due to be published in BJGP in November 23

Dr Iain Bamforth floats a teasing but fundamentally challenging question asking if all people who
visit the doctors are patients. (1 )While this may be almost unilaterally true of secondary care (although
perhaps there may be some hospital colleagues who disagree!) it opens up a far more nuanced
discussion in Primary Care.

As with all things, it is language that creates the starting point. Doctor from the Latin word ‘to
instruct, teach or point out,’ Nurse from an old French version of the word ‘to nourish’ and Patient
from the Latin ‘to suffer.’ It is common shorthand for those in the waiting room to be referred to as
patients, regardless what it is they may be coming in for. But are all those who come actually
suffering?

While language can illuminate it also has the capacity to divide and subjugate. One of the shadow
consequences of the Victorians drive for taxonomy was to create race and hierarchy, and the power
structures that exist implicit within these ideas. When we talk of doctor and patient, we instinctively
see both as very separate groups. Traditionally the medical system is very patriarchal with the doctor
taking on a very didactic role, and the patient expected to be the passive and grateful recipient of
whatever treatment plan was arranged. However much of our modern training has been to see the
relationship as far more equal, or a meeting of ‘two experts’ as Professor David Tuckett describes. (2)

In many ways having defined roles makes things much easier, the clinician is there to help and the
patient to be helped. In terms of the anxiety and uncertainty that an appointment is likely to create,
this structure promises uncomplicated boundaries which should be straightforward to navigate.
But what of the moments when these labels become prohibitive rather than transformative. As we
have all experienced in Primary Care, not all those who come are needing urgent tests nor action. A
great many come in for advice, to discuss a situation or family member, or simply to see what
support is available for something that is ongoing. Does a discussion about the merits of having a
PSA test make someone a patient, or whether to be on statins or that they are struggling with their
child’s behavior at home? What about if they are at the end of their tether about the decline of an
aging parent or their marriage is breaking down?

An increasingly pertinent topic is the menopause, are all women going through this patients? Does
something become medical once medicine is given for it, if that is true then does prescribing HRT
convert the menopause into a medical condition? Does being pregnant make you a patient?

This seems to reveal the area of grey in which Primary Care exists. At what point does the presenting
complaint cross the porous barrier from being a human issue to a medical issue? You only have to
look at the recent increase in options for mental health diagnoses. The DSM, for example, was first
published in 1952 with 102 categories of disease, whereas the DSM 5 TR which was published in
2022 has well over 300 (‘Prolonged Grief’ being one of the latest diagnoses).

At the nub of GP practice is the relationship that is fostered between its participants. A potential
sharing of knowledge, experience and expertise. An awareness that the person sitting in the chair
telling their story could one day be the reality of the person listening. The two protagonists are
perhaps interchangeable depending on circumstance, time and place. There is a deep reciprocity
when approached from this angle, both have something valuable to give the other, both have
something important to receive.

Stripped back of language and assumed meaning, there ultimately sit two human beings in the same
space. Both of whom with the opportunity to share something significant with the other. No
consultation is ever the same, even if it might be with a well-known patient (again I appreciate this
might feel debatable). Undoubtedly we are privileged to temporarily sit where we do on our side of
the clinical line and for this to be our workplace. Even if the current concoction of politics, resources
and workload might conspire to not always allow it to feel that way!

1 Scattered Limbs: A Medical Dream-Book, Iain Bamforth, Galileo Publishing  2020
2 Meetings Between Experts: An Approach to Sharing Ideas in Medical Consultations, David Tuckett,
Law Book Co of Australasia 1985