“LADIES-S-S-S-S AND GENTLEMEN-N-N-N! Ten-n-n-n minutes till we open! Just ten-n-n-n minutes!”
The ringmaster looks out of the upstairs window as she imagines calling to the crowd. It’s 7.30am, and the queue is winding around the corner already. The surgery glows like a ghostly coliseum in the dark. The crowd stamp their feet and blow into their hands in bitter protest against the relentless wind.
It’s a typical Monday morning in general practice. And soon enough, it’s showtime. The silence is broken as the clock chimes 7.45am, and the doors swing open. The stampede of feet echoes like distant thunder, pierced with the incessant shrill of the phones. The simultaneous sound of kettles boiling and computers booting herald the start of the day. The GP plasters a smile on her face, brushes lint off her jacket, and welcomes the first act into her room.
It’s a little fire-breather. Led by her exasperated mother, she toddles in coughing and spluttering helplessly into the doctor’s face. Mum thinks she needs antibiotics. Trying to unravel the squirming child from her six layers of clothing, while juggling the thermometer and explaining antibiotic resistance over her squeals (she’s spotted the reel of stickers already), is an act of its own.
Eventually the mother has to be ushered out with her now beaming fire-breather in tow, puffing out her chest and sporting her new sticker proudly. Ten precious minutes have somehow been swallowed.
The next act is a sequin-clad lady, who’s terrified. She’s seeking an explanation for why faeces is oozing from the pores of her hands. It’s not her fault – she’s suffering from delusional disorder. The ringmaster delves deep into her box of tricks for the remaining six minutes, trying desperately to allay the lady’s fears. Crisis averted – until next time. She’s still got several months’ wait before she can be seen by the community mental health team. The ringmaster closes the door behind her and lets out her breath, silently praying that she’ll be able to continue the fire-fighting until then.
It’s back to the children for the next act. A “human cannon” this time, in the words of his mother. He charges into the room and is soon bouncing off the walls, decorating the room with paper towels, urine dipsticks and purple gloves. The doctor lends an empathetic ear to his parents, while gently trying to wrestle the computer mouse from his grip. It’s clear the family need to see the hospital paediatricians for his suspected developmental disorder, and their patience is running out with the promises of support from his school. It’s a six-month wait for them on the NHS. There’s nothing the GP can do. The difference in the speed of care they’d receive privately is the elephant in the room.
The difference seems even starker when the next act waltzes in, a flamboyantly dressed singer twirling his cigarette baton absent-mindedly. With dramatic gesticulations, he asks for a private respiratory referral to “sort out his chest” for his next audition. The GP’s advice that all he actually needs is help to stop smoking falls on deaf ears – again.
Cue the day’s first SPR (silent printer rage): another four minutes eaten up by a printer refusing to be fooled by the off-on tactic. Her heart sinks a little bit further.
Running half an hour late, she apologises to the patient who’s up next. It’s an elderly gentleman who’s been a regular for many years. He has lung cancer. The main house lights dim as the doctor reaches out and places a hand on his. Together they visualise the tightrope he’s balancing on. His imploring eyes seek help to chase death from the room as it inches closer. Her emotions have been pulled from one spectrum to another. She is humbled by the patient’s grit and stoicism, and can only listen with a lump in her throat.
The gentleman comes in every few weeks just to talk. It’s the only place he feels he can unburden some of the weary load he carries on this lonely journey. With a heavy heart, the GP resolutely ignores the alerts on her computer screen prompting her to check the patient’s BMI and his ability to remember the dates of the second world war. That puppetry won’t steal the show today.
The doctor tries to clear her head before the next act: a little juggler. Her stooped figure shuffles slowly in, manoeuvring a giant shopping trolley around the door. Knowing a true intermission is never going to come, the doctor uses this first MRT (micro relax time) of the day to catch a breath. Eventually, the patient finds her way to a chair. Out comes her prop: the list.
It’s the inevitable consequence of waiting so long for her slot. The GP sees her last name scrawled in capital letters across the top, and tries to steal an upside-down glance as the patient begins to rattle through it. Summoning the energy from her caffeine-soaked brain, she listens attentively, while sketching out management plans and staying alert for cues to check she’s not missing anything. A dismissive comment about sleeping problems catches her attention, and she gently steers the discussion towards this. A whole new story begins. A torrent of tears follows, and 20 minutes later the patient shuffles out. The list lies forgotten on the chair. But the GP knows a small weight’s been lifted off this lady’s shoulders today. That’s one less item for her to juggle - for now.
“I look like an elephant now doc,” the next act declares. The GP has been trying to get the better of this elderly man’s leg cellulitis for several weeks. A trip to the hospital is the last thing the patient is hoping for this morning. Finally the doctor sits back in her chair and concedes that the bugs have won this battle. Defeated, the next half an hour is spent trying to persuade the patient she’s run out of options, get through to the medical registrar at the hospital, write a referral letter and organise transport.
And so it continues, the same as every other morning. Another 14 acts pile in one after the other before lunch; a sprinkle of SSBs (super smiley babies) help a little. All the while she’s trying to remember that she’s meant to tell smokers to stop smoking, drinkers to stop drinking, and to wave her wand at obesity. And stretching her superpowers – to assess homes for new boilers, spot potential religious extremists and, as one MP suggested, advise older people on staying married.
Another lunchtime is spent writing letters, chasing referrals and returning phone calls and emails. Everything must be done accurately and safely, before the second half begins.
Twelve hours later the curtain comes down. The doctor still has to fit in a home visit before she can hang up her hat for the day. She always avoids looking into the waiting room on her way out in case she catches sight of yet another newspaper headline vilifying GPs. Some of the admin team are still there, picking up the pieces backstage from another hectic day.
Her patients aren’t acts, of course They’re just seeking her help. There’s no audience. And she’s nothing more than a compassionate GP trying to do her job.
Sometimes it’s her that feels like the performer, trying not to get caught up in the political circus outside. She feels like her days are spent spinning plates that balance precariously as they oppose invisible forces: her duty to address each patient’s agenda while gate-keeping precious resources. Then there’s a need to sift through each script to separate clinical need from inappropriate demand, her role as the patient-centred port in a storm offering every alternative, yet knowing when to just take control and steer, and balancing micro-management from the top with her autonomy to care for her patients in the way she knows best.
She’s surprised there have been no smashes yet. Primary care is the bedrock of the NHS, dealing with 90% of all patient contact. And it’s the most efficient part, costing less per patient per year than a Sky subscription. But it’s constantly being asked to do more with less.
She still believes she’s privileged to have such a leading role in the greatest show on earth, watching individual scenes and storylines unfold before her eyes. But she can understand why there aren’t many new recruits waiting in the wings.
And somehow, as if by magic, the ringmasters know: the show must go on.
