Modern Wisdom - #202 - The Secret GP - What Really Goes On Inside Your Doctor's Surgery

Episode Date: July 27, 2020

This guest's identity is being kept anonymous. He is a GP working for the NHS in the UK. Trips to the doctor are never fun, but how fun are they for your doctor? What is life like dealing with 70+ patients a week in 10 minute windows? Expect to learn why you should never take a picture of your bumhole to show your GP, why your doctor is always running late, why you can never get a lunchtime appointment, how long a doctor spends fingering patients per month and much more... Exclusive Preview: Get a first look at the Modern Wisdom Academy Notes - https://chriswillx.com/preview/ Sponsor: Check out everything I use from The Protein Works at https://www.theproteinworks.com/modernwisdom/ (35% off everything with the code MODERN35) Extra Stuff: Buy The Secret GP - https://amzn.to/32LEVkW  Get my free Ultimate Life Hacks List to 10x your daily productivity → https://chriswillx.com/lifehacks/ To support me on Patreon (thank you): https://www.patreon.com/modernwisdom - Get in touch. Join the discussion with me and other like minded listeners in the episode comments on the MW YouTube Channel or message me... Instagram: https://www.instagram.com/chriswillx Twitter: https://www.twitter.com/chriswillx YouTube: https://www.youtube.com/ModernWisdomPodcast Email: https://www.chriswillx.com/contact Learn more about your ad choices. Visit megaphone.fm/adchoices

Oh, hello friends, welcome back. My guest today, I kind of don't know who my guest today is. His identity is being kept anonymous. He's a GP working for the NHS in the UK and he's just released a book under the pseudonym Dr Max Skittle. Basically today you get to find out what it's like behind the scenes in your doctor's surgery.

None of us really like taking a trip to the doctor, but it seems to not be always that fun for the people providing the healthcare either. So today, expect to learn why you should never take a picture of your bumhole to show you GP, why your doctor is always running late, how can you never get a lunchtime appointment, how long Max spends with his finger inside of other patients per month and much more. It's really cool. I enjoyed this episode. It was fun to do it with someone. I didn't see his face, the Skype conversation. I don't get to see what he looks like. I don't know where he lives. I don't know anything else. It's just an inner-city GP opening the doors into the world of what it's actually like in your doctor's surgery.

But for now, it's time to speak to a GP whose true name I don't know, but we're going to call him Dr Max Skittle. Ladies and gentlemen, welcome back. This is a first where I'm actually recording with a guest who I don't know who it is. So what should I call you? Mr.GP? Doc? No, I think why don't you call me Max? know who it is. So what should I call you? Mr. GP doc? No, I think why don't you, why don't you call me Max? I think that's, I think that's a good starting point. Cool. So Max, which is the

pseudonym moniker, which you've used to write this book. So why are you anonymous? Yeah, that's right. So the, so the, so I guess my full anonymized name is Dr Max Skittle and Max to everyone including my patients. Why anonymous? Well, I think there's a couple of reasons. The first is to protect my patients. I mean, the whole, when you decide to write something like a walks-in-all book, a medical biography, or sort of talking about your life and the job. You need to protect the confidentiality of your patients and that's not just anonymising them and changing ages and genders and ethnicities, but it's also about protecting yourself. So by me being

anonymous, it gives another layer of protection to my patients, and it probably stops me from getting fired as well. So it's a kind of a win-win. Yeah, I get that. Well, sadly, we've broken at least one of the potential fibs that you had, which was that you could have been maxine in real life. So, that one's out the window. I may just have a very deep voice.

You have no idea. I'd imagine. Or if you're using a really fancy voice modulator, that would's out the window. I may just have a very deep voice. You have no idea, Jim. Or if you're using a really fancy voice modulator, that would have been exactly. That would have been a nice. So you never know. Why did you decide to write this book? It's a good question. I mean, I think there's probably the simple answer

is that I love talking about health and I love writing. And I think that the opportunity came up when I kept coming home and I was like, oh, that's just such a good experience or such a haunting experience or such a hilarious experience. And the emotions that it made me feel on that day, I just thought, you know what, why can't we put this down on paper and why can't we share it with people and let them see what the jobs like? Let them see, you know, life's journeys through the eyes of multiple patients.

And you might find that some of them resonate with you. You might see a journey of a patient that I've written about and gone, yeah, that was me. Or it might be that that's you in the future, that you have no idea. And that's the sort of thing that led me to write the book. It's kind of semi-order biographical diary format, isn't it? It kind of goes through day by day over a tape. Yeah, that's right.

It's a diorite version of a year in my life. And it sort of takes you through the journey of my day-to-day patients, but also gives you an understanding about what happens behind the scenes. Like, how does a GP surgery run? What are the hires and those? What are the hiccups? And then I suppose there's a subcontext to that. It's about my life and about my young family and I guess how that blurring of the work life balance occurs and how it impacted in me. And then because that's something I guess

that we all experience with desperate to try and keep our work and our life separate to a degree, but with technology and just the emotions that work pulls out of people now, you realize that that's not possible. And in the book, there are definitely times when that comes through. Would you say that you're a typical representation of a GP? Are you fairly representative GP if your experience going to be sort of synonymous with many others? Yeah, I mean, I don't think that I don't think that GP's experience is necessarily a

different case load. I mean, we all see the same people walking through the doors. There is a little bit because what happens is people decide who they want to see. So you start to get a bit of a niche. So for example, I knew that I loved seeing children because it allows you to be a kid for 10 minutes, but also sort of adolescents and teenagers who, I guess, prefer someone who, you know, I mean, let's be blunt, I'm not near to their age, but nearer to their age than say a 50 or 60 year old GP. And he's fairly straight talking. And, you know, that's something that I've always tried to do. You know, I don't beat around the bush. I think you need to be honest with people. And that's never more the case than with your

patients in front of you. Yeah. The topic of work-life balance really interested me. I had a question down here that just asked our GPs normal people. But of course, of honoree in the book, it comes across that you are, but there's something weird and everyone that's listening might feel the same, or this might just be some bizarre quirk of my own mentality. But you kind of see GPs, doctors, as these weird, angelic omnipotent sort of fountains of life's givingness,

you almost don't expect them to have a life outside of that, it sounds bizarre. I expect a bus driver to be gruff to me if he's had a bad day, but I don't expect my GP to do that. Does that make sense? It does. It does. It does. It believes that there are almost above the decree, the law of normal, normal behavior.

Yeah. I mean, I think I wasn't sure if I could swear on this, Chris. Fire away, man. Fire away. To be blunt, I mean, it's bullshit. I mean, we're all, we're all human and GP's more so than ever. The concept of emotion is a really difficult one with a GP and I think it varies throughout your career because basically you have to learn to really suppress it when you're in front of a patient because you probably run the book. There are patients that make me see red. There are ones that make you want to cry. There are ones that make you want to bang the desk, shout at them, just be like, what the

hell are you doing? But you had to try and compose that to a degree and then tell them in a steady tone that I think they're crazy, that I think they're mad for making that decision, that I think they're talking shit, and that I'm going to give them the truth, and that's the reality, and that we need to find some way of marrying the patient agenda with my GP agenda, because my agenda is always to try and do the best for that patient, but the challenge is that they don't always see it that way. And that's partly due to the job,

but there's a veneer to being a GP. And what happens, I mean, it happened in the book, Secret GP, that veneer gets scratched away at points because when you've been slammed by, the 15th super complex, unhappy patient, 10 minutes after 10 minutes, like, you just want to explode. And there are times when I feel like, actually, I've had a day like that today where, you know, I've literally come home and I just, I want to sit down,

have beer and just decompress because it's been one of these days. And yeah, I mean, you try and mask it as much as you can, but actually, I think, conversely, patients want to see you as a person. You know, you're not, as you said, this sort of like, you're not a deity, you're nothing like that. You are a human who has learned a job, and you're trying to help the person in front of you. And it's not about being nice to them.

It's about being honest and telling them the truth and helping them through processes related to their health. And you can have a nice shit GP if you want, but that's not what I want to be. That's a good way to put it here. How much time per month do you think that you spend with your finger inside a bomb's total on average? Oh, that's a good question actually. I mean, I don't hang around when I'm up there,

let's be honest. So let's work it out. So what's typical rectal exam length? 20 seconds? Yeah, because you got to essentially get them on their side, laying on the sort of fetal position Knees up. I usually sort of say think a queen of country. You got a lubed Gelled glove into interglutile cleft

Yeah, absolutely No, that were you doctor Skittle. That's one of my best friends. My best friends is also a doctor as well So I found out so you know you know what to ask me now And you discern the at you examine the outside and then you say okay That's because one of my best friends is also a doctor as well. Fantastic. So you know what to ask me now. And you examine the outside and then you say, okay, bit of pressure and then you go and you sweep around feeling for masses and you sweep around feeling the prostate, all the edge of the prostate, and then you come out, look at the glove, you're looking for blood, you're looking for mucus, and then you go away and give them a tissue.

And not to wipe their eye, that is to soil the other end. Or two tissues, sometimes it. And that's it. But yeah, I mean, I've probably got enough, I've probably had my finger up for long enough to see a good ad break in a month. Okay, cool. Yeah, well, I mean, it's all just a cum time, you know, I had Salmonella a couple

of years ago from Africa, yeah, really would not recommend it. Yeah, I got a call. That wasn't a finger up the bum scenario. No, you don't need more for that. Shame. But they're made, they're a paid services everywhere. I'm sure you can find it. Just need to get a really good friend. Exactly. I got a call. He's an interesting one for you. I didn't even think of this.

I got a call from environmental health asking where I'd been eating recently because they knew that I had Salmanella before I got a call from my doctor's surgery telling me that the diagnosis was Salmanella. Yeah, it's pretty swift, isn't it? So public health England will have no too far equal diseases. If Salmanella comes up, they need to find where the source is and track it down and isolate it if need be. I mean, you know, it's a very different game when we think about the

coronavirus pandemic, but it's that one steroids, really, isn't it? Got you. Yeah, I was like, I'm gonna guess that's my diagnosis. Thank you for telling me. And just obviously some fella, some girl on the other end of the phone trying to track down like a hotel that had been serving bad chicken or something. I'm like, unless you fly to Africa, that's not gonna happen.

Pretty tough. How hard is it to get fired as a GP? Well, I haven't been fired yet, but I'm probably working quite hard to. I think it's pretty hard. GPs are in demand. We're short thousands of GPs and government after government make pledges that they're going to boost the GP numbers by 5,000s come 2020, 2021. And it just doesn't quite get there. I think to get to get struck off,

to get fired as a GP, I think you have to have gross misconduct. And they're the kind of guys and girls that you're seeing in the Daily Mail. After they're sort of law-suit, so you're seeing people that are sort of using sexual exploitation, taking photographs, unnecessary examinations. You wouldn't get struck off for just being a bad GP, you get pulled aside,

mentored, trained up. I mean, the training is good. The reason you get, you'd probably get fired if you got a darker side to you that comes down. Yeah, I was thinking that the stakes are obviously quite high. There's a story in the book about a lady who comes through and points a finger at you and accuses you of not detecting her husband soon to onset heart attack that kills him. And it's like, well, that's... Obviously, there's a lot of emotion and not culpability, but there's a potential for someone to find you, create you, be the reason, the behest of this particular problem that occurred.

And to be honest with you Chris, that happens a lot partly because we're the person sitting in front of them. If you're looking for someone to blame for a loved one's death, a GP is someone who's there, is accessible, and often I think I remember I said about this in the book with that particular lady, you know, it's a grief reaction and I've been no bad feelings towards her because while it was a horrible experience for me, her experience was immeasurably worse and what I was receiving from her was her grief reaction. And that I suppose you get a thick skin as a GP, as a doctor in general, I think or as a nurse or any healthcare professional, you get a thick skin because that stuff happens

all the time. You get blamed for missing cancers, you get blamed for not diagnosing heart attacks or not seeing the signs of one. We are human and I will miss things in my career. I will miss cancers. I know that because I'm not infallible and I'm human and it's just, that's the life that we live and every doctor knows that. If you speak to a doctor who says, I'm never going to miss a cancer, I'm never going to miss an acute serious illness that could lead to a fatality, I think they're killing

themselves. I mean, we have to have the humility to say, I'm really going to fuck up at some point, and I'm going to have to just shoulder that. Because if you're seeing hundreds of patients a week, you just need to miss one thing. Just one tiny thing, one subtle symptom. That's... you know,

stakes are high marks, the stakes are really high. But that's why I love the job. I mean, I love the risk that comes with it. People, you know, when I suddenly realized I was coming out medical school and going into being a GP, I was like, oh my God, this is going to be the most boring experience of my life. But, you know, I've done A&E,

I've survived all that, I've enjoyed, it's great fun, but I want to come home on the weekends, I want to come home to my family in the evenings. Let's make that decision. What I found is that every day is just the, a cocophony of, of experiences of, with patients. And I I I love it like from the acute illnesses to the utterly weird and wonderful to the Saba Samba, I mean, you know, you can one day you can be talking about someone's sorny and within 10 minutes You're talking to you know the guy in the book Benny who came comes in and his question is you know seriously max What what's the meaning of life? and that that puts him immediately on my top five patient list of all time, because just to have the guts to come in and ask the question that perhaps we all do wonder from time to time, particularly

at sort of 2am when you can't sleep, to come in and ask me anything that I'm going to have the answer. Yeah, it's a low key compliment, man. Really in and ask me and think that I'm gonna have the answer. Yeah, it's a low key compliment, man. Really, really is. I know who's gonna have the answer to this. Dr. Skittle, Dr. Skittle knows the answer to this one. Exactly, and you know, well, you had to read the books, find out what happens.

But he is one of my all-time favorites. Never forget him. It's a little bit like being a doctor, being a GP sounds a little bit like being a doctor, being a GP sounds a little bit like being a really hard core hairdresser, like everyone that comes in, their hair's shit, like it's totally shit, and the best that you can do is get them to leave with an acceptable hairdo, which might happen in three weeks time.

Yeah, well, you know what, I've got having like you and like all of us just gone through the lockdown and had a lockdown haircut and tried to cut my wife's hair. It is not that easy. And so, at first we'll, let's just give a hats off to the hairdresser's because it is not easy. But yeah, I mean being a GP is a bit like being a shit hairdresser. You do, you have to go in and you have to figure out how to make

people's lives better. But the major factor with that statement is that that doesn't mean anything unless the patient is most fated to change. If the patient comes in and you say you need to X, Y and Z to make this condition better and they don't, that's on them. That's not, and that's the truth. I can do all I can to try and encourage them make them see and understand why they need to do something, but if they have the mental capacity to say, I get if I don't do these treatments, I might come to serious harm or death and they decide not to, there is nothing I can do about that. That really surprised me to find that out. Doctor tells me to do a thing and I'm pretty much to the letter. But you had a lady who had put off a breast cancer assessment four times because of work. You had a guy who was like pre-diabetic, high

blood cholesterol, smoked every day, drank every day, didn't eat anything, was also like looked like you might be a low-key 60-year-old porn star. Mr. Tosca, he was one of my faves. He was like, just came and smelling of sort of stale cigar and sex. He was a great guy. I hope he's still with us. But you're like all these people and then not, you know what I'm saying? Look, this is where you're at. And there was another lady who had an existential crisis. In front of you, I didn't bother to go to her cancer treatment or whatever issues I'd give it to someone that deserves it. And I'm thinking like, yeah.

Just seeing people like that, it must be challenging as a doctor to do the thing, get them to this as much as you can do, lead a host to water, but then you get stuck. It is, and some people find that hard of another. So for me, I'm very, you know, I'm blunt. I will say that, you know, if you don't do this, this is what could happen.

And of course, you do, I don't want people to think that's me being incredibly harsh, and then going, that's it, I've wiped my hands with them. So the lady, for example, who you mentioned, who, and then it was a canister, and it was her diabetes appointment. And she'd said, I'm not good enough to have treatment, give it to someone else who's salvageable.

And in the book, I think I said, I will follow up with her in a few weeks' time, and I will say, oh, have you changed your mind? And here's why you should change your mind again. And you keep doing that. So I guess what I'm saying is people may listen to me or they may read the book, which I'm getting a feeling is going to be a bit of a marmite book with people. They might think Max is a real dick, but actually every single decision I make, everything I say or do is in the patient's interests because that's why I love the job because I'm doing

something to help try and help someone else. You just don't need to sugarcoat this stuff because health doesn't issue good coated enough. You just sort of need to go on Instagram, you can get some shiny enamored tooth doctor who can tell you this stuff. But the reality is that, you know, you had to be blunt, you had to be harsh because you're trying to do everything in their best interests. The rubber really, really does meet the road when you go and sit down with a GP. I don't want the guy on Instagram who did a level 3 NVQ in physiotherapy. I don't want him. I want someone that had to go through the fire and brimstone that is five years of med school, and two years of locom, and blah, blah, blah, blah.

And you experience that, and in the secret GP, I have a couple of flashbacks to, you know, as you chat to about when I went through my GP training and what led me to make that decision. And there are stories in there about, you know, the experiences that you go through as a junior doctor and how you cut your teeth. And as you say, how the rubber eats and it meets the road.

Can we play GP Bingo? Can you try and come up with some of the cliche phrases that you either find yourself saying a lot or that you hear your other doctors saying a lot. So for instance, on this show, I'll tend to say something like the Rubber meets the road or the tip of the spear or you got to have a pair of brass balls for that. What are some of the ones that you find yourself saying a lot. So, I think for me, often it's what you want, because actually, sometimes you just need to cut through all the fat and just say to them, what is it you want? What do you think you've got?

Definitely, what do you think you've got? Because people will come in and I listen to you and then I'll say, actually, I, you know, I've played Dr. Google and I think it's this. That's the, that's the Dr. equivalent of, do you know why I pulled you over? Exactly. Exactly. And then I suppose the other one is, well, so this is, this is,

and I mentioned this in the epilogue as well, this is the pre-coronavirus statement. It's probably just a virus. Okay, and that is the most terrifying thing, isn't it, that for for a GP, you come in, you're like, oh, I need antibiotics, which treat bacterial infections. I've got a cough and I've got a sore throat and runny nose, I need antibiotics and you go, look, it's just a virus, it's a cold, go home, spend time with your family, hug them,

take paracetamol, go to work, you'll be fine. You don't need to stay off work for this, it's just a virus. I mean, fast forward to 2020 and and it's a totally different world. Can you imagine if you'd written this book from mid 2020 until early 2021? Yeah, I mean, it would be, you know, never say never, there might be another one in the pipeline at some point, But um, the Corona GP. That's, that's what I could want. Yeah, I mean, this is, uh, yeah, I mean, it'd be a different book. I mean, I'd be glad to tow in, uh, personal protective equipment. I'd be two, two meters away from everyone. Um, and I'd be on the phone all

the time because, you know, GP has gone from 80% face to face 20% phone call as a split to, you know, what was at one point for many months, 100% face to face. I'm sorry, 100% telephone call. And if you've got any symptoms that suggest you might have a coronavirus infection, you go off to a hot hub where you're met by specialist teams. So it's a totally different game. But things are changing.

We have to say positive, and we have to think that things to a degree will return to a normal semblance of NHS and the healthcare service that we know and love. But you'll probably find that GPs might talk to you on the phone more because we've realized how much we can actually manage on the telephone. And that frees up time, it means that we can speak to more patients and address more issues than perhaps historically we could. You were saying that sometimes a significant portion of the 10 minute window you have to deal with a patient is actually taken up with them getting up from the seat, getting through reception, finding the room that you were in.

So take us through. You press the button and your 10 minute timer starts when you say Christopher Williamson, please come to unit five or whatever. Yeah. Yeah, absolutely. So put it in some context. When I was a first doctor and first a GP, I would read your notes, Chris, for about 10 minutes. And I'd be like, right, I know all about you. I'm going to call you in that. And you press a buzzer, because you

think that to have that information, you're something in some way sort of-armed about what's about to happen, which is just total bollocks, because what happens is you come in and you throw something out of left field like what's the meaning of life. And so that's one of the things. So what we do is we, when I press that button, I stand at the door and I go, look, I wait for them to come

down, all right, it's Max, come in, and then you just wait for them to start talking, because everyone will have a preset idea about what they want to say. So everyone has got a preset sort of opening for you sentences about max, this is my problem, this is what I've got and you need to let them get that out because if you don't, you're basically stopping everything that's been stored up inside from them. And then you listen to it and then you ask some more questions and then by about minutes three three you've got a rough idea you should have or certainly I tried to do, you have a rough idea about what you think they've got

and what you need to do. So what's your management plan? So what test you need to do, what treatment are you going to give and what follow up are you going to have. And then the next seven minutes are basically spend making that dream become a reality and getting them out the door at minute time. Because you know if you let it just kind of waffle on and drag on and let them sort of you know give you a warrant piece, what happens is that you don't really get to the meat of the issue, then you find that you can't address all their problems and then you find that then knocks on to the rest of your clinic. So you have to be quite brutal. I sometimes will just stop people and they're tracts and be like, just what, and like I said, when we're playing GP Bingo, what do you think you got? What do you want?

Because then you can make things happen, whereas if you get to 10 minutes and they're still telling you about their first symptom, you know, you can either push them out the door or you can listen, but then you basically make everyone else late for their appointments. So, you know, you've got to be a little bit bullish about it. It seems to me I've got a number of friends who work in healthcare and the junior doctors or on low-chem or whatever it might be. And they have said unanimously that the worst sorts of patients that they get are the ones who come in and don't have a defined problem.

I don't know whether this is people who are hyperchondriacs, whether this is people who are just lonely and want some attention. Do you often come across those? Yeah, we do. And the undefined problem is sometimes the most unnerving problem because, you know, I've had experiences where patients have come in and they've said, like, I just don't feel right. And you're absolutely right. There is a large group of people that are lonely,

that are isolated, that just want to see you to have company, and that really does happen. Or there are those people that think that they might have something, they've gone online, they're Googled, or they have a family member who's just been diagnosed with a cancer. They come and see you, and they don't want to say, I think I've got cancer max. They just say, you know, I just don't feel right. And you had to explore that. And you sometimes hear particularly sort of, or junior doctors say, oh, he or she was a really bad historian. Like they just didn't tell me what, they didn't give me any information. That that's not true. Like, you're just not good at getting it

and you need to, you know, it's your job, you're the detective, your job is to say, okay, well let's pick apart your life for a second, you know, who's at home with you? What's your daily routine like? What's your after life? What are you eating? Bows okay, passing year in, sweating at night,

any weight loss, bruising at all. Like you just go through and you start and your head to mentally tick off this checklist. But then, as you do that, you then come to the third category of the, I just don't feel quite right people. And they're the ones that have got something serious going on, that this is just the first sign of a niggling symptom that then manifests itself. And, you know, you do your blood tests or you do your chest X-ray and you reveal something else.

And that's why it's really important. It's important never to ignore any patient. And it always to listen to them. And I think the one thing that keeps me going is that I've got diagnostic curiosity. You know, I want to know. I'm curious about that. Sure, like old, yeah.

Yeah, and it's, and when you do it that way, you don't miss stuff. If you get Blasey, that's when you do miss stuff and you make mistakes. Yeah, we said. And then they're the ones that suffer. We said on the show last year, the curiosity is the most important personality trait of the 20th century and it turns out not only is that true for entrepreneurs and podcasters, but also maybe for doctors as well. It's pretty cool. Yeah, absolutely and you get bored in a job like this, you know, you're going to switch off. You're not going to think and

Yeah, then there is coming. I love my job. I wouldn't do anything else. I think it's brilliant. You get to see the light and the dark and all the shades of grain between life. It must be the spectrum of people and experiences that you're exposed to must be a real shock to the system at least initially. It is. So when I was working in the city surgery that were the books set, you did. You saw people from extreme affluence, to extreme poverty, to different socio-economic backgrounds, different ethnic backgrounds, with different cultural beliefs around health to all the way to gang members. So, there are people that would be your friends

that you'd think I'd go out dinner with them, they're up to the people that you cross the road. Actually, to avoid. It's like, when I, in the book I talked about, You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice.

You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice.

You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. You were my voice. sort of who are just hovering around the shop door who just look like they want to kill me.

And then I'm thinking, bloody hell, all the many things I need to go and get is a lollipop. So I go and I pick a magnet because I think that's the most manly, masculine ice cream I could possibly get from the shop. And then on the way out, like one of the kids goes, you know, all right, Dr. Max. And it turns out he's one of my patients. And but you just, so you just don't know, you know, you, and it doesn't matter who they are, you help everyone. And because everyone's got a backstory. No one ended up in that position by choice. No one wants to see their GP. I think that's the other thing to say, Chris,

is people don't, unless you're lonely, people don't wanna come and say, I've got a problem. Like, people want to be healthy. It's just inherent with that in us. There was a very small one hour or two people who do like to be unhealthy and sort of be medicalized but I think that's a story for another day. But you know, majority of people want to be healthy so they don't want to see us and I think that's the other thing that we need to bear in mind

It's an interesting dynamic, isn't it? For the relationship between there's very few things that you have to go out of your way Like maybe the maybe the tax man, you know or maybe like the people that deal with that environmental health If you've got you don't really want to go and see the people that deal with that environmental health, if you've got, you don't really want to go and see the guy that cleans your drains out, but even that's not. Yeah, I mean, I mean, there are, there are lots, you know, there are lots. People don't, you know, we like to think people like seeing us, but actually, you know, making a mature, situation, mate. That's what you do. Yeah, exactly. I didn't know that doctors had performance target. How does that work?

So I think what people might not realize is that a GP surgery is essentially a business. I mean, it makes its own profits. And what happens is there's something called quality and outcome frameworks, which is QWF, which I really don't want to bore your listens with, Grace, because it really is for the insomniacs to hear those. But in a nutshell, you get, if you have, you know, 10,000 people and 1,000 of those have high blood pressure, if you can control 95% of those people's blood pressure to within a certain target, you will get extra payment. So basically they're saying, well done, you've kept their blood pressure in good

control, which means they have reduced risk of cardiovascular disease like heart attack or strokes. Therefore, we will reward you with a financial enumeration. And the concept is that by doing that we are setting all these health indicators that if we can meet those targets, those targets are linked to research that says if you do this, if you have this in this person, they will be healthier and therefore they will have less morbidity, i.e. ill health and less mortality, i.e. death. The issue I have with it is that it's retrospective. It's going, this guy has got high blood pressure, brilliant. Right, let's give him a medication. Check his kidney function blood test once a year, check his kidney function blood test once a year, tell him to exercise and reduce his salt content, get the blood pressure down and tick with our, our, our, our

quaff indicator, our target. What should happen is they should say, we'll pay you for the amount of people that you can keep off of that high blood pressure register. We'll pay you to say think prospectively, rather than retrospectively, to think prospectively and say, you, as a practice, do everything you can to keep them within a healthy body weight, having a healthy diet, exercising, and naturally keeping their blood pressure down, we'll reward that. Yeah, I mean, and it doesn't work like that for every target, but there are lots of, you know, you know, but lifestyle is, you know, the buds, sort of buzzword of the, you know, the 20th century, but it's rooted in fact as

well in science, that if you can do the basics really well, you don't need drugs and you don't need interventions. It's interesting thinking about the parallels between physios, physiotherapy and doctors, because there's a perverse incentive, bizarrely, with a physio, in that when they get a person better, they no longer get paid off that person and it's kind of this quaff thing is kind of somehow working, deriving its metrics of success from that in a weird way. Yeah, they are, but I think the one thing I would say is that even with any healthcare professional

whether it be physiotherapy, occupational therapists,, speech and language or nursing staff, doctors, and there are always patients, always, always. The world keeps turning, people keep getting older, people get muscular, skeletal problems and you see a physiotherapy. It will never be short of supply. How, if you were to coach everyone who's listening, thousands of people that are listening, if you could coach them through how to be the perfect patient, what would you tell them to do?

What can we all do to make your lives easier and to also get better outcomes ourselves as patients? Okay, all right, this is a good one. So let's go with top three. So, top three, number one, turn up on time. Okay. But I appreciate there's probably going to be a lot of people shouting at me and being like, yeah, but Max, you're never on time anyway.

So I can see where that sort of therein' lies the rut. Become circular. Two is if you're coming with something like a rash on your thigh, two is dressed appropriately. So if you're coming to me with a sore knee, don't come wearing knee-high boots and skinny jeans because it takes about 10 minutes for you to get that stuff off so I can actually look at you, Ne. Yep. And thirdly, I would say, don't save up your problems. I think that's a really important one. So I have a lot of people that come to me and think

that they're doing the mean this enormous service by going max-i-ver, I've saved up my seven problems because I just thought, you know, you want to see other people around the, you know, in the previous weeks. So I just didn't want to take it. So anyway, here's my seven problems

and I'm dividing seven by 10 minutes or 600 seconds, which, you know, what, you know, which I can't even do the math. Not long, basically. And you can't do it. So I would say two, three at a real push. But I also, I suppose, Chris, I'd sort of put a little alert on that as well, saying that I guess it, because people sometimes say, oh, by the way, I've just got this little thing, and they think it's a little thing, but I, in fact, think it's a really big thing, and you then have to go through a whole process. So, really interestingly, and I get, the one I get a lot is, women might say, I spoke to them,

I can't talk to them about a couple of different issues and then they'll say, oh, probably just as they're going, I thought, I just got this one thing, I just got this little sort of numb sort of just near my breast. And immediately, you think, okay, well, I can't, I can't unhear that. You're off out of the dog club for a close up. And it may, it could be for many reasons. It might be there anxious about bringing you up. And it's like a 15-year-old going and trying to buy a porn mag in a news agency and they

buy about seven different things before they kind of point at the playboy and say, and I have that as well. It's really difficult. But in any case, I've heard it. And at that point, you have to go, well, I have to examine you, or I would like to examine you if they give you permission. And you need a shaperone, so I need to go downstairs to the reception and get a train shaperone from reception to stand and make sure that everything is above board.

And if anything ever did come to light or be an issue, we had a third independent party. And then you examine them and then you make decision, that is that you can't do that in a minute. So I often will navigate that third tip by going, okay, if they say I've got four things, I'll say, just, I don't want you to go to detail, but just give me the highlights, give me the top four bullet points. Then I'll go. Knee pain, lump in the breast, constipation, and I've got sore right,

and I'll go, okay, tell me about the breast lump first. Organize them in the priority. Yeah, you triage them, you all get to dance them in the whole priority. Yeah, you triage them. You triage them because they might not, why should they know that one is more important the other? That's my job. Sometimes you have to be blunter with others than some, but you try and, again, it's all about trying to get as much maximizing the time and what you can give to that patient and not getting annoyed at the same time.

I think not saving it up is a really, really good point. We were talking on this podcast on the pilot episode, like three years ago, about one of the regular co-host, Yusuf, who had a, I'm gonna forget what it's called. He called it Lemon Ball, but it's actually got a very specific name. It's where one of the ducts, it testicular ducts gets placed.

So you had a varicoseal? Yes, I think. Or a hydrosil. Hydrosil fluid. Hydrosil is fluid around the test. So you're scrotum, you're sack on one side, looks like you've stuffed a party balloon in it.

Yeah, so he had had your seal, but even him as a person, I think, at the time who was third year med school, maybe fourth year med school, even him, the inbuilt denial of medical problems ran so deep that even he was like, no, no, it's always been that size.

It's always one's always been a bit bigger than the other, it's fine. It just like gone around and this is how people like you say can almost accumulate this little collection of things. It's like, well, one of them has got to the point where I need to see you about that. And by the way, here's all of the other shit that I didn't bring up in winter room. Yeah, absolutely. And that's the sort of in the introduction I talk a bit about windows and the idea that as a GP, I hold up this window pane and stare into your life. I see your house, I see

your, I'm looking at your life. And there are different types of patients. So you get the patients who come in and say, hold know, hold up the window and they point to their knees and say, Max, you know, I've got knee pain. Can I, can you, can you look at it? And you get those who sort of hold up the window and go, Max, I'm worried about my cholesterol, but then I say, you're worried about your cholesterol, but I've just spied your blood sugar result and I'm worried about you developing diabetes. So different agenda.

And then finally you get people who hold up the window to someone else and they go, I'm worried about my loved one. And they say, you know, I'm worried often it's I'm worried about my aging parent. I think they're getting a bit more confused. I'm worried they're up to mention. So it's not that they are, it's not about them, it's about another person. And they're the challenging cases because you're kind of, you haven't, you can't talk necessarily talk to that person who's come to see you about somebody else. You can't talk to them about, you can listen to them, you can listen to everything they had to say, but you can't necessarily say, here's what I'm going to do. You can say, I can, I'm going to book to have them come in and see them myself. But you can't discuss someone else's

case with a relative if they haven't given permission. So yeah, it's all about windows and journeys. It's interesting that the process of someone who isn't the patient coming in on behalf of the patient, I imagine that must be there's a whole host of different tripwires for both parties to fall over there. Yeah, absolutely. And it gets, you know, it gets a bit muddy when you kind of look at teenagers, you know,

when you start, you know, you phone up, you see you've got a 15 year old patient, she's phone dark and she wants the oral contraceptive pill. And you look at her phone details and it's got a home phone number and a mobile number. And you've got no idea if that's mum's mobile number, dad's mobile number, the guardians move on number, the nannies, all the patients. And then you phone and you're like, hello, it's Dr. Skittle, can I speak to you so and then immediately, like the next day you might get a phone call from the mother saying, what did you talk to my daughter about?

And you have to say, well, I'm really sorry, but it's confidential. And yes, she's under 16, but she has something called Gillick competence, which basically says. She's specific around sort of contraception. So young girls, you want to have oral contraception. It's called Gillick competence. Gillick GILLICK. Gillick and And there's also phraser competences with competence as well, which is sort of a bigger picture. And but it's basically saying if someone is in a sexual relationship under the age of 16 and it is with someone of a similar age, there's no signs of abuse or grooming and they are going to have sex anyway. You know. You don't want to be the doctor that says, well, fine, I'm not going to give you contraception because you're under 16, what you say is, well, if you are not going to stop having sex, I want to be, help you be as safe as you can be

and against unwanted pregnancies. And of course, it's all counseling about safe sex and condoms and STIs is a whole different issue. But if that patient, if that young woman has a young girl, has the capacity to retain, understand, and communicate the decision that they would like to make, you had to respect that and you had to respect their confidentiality. And the only time you would break it

is if you suddenly found that there were signs of abuse or grooming or anything that made you feel that this was a safeguarding issue. But if the mother calls, you have very, very difficult conversations because you're essentially are your duties to the patient. And all you can do is encourage the, the, the patient to speak to her mother. And, and of course you do that, you know, you don't just go, oh, let's keep this secret

between you and I. You say, she, she, you want to talk about this with your mother, because it's a big issue. And I think that, you know, it would be really helpful if she's supportive. And we get that, you know it would be really helpful if she's supportive and we get that you know I get teenagers coming with their mum and saying I'd like to go on the contraceptive pill and it might not be for safe sex for sort of protecting against them unwanted pregnancies it might be because they're having really difficult problems with their menstrual cycle which you know you know, as a GP, as a male GP, I never thought I'd be so comfortable talking about, but, you know, after all these years, like it's not, it's we see it every day. We talk about it every day.

Just a bit of menstruation. Yeah, yeah, exactly. I mean, that's, and because that is normal. I mean, the worst, most frustrating case I had, just to talk about menstruation for a second, Chris. That's right. That's what we're here for. Was I had a teenager come in with her mum, really embarrassed in the school, that actually asked for her to get a letter from the GP to explain why she was able to be

excused from her classes because of her heavy and painful menstrual cycle, which infuriated me because this is a natural, normal, healthy physiological process for women. And it was 100% stigmatized by that school in that moment. And embarrassed that child. She was a child, you know, she was sort of 14 years old. And embarrassed her for the fact that she has to hand a letter to her teachers. So then I basically said, well, fine, here's a letter. But I'm going to extend my escape of that

letter and say that teachers are not to be asking her what she's leaving the classroom for. So for all I know, she can go out whenever she wants now. So it's a point in. She's got this free whole class, yeah, exactly. Yeah, but the point, and also the school can pick up the phone speak to me if they want to talk about anything else because just a child 14 year olds should not be made to feel like that. And just their things that I feel just really strongly about like you have to fight these people's corner because people will say, no, that's normal, you need to say, no, you shouldn't be stigmatising, something that is a healthy process, a normal physiological process in women, and making this young girl feel uncomfortable,

and make her feel potentially more uncomfortable about talking about it, with other professionals in the future. Any harder? Well, we spoke recently on this show to do with the peak end rule. Have you heard about this? No. Okay. This might be interesting for you as someone who has to deal with a high volume of patience. You don't want to cause problems.

The peak end rule is a psychological bias that suggests our memory applies a higher weight to the most intense and the end of any experience. So, let's say that you're going in a roller coaster, you will remember the most scary bit and the last bit. And the original study was conducted during endoscopies. And what they found was that they could actually extend the length of time that someone was undergoing the surgery and bring their level of discomfort down at the end, and the rate of perceived discomfort retrospectively ended up being significantly lower, even though by every objective measure, they'd actually left it in for longer than it needed to be.

And I wonder, when I was thinking about that, there was this quote where they said one of the most compassionate things that you can do for a young child, your young child that's going to a doctor's or a dentist or whatever, if they're going to have something that's going to make them feel uncomfortable is to do that is to almost extend it and dampen down the discomfort toward the end because over time that compounding effect that girl now you could hit the nail on the head, could be terrified of talking to anybody in authority about anything to do with her body for the rest of life, or a three-year-old that needs to have a complicated dentist operation, and it goes a bit painful and whatever, and that's it, rest of your life, terrified of the dentist. Big implications here. Absolutely. And because of that, I think that you strip the medicine out of it, being a GP or being in healthcare in general, you have a huge responsibility because every patient contact you have, particularly with children, you are setting the tone, you're

setting the tone, you're setting a bar at which their experiences of seeing a doctor or a health care professional, which is why when I see kids, it is as fun for me as it hopefully is for them. There are stickers, we talk about their favourite toys or what sports they like, and often they don't really even realize that they're being examined or that we've done a consultation. And and in the same measure, whenever someone comes with a parent, you talk to the you talk to the child first, like it's you don't talk to the parent and I and that's really been important because they need to realize that you are my focus, it's about you, so I'll be like, Mum and Dad, just sit tight for a second, I want to hear from a little Suzy. And then I'll chat to her and then at the end I'll go, Suzy, do you mind if I

ask you Mum and Dad some questions as well? And more or lot, let's say, yeah, fine. Because it has to be about them. And then, and then they enjoy it. And one of the, you know, most rewarding thing about, about my experiences working in a city GPs that, um, I'll get kids to come back and want to see me. Or even it's a sister of a little boy that I saw, but the little boy wanted to come with the sister because they were coming back to see me and they wanted to have another sticker. Which is great. Which is great.

Which is great. Which is great. You don't see Dr. Skittle, yeah, that's cool, man. Which is really nice. And actually, you know, whatever all the shit that happens, it's stuff like that. This is really heartwarming and it just makes me love love the job and I spoke to a patient

the other day who was having a real change of life direction, had got through some quite difficult mental health issues. And he was like just to say thanks, like you totally changed my life and it's not about change of people's lives and it's, it's, it's not going to do that, but my god, it was really nice to hear that actually you had that kind of impact. That's really lovely to hear. I tweeted something similar the other day that said, if you love your favorite content

creators, tell them that you enjoy their content because a message means an awful lot more to play count. And it's the same for you, like just getting someone better, that is more than sufficient. That's why you say it over and over again in the book, you do it for that reason as a caregiver. But someone coming back to do that must really sort of drive that nail home. It does, it really does. And that's, yeah, I mean, I love it. I mean, that's, you don't go looking for it and you don't sort of go to, I certainly

like go to work every day, expecting to see it or hear it, but when it comes along, it's lovely. Pretty special, yeah. What do you wish that Dr. Skittle from five years ago knew that you know now with regards to work? Or if you've got some junior doctors, perhaps, ones that are just about to graduate,

or ones that are on low-come and about to go into. What are some of the things that they should know or that you wish you'd need? Well, that's a tough question. Let me just think about that for a second. What would I want to tell somebody? Just what are your... Yeah, if you move free. that it gets easier in many respects, that the sort of the conscious processes that you go through as a doctor get more automated and when I see a patient now I don't think, right, what is their presenting complaint? What, what's their past medical history? Right, what's their drug history?

Right, what's their social history? It just comes out in a conversation. And I think that's what I would say from a professional perspective, from a personal perspective, I would say, always look after your own well-being as well. Because you can burn out very easily as a doctor if you, or an nurse or any health care professional.

If you just don't eat, don't drink, don't sleep, don't look after yourself in some way. Don't look after yourself in some way because if you do that, you're then no good to the patient. You need to help be really blunt. You blunt, being really blunt, you need a healthy GP. If you get, you pick a per, a burnt out, exhausted, just emotionally shattered, shall of a man or a woman. They are not going to want to help you at 6.30 on a Friday, if you're the umpteenth patient they've seen, and that is their capacity. You need someone who is just ready to keep going, feels fresh, and that's why it's so important.

And also partly, I really feel like I should explain this. Why we don't work five days a week in clinics. I don't work Monday to Friday seeing patients every single day. There's one day where I do something differently. That's because emotionally you can't handle that burden and you would really burn out quite quickly. I found that so interesting. Partling insight that I'd love to get from you is how doctors deal with the emotional distress and trauma associated with the job because you get taught all of the things that you need to do, but from again speaking to a ton of buddies that have been through

med school, it doesn't seem like there's a massive amount of exploration on how to deal with being able to save a patient's life that you really cared about or hearing a sad story about a family member who doesn't want to come in or any of that stuff. What are some of the ways that you've found are effective for getting through that? So I mean for me I've always found that I've been able to manage those things quite well. But I think what really helps is the things that help all of us, you know, it's exercising, it's trying to eat well and talk into your friends about these things or talking to your loved ones. And just decompressing, writing a book, I don't know, you know, you've just got to find

ways to get through it, but people will deal with it very differently, you know, and general practice is an interesting one because you get characters in your GPs who are incredibly soft and softly spoken to very brash and brutish and everything in between. And I think that there's no big lessons. It's just about this knowing, doing gap. I think we're all in intelligence. We all know what we should be doing. We all know what helps someone de-stress and process work stresses. It doesn't have to be just being general practice or healthcare. It's about recognising what you

know you should be doing and actually doing it. I think sometimes that's the gap. So, for example, for me at the moment, I know I have an exercise for about four weeks. Right, absolutely no, that I should be doing it, but my God, Chris, I cannot drag myself out for that first run. James around soon, don't worry, Max, James are over. We don't know how long for. So we've got, there's some really cool takeaways here. I love the idea of turning up on time, dressing appropriately and not letting everything build up, hopefully will have helped a bunch of doctors and potential med students as well. I mean, yeah, I didn't get around to this,

but another tip would be don't come in and show me a photo of your asshole. That would also be, was it a photo or a video? It was a photo, a photo, like a sort of brown drawstring bag. And I was like, well, you know, what do you want me to do with that? I need to see it. Get it in there. I need to see it. I need to see it.

I've actually had, it's been interesting a few weeks. I've had quite a few dick pics recently actually from patients. So, it's all clinically indicated. Yep. But, you know, it happens and you have, and that's the other probably one of the golden takeaways is don't be embarrassed. Like, I've seen it all. Your GP is seen it all. Like it's don't be shy about talking about problems with your Uranus or a vagina or a breast or

what happens during sex or pain during sex. Like it could be a symptom of something. So just talk to us about it and a good GP will make you feel comfortable when you do that. And I think that's the real litmus test. You know, you had to feel comfortable as a patient with who you are speaking to. And that's something that, you know, I work to every day. It's just an asshole. Everyone's got one. That is the parting note of Dr Max Gittle. Did it have been on the back of the book, didn't it?

It's just an asshole, everyone's got one. I would usually add be, hey man, what do you want to plug? You're people to find you, but you are actively anonymous. So all that I can say is the secret GP will be linked in the show notes below, go and check it out on Amazon. Really cool read, fans of Adam Kay. I've also got Chris Dorke, you see, from Justice On Trial, coming on very soon. It sounds an awful lot like he's the, he's going to do the litigative, the lore side version of this. So that'll be really interesting. But man, thank you so much. Love the book and good luck getting through the rest of Coronavirus. Thanks Chris. Take care. Offends, get offends