Athlete, Painter, Writer and Custodian of the Values of Family Medicine.
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“… growing up in a GP household just immerses you in it. And that’s what you know. I can remember every day after school, going back to the GP practice and doing my homework there, waiting for my mum to finish or going off in the car with her on home visits and waiting outside while she saw her patients. And, I can remember the bottles of wine and the boxes of chocolates at Christmas and all the cards from people saying thank you, and how much you’ve meant to them, and what she’d done. I think that probably influenced me far more, in what medicine can do for people, than I realized.”
Today, I’m talking to Emma Ladds who shares her thoughts and hopes for general practice. Tell us where it all began…
Emma Ladds: Well, I suppose you’re right that growing up in a GP household just immerses you in it. And that’s what you know. I can remember every day after school, going back to the GP practice and doing my homework there, waiting for my mum to finish or going off in the car with her on home visits and waiting outside while she saw her patients. And, I can remember the bottles of wine and the boxes of chocolates at Christmas and all the cards from people saying thank you, and how much you’ve meant to them, and what she’d done.
I think that probably influenced me far more, in what medicine can do for people, than I realized. I’m coming to reflect on that when I have my own patients. It was really from that that my interest in medicine was sparked but it took a long time for me to recognize that.
DMacA: When you were growing up general practice must have been quite different.
EL: Yes and no. I think there are many differences: the kind of continuity that my mum had with her patients and the longevity of working in a practice for 30 years or so, and working with the same group of partners for that length of time. I think that has probably gone in most cases. Honestly though, I think the values of general practice are still the same and they always will be. The desire to promote the principles of general practice; first contact access, free at the point of use, the continuity of seeing patients, being immersed in the community, being family doctors, all of those sorts of principles are, I think, probably the same. We may practice in different ways, and we may use technology and text messaging and emails and, and we may have extra staff in the practice that my mum never had but, actually, we’re trying to achieve the same goals. And it’s really important that we try and hang on to those, because I think that’s who we are. And I think it’s where the value in general practice is.
DMacA: One of the big changes must have been in the pattern of home visits.
EL: Yes. I think that’s definitely changed. And, you know, it’s really tricky, isn’t it? Because we are very pressured, there is a lot of demand, and fitting in home visits on top of everything else is very difficult. That said, it isn’t that we don’t visit, and I know every practice in every area is different, but I still do visit my patients at home, particularly the complex housebound ones, or the palliative patients as they come towards the end of life. I think there’s a real additional value in doing that and seeing the context in which somebody lives. And its a real privilege to be able to do that as well. But I do recognize that for a lot of practices, and for us actually, the practicality of doing acute visits for chest infections or some slight deterioration where people feel unable to get to us, just isn’t possible anymore.
We’re very lucky in our area to have a paramedic visiting service, who are very good and help us out in those kind of cases. More and more in general practice, we’re having to deal with the fact that we have extensions to our team and there are ways that we integrate them that are better than others. Knowing the people you work with, sharing continuity within the paramedics who provide the visiting service gives me confidence in the quality of care we’re giving to patients and allows me to interact with them more meaningfully. The pattern has changed but some of the complexities around visiting have changed as well and they reflect some of the wider complexities.
Oxfordshire GP and DPhil Student
“…the values of general practice are still the same and they always will be. The desire to promote the principles of general practice; first contact access, free at the point of use, the continuity of seeing patients, being immersed in the community, being family doctors, all of those sorts of principles are, I think, probably the same.”
Emma and colleagues creating a Bee garden outside the practice building
One of a series of abstract paintings that decorate the practice
DMacA: General practice wasn’t your first career choice. You took a little diversion along the way.
EL: It’s been a bit of a circular career path, that’s for sure. I did medicine and then trained initially in plastic surgery and loved hands, loved the business of reconstruction after trauma. Then, I suppose, life gets in the way and you reflect a little on how long you might be in hospital for training and how little autonomy you might have over your life in that time. And I think I realized I wanted something a bit different. I’ve got many interests, probably too many. So I took a bit of a diversion over to the United States and did a Masters in Public Health. I spend a lot of my time teaching now, as well as doing a PhD part time, alongside being a GP partner. So, I like being able to combine different things.
DMacA: Tell me about your Masters in Public Health. That must have been fascinating.
EL: It was really interesting. The best thing about studying in the United States is that there’s much more flexibility and much more freedom within your course, and you can tailor your degree to your interests. I did public health but, actually, a large part of my time was spent outside the Public Health School, in the School of Policy, the fine arts Institute, taking all sorts of courses. So I learned a lot about leadership, finance, history, politics, far more so than I might have done if I just studied public health degree in the UK. That’s broadened my horizons and made me think about things in different ways. And I think that’s really helpful for any doctor but particularly somebody who’s a bit more immersed in academia and thinking about service provision and development as well.
DMacA: Public Health in the United States is very different to public health in the UK. It’s not necessarily medical. So, you must have met some very interesting people.
EL: Yes. My course had more than 300 nationalities represented so it was fascinating. And people from all sorts of backgrounds as well, engineers, a lot of policy people, but also, some people who’d been in the financial sector and who wanted to come and relearn skills to be able to apply them in a more meaningful way.And, a lot of people who’d been in consultancy. Fascinating people. And people who were going on to do all sorts of different things. There were a lot of doctors who just wanted to learn a bit more about management or a bit more about public health in general, but there were a lot of people who are going to do overseas work, and a lot of people who were going back home to their respective governments to work in policy, and public health overseas. It was a fantastic opportunity and I was immensely lucky to be able to do it and it’s influenced me in many ways.
“… you can do all the number crunching in the world and you can be the best analyst you’re ever going to be, but unless you can sell the story of what those numbers mean and put it into context for people and give it some real meaning for individuals and or for policymakers, it doesn’t matter, it won’t go anywhere, it won’t have traction. That’s where I realized the value of narratives.”
DMacA: There is quite a contrast between the public health, epidemiology, quantitative side of things and your current interest in narrative medicine. Tell us about your interest in narrative medicine.
EL: There are obviously lots of differences between numbers and large data analysis and the business of stories. What you come to realize more and more, and what you reflect on, is that you can do all the number crunching in the world and you can be the best analyst you’re ever going to be, and I was never going to be that person, but unless you can sell the story of what those numbers mean and put it into context for people and give it some real meaning for individuals and or for policymakers, it doesn’t matter, it won’t go anywhere, it won’t have traction. That’s where I realized the value of narratives.
And I see that every day with my patients. Every consultation is a lesson in different narratives and interpreting them and trying to read people and trying to interpret their stories. I’ve just been able to think about the application of that same process to research and policy and think about how we actually make that happen in practice.
DMacA: You’ve brought that into your own research work. Tell us about your research work and the doctor patient relationship.
EL: Its quite varied. I’ve been a bit scattered all over the place. I did start off in large data analysis and have published a number of papers on that. More recently, I started studying patients who weren’t getting better after Covid, who we’ve come to recognize now as patients with Long Covid, and my team did a lot of the early work interviewing people and running focus groups for these patients who just weren’t recovering as expected, and the impact that their illness was continuing to have on them. We thought a lot about the changes to their identity they were suffering and the losses that they were incurring. They were having to give up work, they were struggling with relationships with families, and with maintaining the same kind of lives as they’d had before becoming ill. And we started to think a lot about how they were interpreting that. There was a lot of anger expressed about the relationships that they’d had with a number of doctors. Initially, I think, doctors were very focused on just treating Covid and dealing with the pressure of the pandemic and a lot of these patients felt like they were being ignored or a lot of them said they were being gaslighted and they didn’t feel listened to they didn’t feel heard.
That started me thinking a lot more about the value of the individual patient doctor relationship and what we may bring to our patients lives or how we may harm our patients lives or when we don’t give those relationships due attention and, due respect. We’ve always known that, it’s nothing new, but there have been changes with the introduction of technology. It raises questions about how we have diluted the relationship or how we enhanced it with text messaging or with emails or asynchronous encounters, e-consult, all those online forms that you have to fill out as a patient that then tell you can’t see your doctor, you have to go to A&E instead. There are all sorts of different influences and it is no longer a single patient- GP relationship. We’re including pharmacists, physician associates, paramedics, all these extra people, in that overall encounter. All this, together with the lack of continuity, the increasing turnover and pace of things. So I’ve been looking at some of those impacts and the effect that it has on individuals, both doctors and patients, but more widely on the system as well. Some of the time, what patients are looking for is an ability to connect, to find somebody who will hear them, who will bear witness to what they’re going through. And often what we’ve done is to design a system that is now much more transactional in nature and doesn’t provide that sort of support for somebody. Yes, it might give you antibiotics or it might give you a fit note or it might allow you to have a referral but a lot of the time it doesn’t allow you to build up that kind of relationship. That might have just meant you had some a sense of security, a sense of being held, a sense of being seen and that in turn drives demand. So I’m looking at that in a bit more depth.
DMacA: In a recent book review, you wrote that you were saddened by what you thought was happening to general practice.
EL: There are many things that sadden me. What saddens me most is that I have to fight harder and harder to be the sort of doctor that I want to be, and that patients would like me to be. And I suppose, if you like, that is the more old-fashioned sort of traditional general practitioner. And it’s not that I’m anti-technology. I love being able to text my patients. I think it’s fantastic. I like to be able to listen to people and I like to be able to give them the time, and I like to be able to see the same person again. And we haven’t designed a healthcare system that values those things.
We’ve designed a healthcare system that values metrics and objective outcomes and access targets, and it undermines those attributes that contribute to relationships. And I think that’s what saddens me, that we’re having to fight harder and harder and work harder to make those relationships, and to make care meaningful, to make care ‘caring’ in lots of cases, and I think there are some easy things that that would improve it. And it’s just sad that we haven’t been able to see that.
“Some of the time, what patients are looking for is an ability to connect, to find somebody who will hear them, who will bear witness to what they’re going through. And often what we’ve done is to design a system that is now much more transactional in nature and doesn’t provide that sort of support for somebody.”
DMacA: You’ve thought about this a lot and some of the principles that you’ve talked about, you clearly hold dear, like continuity of care and the doctor patient relationship. We’re struggling to maintain those. Looking to the future, how would you design general practice? What do you think is going to happen general practice?
EL: It’s the $10 million question that we ask every salaried doctor in our interviews. Nobody knows. And I don’t know either. And I think we are lying if we kid ourselves that our healthcare system can continue as it is. My worry about general practice, and what I want to avoid, is a multiple tier system where there is a very stretched level of general practice, perhaps overseen by GP’s, but not run by GP’s, where demands is very high and the quality of care is lower because people are pressured and stressed. It becomes more transactional because, inevitably, when systems are under pressure, they resort to that because it’s safer and easier and more measurable.
And then there will be a second or third tier of general practice, which will probably to some extent be private, whether that’s resourced through insurance or resourced through individual patients. We’re already seeing that now where consultations are 20 or 30 minutes in length and I’m sure patients get the chance to be heard, to tell their stories, to really feel like somebody is there for them. That sort of care in a good system may mean that the number of referrals are not as high, the number of investigations aren’t necessarily as high, the pressures are less, and so it’s a nicer place to work in. So, that’s my fear.
If I were to try and design it- what do we need? I think we need to be able to fund GP’s properly. There’s an integrative ability that comes through years and years of training that gives a GP different skills to some of additional roles, who are highly valuable in general practice, but do different things. At the moment there’s an assumption that we can break down general practice into tasks and give it to different professions. The pharmacist can do one thing and the physician associates can do another thing, the paramedics can do something else, the nurses can do something else. They all can, and they can do them very well and in a very skilled way. But somebody has to put the pieces together. And that somebody at the moment is a GP. But at the moment the way funding is determined, it’s very difficult to use specific pots of money to fund GP’s.
What I would do is say is that the GP partnership model is terribly efficient. It is probably the most efficient way of running a primary care system. What we ought to do is just put money into the core contract for partnerships so that they can employ the staff they require to meet the needs of their local community.
Everywhere is different, and we shouldn’t expect a one size fits all model. It won’t be like that and trying to force it to be like that will just generate inefficiencies and frustrations and we’ll lose staff and you’ll devalue it. I think that recognizing that partners, who are invested and have a responsibility to a patient list, are in it for the good of their patients 99% of the time. And we ought to trust the profession again.
DMacA: Emma, thank you very much for sharing your vision of general practice. Clearly, the future of the profession is in good hands. Thank you very much indeed.
