesting, it was completely informal, and it was completely devolved, so that there was one person, a GP called the Regional Advisor in the whole of the southwestern region. He gathered the enthusiasts together and said, this is a great idea, do what you can locally.  It was as amateur as that and I was the local Exeter guy.  All we had were two or three models of schemes that had been set up in other parts of the country. and a rough sort of framework from the College that it ought to be a couple of years of appropriate jobs, and there ought to be a year in general practice. 

So, I went around seeing the consultants one by one to see if they would be prepared-  in those days Consultants appointed their own juniors – so it was a tricky business.  Would they let me appoint them?  And they split in half and basically the physicians didn’t want to know but, the geriatricians and the psychiatrists were extraordinarily interested because they could not get decent junior doctors and suddenly the thought that they might get enthusiastic young British trained doctors was very attractive. It was easy to get certain specialties and it was almost impossible to get the others.  I was privileged in Exeter because the guy who was my boss and,  the head of the Postgraduate Institute was a physician, and he backed me as his staff member, said you’ll have my SHO job. So I was one of the few to get an SHO in  medicine.  And the paediatrician was enthusiastic about general practice so he gave me a paediatric job as well. So, in effect, I got all the jobs I wanted. So that was the hospital bit and then I had a completely free hand in setting up the GP bit. 

 I had read that there was an advantage in tasting the subject before you did it so, I introduced a system where by all the Exeter trainees would have two months, just eight weeks in general practice, and then do the two years in hospital. And that was ridiculed and pooh-pooed and everybody said that was silly,  you couldn’t learn general practice in two months, which of course you can’t, but the point wasn’t to learn general practice, the point was for them to learn what they needed to learn from the hospital jobs and it worked like a charm.  And, in fact, I did various studies and showed attitudes were completely different after eight weeks. They got much more out of the hospital jobs because they had tasted the job and they knew what they were coming back to and so we had a two plus ten, and then of course over the years it all had to change and rearrange it. 

And the scheme just grew and grew and I was very lucky that the funding from the Department was for one and a half posts. I had a half, I was a half time GP still in the practice and a half-time senior lecturer, and I was able to appoint three really stunningly good colleagues and that was what made Exeter special.  We had, in effect, four enthusiasts running a vocational training scheme.  That didn’t happen anywhere else in England. Because we had central funding, we had senior lecture status, and we were absolute enthusiasts.  In most parts of England one part-time GP was left to set up a vocational training him on his own or her own and it was a pretty difficult business.  We had all the privileges and so we then said, if we’ve got all this, we should actually treat it academically.  So we really studied everything that happened. We recorded it, we were ready to analyse it, and we started to produce a series of writings and articles.  There was a very important occasional paper in 1977 called, “A system of training for general practice” which turned out to be a blueprint for GP vocational training that went all around the world and I found it in Australia and Canada and everywhere. And the first three books on vocational training in English all came from the Exeter Department because we alone had four senior lecturers who could think and write. So it ended up with the Department making quite a significant contribution to the way the national system evolved.

 

The future of Teaching in General Practice

I think the medical schools, first of all, are making a very serious mistake.  They are working on the assumption that if you just send students into general practices they will choose to be GPs.  There is some research which shows there’s a 0.4 correlation between experience in general practice and choosing it so, it’s not a silly thing to do. There is some research that if you’ve had a good experience in a general practice you’re more likely to choose it.  But, the teaching in general practice is all experiential.  It’s “I found this good, you know, this is my way of doing things” and we’re dealing with the brightest generation of medical students that’s ever been. To their credit, they’ve  all been selected on really high A grades.  

They are a brighter, a more intellectual group than  ever had- much brighter than their teachers -and they’re not being given what these bright students need, which is the intellectual or raison d’être of the subject. So that, for example I have seen local students who have never heard of, let alone read, Professor Ian McWhinney in Canada or Professor Barbara Starfield in America, who happen to be two of the greatest thinkers about the subject.  They’re not even in touch with the thinking. So these very bright brains are being dumbed down into a system where it’s all about what the latest guidelines and NICE is, and they don’t find that very satisfying and they’re choosing hospital medicine.  That’s the first problem, that’s in all  the medical schools, and, then to compound that, the medical school’s downgrade general practice systematically by not including General Practice in the final MB examinations.  

So these students come  into medical schools for five years (and) the one thing they want to do is to be a doctor. To be a doctor you have to get the MB so, they analyze the MB with their first class brains, and they find there’s no General Practice in it so, why bother then and indeed, when GP material is produced of course they just forget it and don’t bother.  And, in fact,  in Exeter recently we had a case where they didn’t even come, half of them didn’t even come to a GP week, so because they are saying it’s not in the MB, it doesn’t matter.  So the second thing the medical schools have to do is to have a compulsory mandatory questions 15 to 20 percent of the questions on the McWhinney, Starfield stuff that is internationally known, internationally validated, and a great truth and that will change that. 

Then,  in vocational training a very similar thing has happened.  The pressures to, sort of, do all sorts of itsy bitsy- must do safeguarding, must do resuscitation, must do this, must do that,  has fragmented the subject and it’s now much harder for new GP trainees to see the glory of this great overview Personal Care, understanding a patient as a person, and really meeting their needs.  It’s got fragmented so GP training is too short, it’s the shortest of all the branches of medicine by a mile. I mean I’m meeting junior doctors in training who do seven years in cardiology, seven years, and no GP does more than four. So I mean there’s a complete imbalance in postgraduate medicine and basically the training is too short to give them the breadth of understanding that they need for this very interesting but rather complex job.

 

 General Practice Workforce

 In England, or Britain anyway, we are about 5000 GPs short and the the result is that they are just being asked to do more work than is comfortable for them so we’ve got some very serious problems with recruitment and problems with 50 year olds, in particular, retiring earlier.  So I think it’s a real crisis, comparable to the crisis general practice had in the 1960s, which I just did experience when I started. On the other hand, the future and the potential is absolutely stunning because we’re now realising that- the  Institute of Medicine has just said that- the social determinants of illness are more important than medical disease and GPs are the one group of doctors who actually see the social determinants face to face.  

We now know that continuity, which is really a GP thing, is now associated with life, and actually the sheer interest, because this is about the human side of medicine not the technical side of medicine, is very rich indeed and GPs have the longest and deepest working relationships with patients anywhere in in Europe. The potential is all there.  It’s just, I think, a question of whether we can persuade the government, because this is a government run system in Britain, to actually free up the resources and give the recognition that general practice needs.

 I hope you’ve enjoyed this conversation with Professor sir Dennis Prairie gray which we recorded in Exeter in July 2019.

 

I was very lucky, I’m the son and grandson of an Exeter general practitioner so I grew up living in a family doctor’s house so I saw it first hand all through my childhood but I noticed that he had very good relationships with his patients, which seemed a sort of very nice way to live and work really, and then when I came into general practice, of course, I didn’t have it for the first few years.  It does take a few years to get to know patients and it was really, sort of after I’d been in a few years, it suddenly began to dawn on me just how much more effective, how much more efficient, and how much more pleasant it is if you are seeing patients who have got to trust you, and you understand where they’re coming from.
The Department of General Practice, this is in the University of Exeter,  there was a very interesting development in that Exeter was the first city in Britain to develop a Postgraduate Institute outside the big London teaching hospitals, and that was done by a set of very far-sighted Exeter Consultants.  They had a new University founded in 1955 in Exeter and they said, why don’t we have a medical department in it and they managed to get the money from the Nuffield Trust and so, I came along and said what happened, we’ve got a medical department and they said why shouldn’t it have a Department of General Practice. Exeter is one of those unusual places, as Robert Kennedy said, it has a can-do attitude. So, instead of everybody’s saying- that’s a silly idea, nobody’s done that before- people on the whole said to me, well that’s fine, try it out but who’s going to pay.  And we then had three, four years struggling to find the (money). The Nuffield Trust didn’t follow it up although they’d funded the parent body.  And then there was an accident of history, and you need a bit of luck in life.  The accident of history was that  the Royal Commission on medical education suddenly said in 1968 there ought to be postgraduate training for General Practice and there wasn’t any, and the Department of Health then said, we ought to treat it like we treat the hospital specialties which meant the Health Service ought to support it.  And suddenly there was a crisis in the Department of Health because they suddenly had the biggest branch of medicines (and they) had got to start from scratch, and don’t know what to do.  At that very moment in time our application from Exeter dropped in their lap saying we’d like to form a Department of General Practice that might actually be able to develop vocational training.  And it’s the only time in history that the Department of Health has funded a university department, and it’s never done so since. So I had the most extraordinary good luck that the application from Exeter arrived at the very moment when the department of DHSS, as it was in those days,  was struggling to know what on earth to do about vocational training.
 
 
My involvement with the College was…I didn’t know anything about the college, I mean that’s an indictment of my medical education. When I was a young GP one of my local colleagues said you know you really got to join this College. I didn’t know anything about it so I became what was called an associate, which means you just sort of sent a subscription, and then I got a little white journal every couple of months or so, and I was sort of browsing through this and suddenly I found that in this journal at a time when everybody was saying general practice was finished, and people like Lord Moran were going around saying GPs have fallen off the ladder. Suddenly it was this little white journal saying this is a great job, and this is how you can do it better, and we can do this and we can do that, with a really positive attitude and that lit me up.  So, I sort of got involved with this College, it seemed to be where my heart was.  Meanwhile I got on to the BMA Council and I was an active member of the Council for four years and then one of the leading College people  came along to me and said Denis,  Gray he used to call me those days- it was surnames.  Gray,  you can’t ride two horses.  You’ve got to make your mind up, are you a College man or are you a union man? And that was actually quite easy because it was perfectly clear that the union was always reacting to the problems of the day, as a reactive organization that was looking after the interests of doctors,  (while) the College was a proactive organization looking after the interests of patients, so it was a very easy choice.  Then I got hooked into the College Journal that had lit me up and I got put on the editorial board and then suddenly there was a vacancy because the editor retired so, to cut a long story short, I was appointed as a very young editor. A dangerous appointment for the college because I was 35 (and) that’s a very dangerous age to appoint a young man with no academic experience but they took a chance on me and I’ve been very privileged to develop the Journal. For the nine years I did it. And then, of course at the end of the nine years when I was an observer on the Council, I suddenly realised that I was hooked on this organisation so then I stood in an election. I was lucky enough to get elected to the Council and then I stayed there.
 
It was very interesting, it was completely informal, and it was completely devolved, so that there was one person, a GP called the Regional Advisor in the whole of the southwestern region. He gathered the enthusiasts together and said, this is a great idea, do what you can locally.  It was as amateur as that and I was the local Exeter guy.  All we had were two or three models of schemes that had been set up in other parts of the country. and a rough sort of framework from the College that it ought to be a couple of years of appropriate jobs, and there ought to be a year in general practice. So, I went around seeing the consultants one by one to see if they would be prepared-  in those days Consultants appointed their own juniors – so it was a tricky business.  Would they let me appoint them?  And they split in half and basically the physicians didn’t want to know but, the geriatricians and the psychiatrists were extraordinarily interested because they could not get decent junior doctors and suddenly the thought that they might get enthusiastic young British trained doctors was very attractive. It was easy to get certain specialties and it was almost impossible to get the others.  I was privileged in Exeter because the guy who was my boss and,  the head of the Postgraduate Institute was a physician, and he backed me as his staff member, said you’ll have my SHO job. So I was one of the few to get an SHO in  medicine.  And the paediatrician was enthusiastic about general practice so he gave me a paediatric job as well. So, in effect, I got all the jobs I wanted. So that was the hospital bit and then I had a completely free hand in setting up the GP bit.  I had read that there was an advantage in tasting the subject before you did it so, I introduced a system where by all the Exeter trainees would have two months, just eight weeks in general practice, and then do the two years in hospital. And that was ridiculed and pooh-pooed and everybody said that was silly,  you couldn’t learn general practice in two months, which of course you can’t, but the point wasn’t to learn general practice, the point was for them to learn what they needed to learn from the hospital jobs and it worked like a charm.  And, in fact, I did various studies and showed attitudes were completely different after eight weeks. They got much more out of the hospital jobs because they had tasted the job and they knew what they were coming back to and so we had a two plus ten, and then of course over the years it all had to change and rearrange it. And the scheme just grew and grew and I was very lucky that the funding from the Department was for one and a half posts. I had a half, I was a half time GP still in the practice and a half-time senior lecturer, and I was able to appoint three really stunningly good colleagues and that was what made Exeter special.  We had, in effect, four enthusiasts running a vocational training scheme.  That didn’t happen anywhere else in England. Because we had central funding, we had senior lecture status, and we were absolute enthusiasts.  In most parts of England one part-time GP was left to set up a vocational training him on his own or her own and it was a pretty difficult business.  We had all the privileges and so we then said, if we’ve got all this, we should actually treat it academically.  So we really studied everything that happened. We recorded it, we were ready to analyse it, and we started to produce a series of writings and articles.  There was a very important occasional paper in 1977 called, “A system of training for general practice” which turned out to be a blueprint for GP vocational training that went all around the world and I found it in Australia and Canada and everywhere. And the first three books on vocational training in English all came from the Exeter Department because we alone had four senior lecturers who could think and write. So it ended up with the Department making quite a significant contribution to the way the national system evolved.
 
I think the medical schools, first of all, are making a very serious mistake.  They are working on the assumption that if you just send students into general practices they will choose to be GPs.  There is some research which shows there’s a 0.4 correlation between experience in general practice and choosing it so, it’s not a silly thing to do. There is some research that if you’ve had a good experience in a general practice you’re more likely to choose it.  But, the teaching in general practice is all experiential.  It’s “I found this good, you know, this is my way of doing things” and we’re dealing with the brightest generation of medical students that’s ever been. To their credit, they’ve  all been selected on really high A grades.  They are a brighter, a more intellectual group than  ever had- much brighter than their teachers -and they’re not being given what these bright students need, which is the intellectual or raison d’être of the subject. So that, for example I have seen local students who have never heard of, let alone read, Professor Ian McWhinney in Canada or Professor Barbara Starfield in America, who happen to be two of the greatest thinkers about the subject.  They’re not even in touch with the thinking. So these very bright brains are being dumbed down into a system where it’s all about what the latest guidelines and NICE is, and they don’t find that very satisfying and they’re choosing hospital medicine.  That’s the first problem, that’s in all  the medical schools, and, then to compound that, the medical school’s downgrade general practice systematically by not including General Practice in the final MB examinations.  So these students come  into medical schools for five years (and) the one thing they want to do is to be a doctor. To be a doctor you have to get the MB so, they analyze the MB with their first class brains, and they find there’s no General Practice in it so, why bother then and indeed, when GP material is produced of course they just forget it and don’t bother.  And, in fact,  in Exeter recently we had a case where they didn’t even come, half of them didn’t even come to a GP week, so because they are saying it’s not in the MB, it doesn’t matter.  So the second thing the medical schools have to do is to have a compulsory mandatory questions 15 to 20 percent of the questions on the McWhinney, Starfield stuff that is internationally known, internationally validated, and a great truth and that will change that. Then,  in vocational training a very similar thing has happened.  The pressures to, sort of, do all sorts of itsy bitsy- must do safeguarding, must do resuscitation, must do this, must do that,  has fragmented the subject and it’s now much harder for new GP trainees to see the glory of this great overview Personal Care, understanding a patient as a person, and really meeting their needs.  It’s got fragmented so GP training is too short, it’s the shortest of all the branches of medicine by a mile. I mean I’m meeting junior doctors in training who do seven years in cardiology, seven years, and no GP does more than four. So I mean there’s a complete imbalance in postgraduate medicine and basically the training is too short to give them the breadth of understanding that they need for this very interesting but rather complex job.
 
 In England, or Britain anyway, we are about 5000 GPs short and the the result is that they are just being asked to do more work than is comfortable for them so we’ve got some very serious problems with recruitment and problems with 50 year olds, in particular, retiring earlier.  So I think it’s a real crisis, comparable to the crisis general practice had in the 1960s, which I just did experience when I started. On the other hand, the future and the potential is absolutely stunning because we’re now realising that- the  Institute of Medicine has just said that- the social determinants of illness are more important than medical disease and GPs are the one group of doctors who actually see the social determinants face to face.  We now know that continuity, which is really a GP thing, is now associated with life, and actually the sheer interest, because this is about the human side of medicine not the technical side of medicine, is very rich indeed and GPs have the longest and deepest working relationships with patients anywhere in in Europe. The potential is all there.  It’s just, I think, a question of whether we can persuade the government, because this is a government run system in Britain, to actually free up the resources and give the recognition that general practice needs.
 
 I hope you’ve enjoyed this conversation with Professor sir Dennis Prairie gray which we recorded in Exeter in July 2019.
 

Related Articles

Leave a Comment