Black Wednesday had arrived and along with it, a familiar feeling; like I was going to be the only doctor present at the scene of a simultaneous cardiac arrest, status epilepticus and anaphylaxis. Looking back, the probability of all three occurring at the same time seems low to the rational mind, and even lower considering I was starting a new job as a GP FY2.
Chances are, I actually knew how to treat a status and anaphylaxis, but rashes, toenails and ears, I did not. Naturally I was apprehensive about starting work as a pseudo-GP. It was different kettle of fish, perhaps even a different species altogether…
In fact, I was relieved when a left sided chest tightness or a right upper quadrant pain arrived. I had seen it a dozen times in hospital and I knew what to do.
Working as a GP meant being comfortable with uncertainty.
Why was it that I felt comfortable working 12-hour shifts, six days in a row in acute medicine more than an 8-6 job in general practice? The answer… uncertainty. Working as a GP meant being comfortable with uncertainty. It meant being able to shift from melanoma to depression, from hypertension to croup. It meant being able to send a patient back home based on a ten-minute assessment and being able to sleep at night sans panic attacks. This was not something I was used to.
I had worked in luxury! Every patient wheeled in was accompanied by bundle of clues: blood results, ECG, chest Xray, and if you’re lucky, a Consultant A&E review. We are the tools in GP-land. Our own two hands measuring temperature and BP (which in all honesty I’ve never had to do in hospital), eyes to inspect, and ears to auscultate. My five senses and a pen were my kit. I had to start trusting myself more and work with what I had.
This was particularly true on home visits. I once found myself in an oxygen-deprived smoker’s home who complained of low back pain radiating down both legs and urinary retention. Stuck in an odd half-on-half-off position in bed, surrounded by an irate daughter and a cachectic dog in a pelvic sling, this was not the ideal environment to examine for anal tone (it was not a pleasant situation for the dog either, who I was told was to be put down the following day). I had to make a clinical judgement based on minimal information and in a short amount of time.
Time is a valuable gift in general practice. It is the prescription of choice for most ailments that come in through the door, one that was not on my personal formulary in hospital medicine. However, to decide whether surveillance is the best option necessitates a careful clinical assessment.
In hospital, the patient is seen in a specialist clinic or has a senior review on a ward round with instant access to the patient should the decision change.
In the community, there’s no going back to check ‘just one more thing’ or have hourly NEWS scores to highlight things taking a turn.
In the community, it is based on a ten-minute appointment where the patient then leaves to drive their kids to school or work on a rig. There’s no going back to check ‘just one more thing’ or have hourly NEWS scores to highlight things taking a turn. General practice as an FY2 involves a lot more risk-taking than working in hospital medicine.
I think that all foundation doctors should do a placement in general practice if they are able to. The skills I have picked up so far in general practice are unique yet transferrable across all aspects of medicine. I have broadened my mental gallery of conditions from infant jaundice to metastatic breast cancer. I have followed-up my own patients and worked through their anxieties. I am better at venepuncture using Monovette needles, because butterflies are a luxury. I am able to manage non-life threatening conditions like acne and fungal nail infections and understand the impact they have on quality of life. Working as a GP FY2 has improved my practice globally. Even if you have no interest in being a GP, it is worth getting a glimpse of what it’s like in the community. If nothing else, you will never again write “GP: check bloods” in a discharge letter.
Photo by: Hush Naidoo