general practice

Just get back on that horse

“Tom Wolfe was right. You can’t go home again because home has ceased to exist except in the mothballs of memory.” (John Steinbeck, Travels With Charley)

Once you leave something, can you ever truly come back? Yes, you can physically return but even if things are the same as when you left, you will surely find yourself altered by your leaving, your being away and the often difficult path of coming back.

I know from the experiences of friends that after long periods of sick leave, maternity leave and other career breaks, that it can be hard getting back on the medical horse.

I didn’t work a lot last year, and the financial repercussions of my lighter work load eventually caught up with me and my family. This prompted me to look for a way to catch up. And so I came to sign up for two weeks of locum work up north. 9-6, five days a week, plus a busy Saturday morning clinic on one of the weekends. 

As well as the financial motivation, I was also getting sick of being out of the game, and worried that the longer I stayed away, the more likely I would lost all my confidence and would never be able to go back. This was, in some ways, a test. 

I chose a locum in the same town in which my mother (also a GP) works, so if I got stuck I could ring and say ‘where should I send this patient?’ or ‘does this plan sound reasonable to you?’ 

Happily my good friends would also be holidaying near there, my parents live there of course, and other supportive friends had said to ring them if I needed to at any time. My own family would be far away- but there was Facetime. 

The anticipation of the long hours and stress, along with feeling uncertain of whether I still had the requisite knowledge and skills had me wondering if I was making a huge mistake. I imagined all sorts of situations where I would be helpless. The ‘drug seeking patient’ was one scenario I doubted my ability to manage in a way that would leave me and the patient not too shaken by the encounter.

I asked colleagues how they would prepare themselves for returning to work after being stranded on a deserted island or similar, for the better part of a year. Their tips included sitting in with a colleague for a session, which I did. I asked a colleague whose work embodies the kind of practice I aspire to myself if I could observe her, and this proved very valuable. 

Watching and listening as she saw her patients reminded me that this was all still familiar. I would not be at a complete loss. As an esteemed GP e-friend said this part of me would always be there; it could not be forgotten. This part, the doctor part of me, will always know how to develop rapport, engage with a patient, hear them (truly hear them) and respond. To prioritise clinical issues. To weigh up risks, and set out a plan. 

Any small factoids of clinical knowledge that are forgotten or simply hidden from the conscious mind can be looked up, re-learned. 

Another friend of mine, handily also a psychiatry registrar, gave me some mantras to recite to myself as I navigated my way through the nervousness on the first days of work. One of these I think we could all benefit from:

Feelings are not facts.

You may feel out of your depth and as though you aren’t coping, but just because you feel this, doesn’t mean it’s real. Look at what is real. See, you just saw three patients. You’ve finished your notes, you’re walking to the waiting room to call another. You smile at the nurse in passing. Look at you. You’re coping and you’re getting things done, despite the way you feel. As the hours and days pass, the feeling lessens, because it is no longer relevant. It is a false clue, pointing to a false reality.

Because you can come home. It’s different and you are different, but it’s still home and you’re still you. And you’re not alone.  

When the time came, I did just fine.

GPs- up to their elbows in humanity

In medical school we made paper fortune tellers (a hark back to primary school) to see which specialty we’d end up joining. I highly recommend paper fortune tellers as a decision making aid.

I got psychiatry, which pleased me as it’s human brain-related and I was all about neurology back then. My tutor said ‘Yeah I can see you as a shrink. You’re quite… laid back.’ I’d wondered if she was commenting on my near horizontal position in my chair. At early morning sessions I was so laid back I’d be nearly asleep. I’m an afternoon kinda gal.

We discussed our fortunes and our wishes with another tutor, who commented that cardiology, as one of us wanted to do, was ‘pretty sexy.’ I’m glad to say he really was talking about the specialty and not my good-looking friend, or this’d be a whole different post.

When the sights, sighs, secrets and smells of the GP consulting room threaten to overwhelm, well might we think ‘there’s nothing sexy about general practice.’

We’d be wrong.

I grew up with a GP parent and thought of her colleagues as extended family, so my early impressions of the career have been impossible to shake. These were grass-roots country doctors, stitching cuts, taking blood, delivering babies, counselling and empathising. All with a twinkle in the eye and an air of tired-but-calm patience.

Now a GP myself, I am well aware of the challenges and frustrations of the job, but I like to think about its good points as much as possible.

The beauty of general practice, lies partly in its breadth and thoroughness. GPs get their hands dirty. We don’t just adjust our pince-nez and peer down at your new mole. We’ll measure it, feel its surface, get out our dermatoscope and ogle it. Got a sore foot? We’re down on our knees. Got pus? We’ll be there with a swab. Got an itch in your ear? Never fear, your GP’s here, otoscope in hand. No problem is too big, or too small.

If you look at our faces as we examine something you deem shameful or embarrassing, you’ll see interest, curiosity and concern, not horror or disgust. It’s comforting and reassuring to know your doctor accepts you, warts, pus and all.

We love the variety of our jobs. You can come in to discuss your OCD and we’ll happily look at your rash as well (if there’s time- please book a long appointment if you want the full service)!

Another plus is the GP’s versatility. We can see your baby, your partner, your father, your eccentric great uncle- and some suitably qualified GPs will even see your dog. We’ll see babies grow up, see people retire, watch as an illness wreaks havoc on lives, watch recovery unfold gracefully and hope return to sad eyes.

We’ve got skills. We can wield a speculum, insert contraceptive implants, biopsy your skin, help you quit smoking, check your prostate, and teach you relaxation techniques (which come in handy if you’re having your prostate checked). We can question you gently but in a way that uncovers hidden issues.

We are the ultimate holistic practitioners. We’re at home with the foibles and vulnerabilities of the human mind; the functions and malfunctions of the human body. The good GP is approachable, understanding, capable and wise.

Now that’s pretty damn sexy.

Photo from Wikipedia page ‘Paper Fortune Teller’.

Please comment below if you’d like to mention anything else that’s fabulous about general practice! Or to correct my spelling.

Those who can, teach #2

Last week I spent a session sitting in with a GP who works in bariatric medicine- similar to me, but she has been doing it for seven years. I learned a lot during the session. She involved me in the consultations and spent a good amount of time answering my questions and discussing cases. Since then I have received emails from her with useful references and resources. She has also offered to talk with me over Skype about my own cases.

This was all pro bono.

I know. I am duly humbled and very appreciative of the valuable time I have been given.

One of the lovely aspects of the medical profession is our propensity to mentor each other; helping shape junior doctors into kind and expert clinicians who will give their patients the very best of care.

Often this guidance is unpaid, yet many doctors give so generously of their time and wisdom for the sole reason of improving the care of future patients. Part of being a doctor is looking after our colleagues and aiding each other’s learning. As we work for the benefit of our patients above all, their wellbeing is often the only incentive for our efforts.

I’m a member of the Facebook forum GPs Down Under. This is a cluster of GPs in Australia and New Zealand who offer each other advice and support online. It’s a fantastic group. One GP on the forum said she was talking to a lawyer friend about our forum, who was apparently stunned that we were ‘giving our time and expertise away for free’ (or similar).

I wrote recently about my dear friend in Virginia who passed away last month. She was a shining example of a clinician who was dedicated to fostering the learning of her colleagues and students. She would stay up in the evenings coaching residents for their vivas. She tirelessly taught me, fed me, nurtured me, all out of the goodness of her heart. I know she cared for others in this same way, friends and colleagues alike.

The time I spent with her and the rest of the team at Atlantic Anesthesia was so valuable. And they weren’t paid a cent. It’s not like I was a US med student and a potential future member of their team. I was an Aussie med student and future Aussie doc. What was in it for them?

Knowing that some patients somewhere, some day, will receive better quality care as a result of your careful instruction- this is one incentive. The other? Genuine care for our colleagues, wanting to support them in their development as clinicians and help them flourish.

I think that’s pretty damn amazing.

I would love to hear your stories about memorable mentors and caring coaches, who I know are not limited to the healthcare professions.

Image: Dr De Loony as an impressionable med student far from home, in Virginia USA.

Be Patient, Doctor

I’ve been told I’m a really good patient. I think it’s partly my desire to please, to make my health professional’s job easier that reminds me to give a succinct history; makes me compliant to treatment. I also know the value of evidence based care and have the good sense to apply it, with guidance, to my own health issues.

I guess wanting approval doesn’t necessarily mean you will be a good patient. A misguided attempt to lighten the doctor’s load could see you give a history full of holes, or leave some complaints unvoiced. It could lead to over-tolerance of side effects and treatment failure, as you don’t want to ‘fail’ your doctor.

Contrary to popular opinion, I think many doctors make excellent patients. Certainly the doctors I have cared for, and their families, have all been wonderful to treat. An appreciation of the doctor’s role, the capabilities and limitations, and knowing the limits of medical knowledge itself, means you may be more accepting of the care you are given. Your expectations may be more realistic.

When I am treating a doctor, especially a fellow GP, I feel self-conscious; highly aware of my shortcomings. I don’t mind though, as I know they are likely to be similar: self-critical, but very forgiving of others. They know what I can offer, and what I can’t.

My physiotherapist tells me that his doctor-patients are more respectful of his time than the average customer. They ring to cancel if they aren’t going to make it. If they miss an appointment, they insist on paying for it anyway.

I think these doctors are being ‘the change they wish to see’ in their own patients. We would do well to insist our own patients treat us with this much courtesy. Going a little off topic now: what makes a good patient?

I appreciate patients who:

– are on time for their appointments (I try to reciprocate by being on time myself)

– if they have multiple concerns, show me the list at the start of the appointment, so we can prioritise. ‘By the way, I’ve been having chest pains’ is not a good thing to tell me at the ‘end’ of our allotted time. We won’t finish for a long time after that! Try to tell me at the start

– know how long their appointment is and that not everything can be sorted out in the one visit. Book multiple appointments, or a double if you have a lot of issues to sort through.

– ring to cancel rather than just not showing up

– offer to pay for appointments they missed or forgot about

– believe that I care about them, know I’m not a Big Pharma shill, I am their doctor who wants the best for them

– know that I have trained for a long time to practice good, evidence based medicine; that I actually do keep up with the latest science, which believe it or not, trumps google university or watching 60 Minutes on telly

– know that it’s my job to give them the best health advice, but it’s their job to prioritise their health and to implement the advice. I can’t solve all their problems for them, even when I wish I could, and

– are willing to pay me for my time (depending on their financial and health situation).

Many private patients don’t realise that by asking me to bulk-bill them, they are asking me to work for about half my normal rate. After a percentage goes on the practice overheads, tax, etc. bulk-billing an appointment leaves me with about $15 in my pocket. I doubt they would ask any other professional to reduce their hourly rate, just for them, because they just had to pay their naturopath $300 and now they’re a bit short of cash, or say to their hairdresser ‘I know you charge $65 for this usually. But how about today you just accept $37 for the same job? Just don’t pay your mortgage or feed your family this month.’

I had one pensioner patient who insisted she pay the full private fee instead of me bulk billing her and claiming the incentive. ‘My health is worth just as much as anyone else’s. Why should you get paid less, just because I’m old and on a pension?’ She asked.

Why, indeed? Needless to say, she’s been a favourite of mine ever since.

Some things are easy, but GP ain’t

One of the first things I remember noticing as a new GP registrar was the isolation. After working as part of a team for two or more years in the hospital system, suddenly you are in a room by yourself. Managing your own patients. All by yourself. If you have a nice, approachable supervisor then good advice is a phone call or door-knock away, but you are the one who decides when to call, when to knock.

It’s like you’re on an island sometimes, working as a GP. The patients one by one maroon themselves on your island and you try to help them get back to shore. The other practice doctors are like ships passing in the night. Sometimes you blink SOS signals to each other. But they have their own islands to attend to.

The responsibility skyrockets. After working in a hospital where the ultimate responsibility rested with your consultant, as a first term GP registrar, you see patients who are ‘yours’. If they sink or swim, you are responsible. All the enormous problems they carry in with them are yours for the sorting. You are heavy with this weight and can rarely put it down, if you are anything like Dr. De Loony.

There is so much to know. So much that is barely taught in medical school and that you aren’t expected to know in hospital. The whole of dermatology, for instance. Musculoskeletal medicine, the non-emergency kind. Counselling. Managing depression and anxiety disorders. Nutrition. Advanced paediatric medicine.

You are never finished learning. In any branch of medicine it is the same, but it’s a wider array of subjects to learn about in general practice, that are continually evolving. You not only need to read the studies, but also need to assess the quality of the evidence, to determine how seriously to take the findings.

The RACGP exams are no walk in the park. Dr. De Loony considers she was lucky to pass and credits this achievement entirely to her study group. She was not entirely useless in study group, being voted the most likely to ‘volunteer to fetch beers from the fridge’.

If you are going to sit for the college exams, having a small group of peers (ideally people you like) that you study with is my top tip for success. Resources and knowledge are pooled. You cover more ground and keep each other on track. ‘Have a study group’ and ‘Go to Work’ are the two most passed on exam tips I have heard.

For those non-medicos and medicos-who-don’t-know-any-better who think being a GP is easy and you just have to type referrals, print scripts and sick certificates, trust me. It’s not an easy job. Well, it’s not an easy job to do WELL. And if you’re not doing it well, or suspect you’re not, it’s a scary job to be doing.

A GP, slaving away in the trenches, can encounter any problem in any patient. Newborns, children, adolescents, young adults, the middle aged, the elderly… No patient is ineligible for GP attention. They can walk in with anything and they bring with them their own context, history and emotional baggage. The good doctor engages with them and sifts through the history, performs a laying on of hands, thinks hard while tapping out notes (leading some patients to think we are feeding info to the computer that then spits out ‘an answer’).

There is the world of billing to contend with. It takes practice to charge people for your time, especially when there is a strong altruistic element to your work. Bulk-billing means you take a pay cut, but you may do it too readily as you are kind. Your patients ask you to do it, perhaps not realising your take home pay can be drastically reduced as a result of bulk-billing. You end up not being paid enough to do what you do, to work so hard. Resentment brews.

A GP doesn’t sort out one problem and then send their patient back… to their GP. The patient comes back again and again. You are never finished with them. They are never finished having issues. They are never fixed.

It’s not easy.

As a junior registrar I would find myself fretting over clinical conundrums and finally thinking ‘what this person needs is a really good GP.’ Then I realise ‘Oh. That’s supposed to be me.’

Image courtesy of freedigitalphotos.net.

Great Expectations

I’ve been thinking about the rigorous demands society places on the medical profession, the demands doctors place on themselves, and the resulting fall-out.

A recent article in Good Practice discussed the Good Samaritan laws and the now well-known case of the radiologist who ‘failed’ to stop and render assistance by the roadside (at night on a lonely road, with no torch, no phone and no equipment, in a state of shock). She was found guilty of ‘unprofessional conduct’ though later this judgement was, thankfully, overturned. I say thankfully, as otherwise we’d have to change the meaning of ‘D’ in DRABC.

The Good Samaritan laws are not just there to protect doctors. In some states, the law mandates our response in emergencies. Common law apparently obliges no one to rescue another person who is not known to them- unless you are a doctor. In NSW, for example, a doctor may be guilty of unsatisfactory professional conduct if he or she ‘fails to attend’, in an emergency, or to make provision for another doctor to attend in their stead. To me, this amounts to all doctors always being on call, which is hardly fair. Can’t we at least make a roster?!

Does this mean a doctor should never sleep with earplugs, should never get drunk, should never retire, in case it affects our ability to respond effectively to a medical emergency?

Many would argue that this is the price you pay for becoming a doctor, that with the privileges of the profession come responsibilities. To an extent, I agree. However, shouldn’t individual autonomy and humanity come first? And are the privileges really so great?

I certainly agree that we should assist where we can. Where we can! Most doctors have a strong sense of duty without legal dictation, myself among them. Should our actions be a legal requirement, though? We should have the choice, even if the ‘right’ choice is to assist.

I’m still mulling it over and would welcome your input. There has been interesting debate about the case on the Australian Doctor and Medical Observer websites.

I have been guilty myself of expecting too much of doctors. Growing up in a medical family that regarded the rest of the town practice as extended family, GPs seemed to me like demigods, all powerful, unflappable, a noble breed. Is it any wonder I chose GP training in the end, with this upbringing? And is it any wonder that I found myself lacking when compared with this youthful ideal?

I remember, prior to medical school, expressing disappointment with someone’s actions to a friend, saying ‘I mean, she’s a doctor!’ My wise friend replied ‘I don’t like it when people assume doctors aren’t human. They are, with normal human faults,’ or words to that effect.

When I have accidentally let slip to my patients that I am a real human and not some robot automaton, the reactions have varied. To sum it up in the words of a pre-teen, when I mentioned that I see the same physio as her: ‘um, that’s weird.’

I took the hint and try to keep myself, the person, out of consults. However I do sometimes resent this. It is a bit artificial to give nothing of your personal perspective when you are seeing people for people-problems. I know we are professionals and that part of what we offer is impartiality, but there is a limit. Do our patients really want robots?

Sometimes it is a relief for me to have a patient who is also a doctor. I feel they know how much they can expect of me, understand what I cannot provide and that they come with the knowledge that I am a fellow person. Many doctors actually make fantastic patients, in part for this reason.

So, do the ‘privileges’ of our profession really make up for all the demands? With falling rebates, high patient expectations, pressure from the bureaucrats, and harsh judgements like the initial ruling on the WA radiologist, we all may wonder.

A Burnt Out Case

It is a difficult time in Australian general practice at the moment. The government has been toying with Aussie GPs by arranging to cut Medicare rebates. Instead of investing more in primary, universal health care, they are trying to devalue it and make it unsustainable. I can foresee even greater time pressure and responsibility as we try to care for our patients in fewer visits. I envisage less remuneration, with constant pressure from patients to accept a lower fee for the same good quality care.

It is at times like this this that a GP may be even more vulnerable to burnout.

What are some of the warning signs of burnout?

You may notice:

Irritability- increasing exasperation with patient demands, the critic in your head that talks back to patients becoming louder and more voluble.

Feeling empty, drained- with nothing left to give. Certainly nothing left over at the end of the day for the people that matter most; family and friends.

Compassion fatigue- Our capacity for empathy is not endless, despite what we set out believing during medical school. You may become impatient with the suffering you encounter. ‘You’ve got a sore elbow? Oh poor you. Some people have real problems!’ says the critic in your head. Meanwhile, the poor patient is actually in great discomfort and perceives you as uncaring, and the patient-doctor relationship is damaged.

Feeling like a fraud- this is quite common among sensitive, perfectionistic doctors to begin with. You may feel you are unfit to be practicing as you are ‘bound to miss something’ or somehow do the wrong thing (although in reality you are probably a very thorough and competent practitioner).

Disorganisation- feeling unable to cope with the competing demands, to juggle paperwork, patients, phonecalls, getting to daycare pick up on time, getting more and more frazzled with no relief in sight… Being an organised GP is hard at the best of times!

Signs such as those above may indicate you need a break, more support, or a change in the way you practice.

What are the signs you watch for in yourself, that tell you it’s time for a holiday, (or a career change)?

Wouldn’t we all love to be the reliable, full time country doc, there in his chair for generations to come, always available, always kind, competent and zen? However, not all of us can do that, and that’s ok. For some of us, this is just not a sustainable life.

I don’t think I can always be that doctor. I need to work out, and then be, the kind of doctor I really am.

What to do if you are burnt out:

Take time off- this is essential. How much? Enough.

Physical exercise. Intense, heart pumping exercise is a great treatment for anxiety. It also helps regulate your mood and manage stress.

Clean habits- good food in sensible portions, quality sleep. Reduce alcohol.

Peer support. This is vital. (My study group has reformed, years after our exams, to enjoy the support that was the best part of our study sessions. We hold ‘study group’ once a month but for the purposes of peer review, friendship and case discussion. It is fantastic).

Watch how you practice. When you start back at work, go slow and take your time. Don’t overload yourself in the attempt to catch up. (‘None of us are indispensible’, a mentor said to me recently, and it is good to remember this. There are other doctors there to care for our patients when we can’t be there).

Remember, it is the patient’s responsibility in the end, to prioritise their own health. Your job is to give them the best advice and care you can, but it is entirely up to them whether to take that advice and accept that care. This can be difficult, especially when the medical profession is made to feel legally liable for everything our patients do. Being on the frontline of healthcare as a GP is particularly tough as we are the first and often the last port of call for all aspects of patient health.

As always, I welcome all of your insights and suggestions for avoiding and managing burnout, a common problem in medicine and other caring professions.