My number one learning-point as a GP registrar

Laurence Dorman is former Chair of RCGPNI and is a GP in Kilkeel where he has interests in palliative care and early cancer diagnosis. He is on Twitter/X: @laurence903

Dear Colleagues,

Please allow me to offer my own personal best wishes to all Specialty Trainees who are joining practices this month in Britain. The main challenge I found during my training was the difficulty in trying to deal with multiple complaints in one single 10-minute consultation. Each ‘consult’ could contain coughs, rashes and sore big toes causing my head to spin.

A wise piece of advice helped enormously.

“You don’t have to solve every problem in a single consultation,” advised my father.¹

My Dad, Dr David Dorman, worked as a rural GP in Northern Ireland for 40 years. He was a passionate educator and provided family care through the worst days of the troubles.

He highlighted his point with a story about one of his patients – a 5-year-old boy called “John”.² A traumatic experience of childhood vaccination had left John with a deep-seated fear and mistrust of medical professionals. It thus took enormous effort for John’s mum to bring him into the surgery.

“I think one of his testicles is not right doctor” she advised. Through considerable persuasion she and my Dad managed to wrestle John into submission where Dad confirmed an undescended left testis. “He will need to be examined in hospital” advised Dad out of earshot of John.

Months after writing the referral, Dad was telephoned by the distraught mother. “Dr David” she began, “I am so embarrassed. The appointment to see the surgeon arrived last week, but no matter what we did, we simply could not get him to go… What will we do now?”

At that time, hospital consultants performed domiciliary visits to patients at the request of their GP colleagues. It was a valued service, and one Dad did not use lightly but it appeared to be the best option.

The surgeon was the last of his generation of exceptional generalist surgeons working in the local District General Hospital. He performed a wide variety of operations including hip replacements while also dealing with the multiple traumas from civil unrest. Dad wrote to his colleague who dutifully arrived at the patient’s home one afternoon. Spotting the strange car from the front kitchen window, John sensed danger and quick as a flash – before anyone could stop him – bolted straight out of the back door and was across the fields. Well beyond any medical reach!

Dad was embarrassed, feeling he had inconvenienced his colleague for no good reason. He rang to offer his apologies. “…I am so sorry about this” he began, but his surgical colleague reassured him “Don’t worry at all about it, David” he said. “These things always work out fine in the end. We’ll catch up with him soon – you’ll see”.

Sure enough, almost one year later a sore, an evidently unwell John was carried into Dad’s surgery by the mum. He had right iliac fossa pain, too sick to protest. Dad diagnosed acute appendicitis and arranged for him to be admitted to the local DGH where the same surgeon (who happened to be on call) was waiting for him!

There he deftly removed John’s appendix and with a wry smile also performed a skillful orchidopexy, gently securing the left testis back down into the scrotum where it belonged.

My number one learning point as a GP registrar was to use time as a diagnostic tool. You can’t solve every problem in a single consultation, so don’t be afraid to agree a particular course of action, with the option to return for a change of plan – or possible escalation. In my early days when still unsure of my own skills, I ensured these reviews were specific, rather than putting all the responsibility on the patient. “Mrs Jones: let’s try this medication for your heartburn/sore toe/piles” I would advise, “But I would like to review you on the 9th of next month at 2pm. I have already made the appointment, but if your symptoms settle, please do not hesitate to cancel it.”^3,4

I hope you all enjoy your training and learning about general practice – I’m looking forward to welcoming you to my own surgery and working with you.

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Deputy Editor’s notes

1. Dr David Dorman has given explicit permission to be quoted, and this been confirmed to the BJGP Life team and all other names in the story are fictional. The events took place many decades ago and patient consent has not been possible, but care has been taken to anonymise the story as far as possible.
2. This is a patient ‘archetype’ rather than any one particular person
3. For an InnovAIT article on cases and writing about them see Salisbury H, Dixon S, Papanikitas AN. Everyday clinical dilemmas. InnovAiT. 2017;10(8):442-447. doi:10.1177/1755738017710963https://journals.sagepub.com/doi/10.1177/1755738017710963

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