The gatekeeper and the wizard: fan fiction

Wizards aren’t just characters of a mysterious nature sometimes found in Middle-Earth. They are also helpful in depicting the relationship between primary and secondary care doctors. Mathers and Hodkgin wrote such an article in 1989 and there have been a few sequels published since. Although the original paper is nearly 30 years old, it is perhaps more relevant today than it was when first published.

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Learning objectives

1. Read The Gatekeeper and the Wizard: a fairy tale

2. Consider what the future has in store for generalism

2. Have you endure my fan fiction

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Have a read of the original paper available (a full text PDF is available here: http://www.bmj.com/content/bmj/298/6667/172.full.pdf).

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Questions

What do you think about the gatekeeper function of primary care physicians?

What do you feel patients think about the gatekeeper role?

Has the perception and function of the gatekeeper role changed since the article was published in 1989? If so, how and why has it changed?

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Some influencing factors on he role of the gatekeeper include changes in patient morbidity, patient expectation, advances in medical diagnostics and treatment, increased availability of medical information and litigation culture. However, it’s not just patients who have changed, doctors have too.

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Questions

Can doctors in primary and secondary care remain objective in their opinions about the other when the patients they are exposed to are so different?

Should doctors bother to try to understand each other better?

Has the divide between primary and secondary care widened or not?

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The term “gatekeeper” or “filter” being used for general practitioners could be considered demeaning. Conversely, there this old joke: What’s the difference between God and a surgeon? Not even God thinks they’re a surgeon.

Here come the cringe part. I’ve written my own fan fiction sequel and we all know how bad sequels can be…

It was a strange time in the town. The magic potions were stronger and the people were living longer. Yet, the people were not happy. They felt more poorly than ever and said the Queen was to blame. The ministers knew that if something wasn’t done quickly that there might be a revolution. The Queen decided to jump before she was pushed and abdicated.  After a short but nasty struggle between the contenders for the throne, a new King emerged. He knew he had to secure his position quickly and decided to placate the people with new promises. He told them that he could make the queues in the courtyards smaller by reorganising the system and they wouldn’t have to pay an extra penny. Indeed, if the Gatekeeper and the Wizard did not become more efficient at their work he would pay them less. The King wasn’t stupid, he delegated the task to his minister so that if anything went wrong he could blame the minister but take the credit himself if the people were happy again.

The minister created some targets for the Gatekeeper and the Wizard which would have to be met if they wanted to be paid. Interestingly enough, the targets were mostly met as the Gatekeeper and the Wizard were already super efficient. There was actually an unintended pay increase. Yet the queues got bigger because there were more people and those people felt more poorly. This put the minister a difficult position. She could not ask the King for any more money since increasing taxes would surely put him at risk.

The people weren’t stupid. They knew there was another way to get to see the Wizard without having to wait to see the Gatekeeper. At the back of the castle was a special entrance where only the most seriously poorly were supposed to visit. Some people decided that instead of waiting for an appointment with the Gatekeeper they would go to the special entrance instead. The Wizard tried to tell the people queuing at the special entrance that many of them should be seeing the Gatekeeper but because the predictive values of the crystal ball he found it hard to separate the the genuinely very poorly from those who were just worried about being very poorly. In the end the Wizard had to see most of the people using the special entrance and this cost even more money as lots of crystal balls and magic potions were used ‘just in case’. Word spread amongst all the people in the town and soon it became normal for them to turn up at the special entrance expecting a magic potion.

The minister thought it a good idea to try and better educate the people about their own health and trying to keep them away from the special entrance. However, this seemed to make the problem even worse. Telling the people that some common symptoms were potentially serious and that they should see the gatekeeper meant the queues got even bigger. The spread of the new google religion compounded the problem since the google fanatics only preached interesting stories about when common symptoms were actually the result of rare but serious diseases. They started to circulate poorly translated fragments of the Wizards spell book which some people liked reading but made them more worried and anxious. Eventually, many people didn’t know what a medical emergency was anymore. Waiting even a little while to see the gatekeeper seemed dangerous.

The minister then had an idea. What about moving the Gatekeeper to the Special Entrance! Alas, when the gatekeeper was directly outside the special entrance he started to work more like a Wizard because there was a crystal ball nearby. This also confused the people because they no longer knew who they were seeing and kept coming back for second opinions. Costs soared, the minister resigned and ended up as an experienced adviser to a merchant providing private magic to those who could pay.

The King appointed a new minister. The minister wanted to impress the King and the people. He also had an eye on impressing future employers like his predecessor. He promised to reorganise the system again to make it more efficient without increasing taxes and chastised the Gatekeeper for earning more and doing less. The minister forced the Gatekeeper to take charge of what money was available which he very well knew would not be enough to satisfy the people. This option not only protected him from the anger of the King but also deflected the anger of the Wizard and the people to the Gatekeeper. The people became increasingly confused and polarised in their opinions of both the Gatekeeper and Wizard; some defended them while others began to resent them as they felt they were not getting value for money. Some suspected that this situation suited the King perfectly.

The Gatekeeper and the Wizard felt sad and thought about retiring early or leaving the town to find another King or Queen to work for. Indeed, some of their young apprentices had already made the decision to leave before they had completed their training which was quite concerning but that would be a problem for another King or Queen in the future.

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“The value of a diagnostic test depends on the prevalence of the condition in the population tested”.

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Questions

Can doctors in themselves be considered diagnostic tests?

What is the value of the Gatekeeper?

Is generalism a specialism?

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Some papers, like the Gatekeeper and the Wizard feel like they have become embedded in the culture of medicine. They crop up in unexpectedly in discussions between colleagues, often years after publication. Sometimes students are exposed to them by more experienced clinicians, but these lessons are not part of any formal teaching programme or curriculum. They do not appear on any exam paper but do influence the way in which doctors think and work. If you can think of any other such papers please comment below.

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Summary

As the patient population changes so do doctors. The term “generalist” in medicine might be an oxymoron. See, there was some point in learning statistics at medical school.

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Further resources